2013 ANNUAL PERFORMANCE REPORT

ASANTE-AKYEM PRESBY HEALTH SERVICE

PRESENTED BY

ALEX KESSE NYAMESA (FRSH)

GENERAL MANAGER

PRESENTATION OUTLINE

• Introduction

• Key Priority Objectives

• Highlights

• Implementation of Plans and Budgets

• Main Achievements

• Constraints/Challenges

• Way Forward

• Best Practices/Innovations

2

INTRODUCTION

The Asante-Akyem Presbyterian Health Service operates in Ashanti, Eastern,

Western and Central regions of Ghana.

The institutions under the Asante-Akyem Presbyterian Health Service are:

Agogo Presby Hospital (District Hospital)

Agogo Presby Nurses’ Training College

Agogo Presby Primary Health Care

Kwahu Praso Presby Health Centre

Aowin-Suaman Presby Primary Health Care

Assin Praso Presby Health Centre

Assin Nsuta Presby Health Centre

Kom Clinic, Aburi

3

Services Provided – Agogo Hospital

• Internal Medicine

• General Surgery

• Child Health

• Obstetrics/Gynaecology

• Dentistry

• Pharmacy

• Ophthalmology

• Ultrasonography

• Electrocardiography

• Physiotherapy

• Laboratory Services

• X-Ray Services

• HIV/AIDS:

– VCT

– ART

– PMTCT

• Special Sickle Cell Clinic

• Special Diabetic Clinic

• Special Hypertensive Clinic

• Special TB Clinic

• Special Psychiatry Clinic

• Morgue Services

4

STAFFING POSITION – AGOGO HOSPITAL (AS AT 31-12-2013)

STAFF CATEGORY STAFF AT POST

Medical Officers 21

Medical Assistants 6

General Nurses 101

Midwives 20

Auxiliary Nurses 31

Pharmacists 3

Pharmacy Technicians 10

Biomedical Scientists 5

Physiotherapist 1

Technical Officers (X-Ray) 2

Nurses Anaesthetist 5

Others 218

TOTAL 423

5

STAFFING POSITION – HEALTH CENTRES/POST(AS AT 31-12-2013)

GRADEAGOGO

PHC

ASSIN

PRASO

ASSIN

NSUTA

KWAHU

PRASO

ENCHI

PHC

DDNS/PNO/SNO/NO/SSN/SN - 1 2 - 7

Med. Asst./Rural Nurse

Practitioner- 2 1 1 2

Accounts/Administration 3 1 1 - 1

Midwives/Midwifery Supt. 1 1 1 1 1

Enrolled Nurse 7 5 3 - 10

Lab Technician/Assistant - 2 - 2 3

Community Health Nurse 21 5 7 5 9

Pharmacy Technician/Assistant - 1 1 - 4

Field Technician/Technical

Officer2 6 - - 1

6

GRADEAGOGO

PHC

ASSIN

PRASO

ASSIN

NSUTA

KWAHU

PRASO

ENCHI

PHC

Driver 2 1 1 - 2

Medical Record Assistant - - 2 - 3

Health Aides/Ward Assistant 3 8 12 1 3

Labourer/Orderly - 2 3 5 5

Watchman 2 - 2 1 2

Tradesman - 1 - - -

Storekeeper - - 1 - 1

Others 4 1 7 - 9

TOTAL 45 37 44 16 63

7

KEY PRIORITY OBJECTIVES

1. To increase access to health services and bridge equity gaps

2. To improve quality of care

3. To improve financial and human resource mobilization

4. To increase efficiency in resource utilization

5. To improve maternal and child health care

6. To prevent and control non-communicable diseases

7. To control the incidence of Malaria, HIV/AIDS, STI/TB

Transmission and other Communicable Diseases

8. To spread the gospel through health service delivery

9. To improve collaboration and networking with MOH/GHS and

other stakeholders

8

ASANTE-AKYEM PRESBYTERIAN HEALTH SERVICE

ANNUAL PERFORMANCE REPORT

JANUARY – DECEMBER 2013

HIGHLIGHTS

• 281,435 outpatient attendances were recorded, it was 5.2% above the figure of 267,442 recorded in 2012

• 91.0% of all cases was insured. The total number of insured cases was 219,917 (excluding Agogo PHC and Kwahu Praso) which was 2.2% higher than the percentage figure of 88.8% in 2012

• The total number of Admissions was 12,930 which was 6.9% above the figure of 12,092 recorded in 2012.

• Discharges totalled 12,438 and there were 380 deaths. Discharges and Deaths recorded 6.6% and 5.5% respectively as compared to 2012 figures (i.e. 11,657 discharges and 360 deaths)

• 5,489 Antenatal Registrants were recorded as against 5,782 in 2012, indicating a decrease of 5.1%

9

• Supervised Deliveries totalled 3,142; 5.5% above the figure of 2,978 for 2012

• There were 2,833 Postnatal Registrants as against 3,393 in 2012, indicating a

decrease of 16.5%

• 2,078 General Surgeries, 1,389 Obstetric/Gynaecological Surgeries and 859

Eye Surgeries were performed. The total number of Surgeries performed was

4,326 which recorded 5.1% lower than the 2012 figure of 4,559

• Laboratory Investigations for Agogo Hospital totalled 84,556 which was 2.3%

above the number of investigations recorded in 2012 (i.e. 82,582). Assin Praso

Health Centre and Enchi PHC conducted a total of 16,143 laboratory

investigations indicating 20.3% increased compared to 2012 total recorded

figure of 13,416

• 7,056 X-Ray Investigations were carried out which was higher than the 2012

figure (i.e. 5,790) by 21.8%

10

• Ultrasound Investigations totalled 4,012 which was 7.1% below the recorded

figure of 4,323 for 2012

• There were 7 Maternal Deaths as against 6 in 2012; 65 Stillbirths as against 75

in 2012; 34 Neonatal Deaths as against 36 in 2012. These convert into

Maternal Mortality Ratio of 329 per 100,000 life births as against 298 in 2012;

Stillbirth Ratio of 29.7 per 1,000 births as against 34.9 in 2012 and Neonatal

Mortality Ratio of 16.0 per 1,000 life births as against 17.4 in 2012. Death Rate

of Admissions remained the same as 2012 (3.0%)

• Malaria retained its position as the topmost cause of outpatient attendance and

admission and also the first amongst the top ten communicable diseases in

Agogo Hospital

• As a proportion of all Malaria Deaths, Under-Five Malaria Deaths fell from

87.5% in 2012 to 56.3% in 2013

11

• Recorded EPI coverage was as follows:

BCG 124.0% OPV III 122.7%

Measles 155.1% Yellow Fever 113.0%

Penta III 120.1% TT2 176.6%

• A consolidated Income and Expenditure Account gave total income as

GH¢14,736,206.40 and total expenditure as GH¢13,693,423.54 indicating a

surplus of GH¢1,042,782.86

• Development Expenditure was GH¢774,461.86 giving a ratio of development

expenditure to re-current expenditure of 1.0 : 17.7

• Total Internally Generated Fund (IGF) was GH¢8,205,962.13 which was

55.7% of total income

• Government subvention was GH¢6,472,569.28 which was 43.8% of total

income

12

• Donations from Overseas Partners and Friends totalled GH¢12,300.59 which

was 0.1% of total income. The percentage for 2012 was 0.2%

• Drug Sales Income was GH¢4,421,061.65 which accounted for 53.8% of IGF.

Total cost of drugs sold was GH¢2,499,450.59 giving a gross margin of

GH¢1,921,611.06 or 76.5%

• Total expenditure on Church Salaries and Allowances was GH¢2,096,233.91

which took 25.5% of IGF

• Total revenue from insured clients was GH¢5,531,916.03 which constituted

67.4% of IGF

• Outstanding health insurance reimbursements for all facilities as at 31st

December, 2013 totalled GH¢1,608,266.65

13

IMPLEMENTATION OF PLANS AND BUDGET (JAN – DEC 2013)

PLANNED ACTIVITIES CARRIED OUT, OUTPUTS AND OUTCOMES

OBJECTIVE 1: INCREASE ACCESS TO HEALTH SERVICES AND BRIDGE

EQUITY GAPS

ACTIVITY OUTPUT OUTCOME

STRATEGY (I) Strengthen Hospital’s Capacity to Respond to Challenges of National

Health Insurance Scheme

Strengthen Health

Insurance Claims Office

in the Hospital

A total amount of

GHȼ29,489.00 has been

devoted for the first phase

of the computerization of

the hospital OPD systemHealth insurance claim’s

accurately prepared and

promptly submitted at all timesEngagement of two (2)

permanent staff to assist in

the processing of insurance

claims14

Prepare and Discuss

NHIS Implementation

Report monthly at IMC

meetings – Agogo

Hospital

12 Health Insurance

Operational reports,

including monthly

statement of health

insurance account,

discussed by management

Smooth implementation of the

National Health Insurance

Scheme evidenced by two

Clinical Audits

Provide Training &

Refresher Trainings for

all Staff in the

Implementation of

NHIS – Agogo Hospital

A 5-day in-service training

on E-CLAIMS organized

for staff at the Health

Insurance Unit

Significant improvement in

Health Insurance

documentation

Accuracy in claims submission

enhanced

15

Continue

Implementation

of NHIS

Total No. of Cases: 240,067

Total Insured cases: 219,917

% of Insured Patients: 91.0%

Total IGF: GH¢7,683,662.87

Revenue from Insured: GHȼ5,531,916.03

As a % of IGF: 71.0%

Total Reimbursement: GHȼ3,923,649.38

Outstanding Reimbursement:

GHȼ1,608,266.65

Increase in access to

health services as a

direct result of the

health insurance

scheme; total number of

insured cases rose

marginally by 3.0%

compared to 2012

16

NHIS Accounts exclude Agogo PHC and Kwahu Praso H/C

17

STRATEGY (II) Provide Subsidies to Poor and Sick

Provide Free Treatment

for Uninsured Poor and

Sick

A total of GHȼ2,684.00

(including feeding and

transportation as well as

registration with NHIS) was

spent on Poor and Sick in

all facilities

The poor and sick had access to

health care

STRATEGY (III) Improve on Existing HIV/AIDS Response System

Increase Service Hours

at ART, VCT, PMTCT

Centres

1,083 clients received HIV/

AIDS clinical care at ART

Centre

1,156 clients were

counselled and tested at

VCT Centre (666 females;

490 males)

Increased access to services for

clients at ART, VCT and

PMTCT centres in the hospital

Increase Service Hours

at ART, VCT, PMTCT

Centres

275 tested positive (174

females; 101 males)

1,922 ante-natal registrants

were counselled and tested

29 tested positive

29 Mothers received ARVs

43 Babies received ARVs

Increased access to services for

clients at ART, VCT and

PMTCT centres in the hospital

Organize World AIDS

Day

World AIDS Day organized

on 1st December. Activities

included:

Health talks at Agogo

(APCE & Asempa FM,

Akutuase, Konongo (Kings

FM)

Float on the principal

streets of Agogo

Improved public knowledge on

HIV/AIDS issues

18

STRATEGY (IV) Provide General/Specialized Out-Patient and In-Patient Services

Provide 24-Hour

General/Specialized

Out-Patient Services

134,758 attendances were

recorded at the General

OPD in Agogo Hospital, out

of this;

16,832 were specialized

surgical consultations

11,878 were specialized

obstetric/gynaecological

consultations

30,459 specialized

paediatric attendances were

recorded

22,598 attendances were

recorded at the Eye Clinic

3,049 attendances were

recorded at the

Physiotherapy centre

1,426 attendances were

recorded at the Dental

Clinic

9.7% decrease in OPD services

compared with 2012 figure of

149,230

19

20

Provide 24-Hour

General/Specialized

Out-Patient Services

OPD attendances recorded

at PHC/Health Centres:

Agogo PHC – 4,107

Assin Praso H/C – 30,997

Assin Nsuta H/C – 40,571

Enchi PHC – 33,741

Kom Clinic – 11,342

Kwahu Praso H/C – 25,919

Total: 146,677

24.1% increase in attendances

compared to the total figure of

118,212 recorded in 2012

Provide In-Patient

Services

12,930 admissions; 12,438

discharges; 380 deaths were

recorded in Agogo Hospital

6.9% increase in admissions

compared to 2012 figure of

12,092

Provide Laboratory

Services

84,556 laboratory

investigations were carried

out in Agogo Hospital

8,907 investigations were

recorded at Assin Praso

Health Centre

7,236 investigations carried

out at Enchi PHC

2.4% increased in laboratory

services in Agogo Hospital as

compared to 2012 figure of

82,582

20.3% increased access to

laboratory services at Assin

Praso and Enchi PHC

compared to 2012 total

recorded figure of 13,416

Provide X-Ray Services

A total of 7,056 x-ray

investigations were

recorded

21.9% increased access to x-

ray services compared to 2012

figure of 5,790

Provide Physiotherapy

Services

3,049 attendances were

recorded at the

Physiotherapy Centre

27.2% increase in attendance

over the 2012 figure of 2,397

21

Provide Surgical

Services

Surgeries performed:

642 major General Surgeries

1,569 minor General Surgeries

743 major O&G Surgeries

646 minor O&G Surgeries

746 major Eye Surgeries

113 minor Eye Surgeries

4,459 major and minor surgeries

A decrease of 2.1% in

access to surgical services

compared to 2012 figure

of 4,559

STRATEGY (V) Promote Nutrition Activities

Carry out Health

Education on Exclusive

Breast Feeding,

Complementary Feeding

and Micro Nutrient

Deficiency

Health education talks given

regularly at Antenatal Clinic

days by all facilities

Exclusive breastfeeding is

practised by most nursing

mothers

upgraded knowledge,

attitude and practice on

the part of mothers in the

use of locally available

food items

22

Carry out Cooking

Demonstrations

Cooking demonstrations

carried out on monthly basis

using local food items

Upgraded knowledge, attitude

and practice on the part of

mothers in the use of locally

available food items

STRATEGY (VI) Implement Special Programmes

Provide Eye Care

1,686 attendances at Eye

Clinic recorded at Enchi

PHC

17.2% decreased in eye care

services compared to the 2,037

recorded in 2012

Search for Buruli Ulcer

Cases at the Nodular

Stage – Agogo PHC

Buruli Ulcer cases identified

Nodular stage - 21

Plaque stage - 14

Oedema stage - 0

Ulcer stage – 12

10.5% increased in cases

detected at the nodular stage

(i.e. from 19 in 2012 to 21 in

2013)

Participate in Malaria

Vaccine Trial – Agogo

PHC

The third phase (MAL 055)

has ended with no adverse

effect seen

MAL 063 also begun in May

2012

MAL 055 final result is yet to

be published

MAL 063 is on-going

23

24

OBJECTIVE 2: IMPROVE QUALITY OF CARE

ACTIVITY OUTPUT OUTCOME

STRATEGY (I) Strengthen Existing Quality Assurance Programme Implementation

Draw and Implement

Quality Assurance

Action Plan on

Quarterly Basis

Yearly Quality Assurance action

plan drawn

Four (4) Quality Assurance

Team meetings held in the year

Two (2) Quality Assurance

reports discussed at IMC

meetings

Improved quality of care

Discuss Quality

Assurance Activity

Reports quarterly at

IMC meetings

25

Review Cases at

Accidents and

Emergency Department

every morning

All cases at Accident &

Emergency Department

reviewed by full Clinical Team

every morning from Monday to

Friday except ThursdaysImproved quality of care:

Improvement in

Neonatal Mortality Ratio

from 17.4 per 1,000 Life

Births in 2012 to 16.0 per

1,000 Life Births in 2013

Reduction of stillbirths

from 34.9 per 1,000 Births

in 2012 to 29.7 per 1,000

Births in 2013

Hold Weekly Clinical

Meetings36 clinical meetings held

Hold Monthly Mortality

Conferences/Audits

12 mortality conferences/audits

held

Hold Half-Yearly

Clinical Review

Meetings

2 clinical review meetings held

26

Conduct User

Satisfaction Survey

Twice a Year at all OPD

Units (General, Eye,

Antenatal, etc.) and

Inpatient Departments

and Disseminate Results

Agogo Hospital:

Two (2) surveys were conducted

Assin Praso H/C:

Two (2) surveys were conducted

Assin Nsuta H/C

One (1) survey was conducted

See APPENDIX I (a – f)

Standard level of clients

satisfaction maintained

Conduct Quarterly

Rational Drug Use

Survey

Four (4) Rational Drugs Use

survey were conducted

See APPENDIX II

Significant improvement in

prescription habit

STRATEGY (II) Update Staff Knowledge on Infection Prevention and Control and

Clinical Protocols

Organize In-Service

Training Workshop on

Infection Prevention and

Control

Five (5) members of staff

benefitted from a workshop on

Infection Prevention and

Control in Enchi PHC

Knowledge of staff in

infection prevention and

control improved

27

STRATEGY (III) Ensure Availability of Requisite Medical Equipment and

Logistics

Procure Requisite

Medical Equipment

Various types of medical

equipment purchased:

Agogo Hospital:

GH¢110,766.45

Assin Praso: GH¢21,700.00

Enchi PHC: GH¢9,530.00

Total: GH¢141,996.45

Improved tracer medical

equipment availability for

improved quality of care

Make Quarterly Bulk

Purchase of Basic Inputs

Total expenditure on drugs and

non-drugs medical consumables

as a percentage of total non-

wage expenditure for each

facility was:

Agogo Hospital: 68.9%

All other facilities: 60.2%

Adequate stocks of basic

inputs available in all

facilities almost at all times

28

STRATEGY (IV) Provide Additional Infrastructural Facilities

Construct Identified

Priority Infrastructure

Assin Nsuta

Construction of Nurses

Quarters: GHȼ12,187.00

Project on-going at roofing

level

Assin Praso H/C

Construction and mechanization

of borehole at a total cost of

GHȼ10,558.90

Continuous supply of

water for the facility

ensured

STRATEGY (V) Ensure Availability of Functioning Assets in all Facilities

Identify and Procure

Needed Assets

Agogo Hospital

One (1) Toyota Land Cruiser

Prado, Furniture, Medical

Equipment and Non-Medical

Equipment

Total: GHȼ325,244.40

Availability of needed

assets for improved quality

of care ensured

29

Identify and Procure

Needed Assets

Assin Praso H/C:

Furniture, Medical Equipment

and Non-Medical Equipment

Total: GHȼ22,286.00

Assin Nsuta H/C:

Non-Medial Equipment:

GHȼ2,900.00

Enchi PHC:

Furniture, Medical Equipment

and Non-Medical Equipment

Total: GHȼ14,730.00

Availability of needed

assets for improved quality

of care ensured

30

STRATEGY (VI) Organize In-Service Training

Draw and Organize

Training Plan

Agogo Hospital

327 various categories of staff

participated in six (6) different

in-service training workshops at

a total cost of GHȼ1,421.00

Assin Praso H/C

Exclusive Breast Feeding for

all category of staff

Quality Assurance Refresher

course for the Quality Assurance

Team

Other topics included: Jadelle

Insertion, Malaria in Pregnancy,

Medical Terminology and

Disease Coding, TB, Nutrition &

PMTCT

Improved human resource

capacity building for

improved quality of care

31

Draw and Organize

Training Plan

Enchi PHC

112 various category of staff

benefitted from 13 different

workshops in Tuberculosis,

PMTCT, Laboratory

Techniques, Obstetric and new

born care, Emergency care,

Quality Assurance, Procurement

and stock management, etc.

Improved human resource

capacity

STRATEGY (VII) Improve Infrastructure

Carry out Renovation of

Existing Structures

Agogo Hospital carried out the

following renovation works:

Conversion of Doors and

Windows to Aluminium Glazing

type

Conversion of KVIP into WCs

at the staff quarters

Repair of Underground Water

Tanks

Infrastructure modernized

32

Carry out Renovation of

Existing Structures

Completion of the Front View

Fence Wall

Conversion of the Houseman

Flat into two bungalows

Modernization of the

Pharmacy

Rehabilitation of Residential

Buildings

All at a total cost of

GHȼ225,067.78

Assin Praso H/C

Extension of OPD waiting

Area: GHȼ1,270.00

Enchi PHC

Renovation of Amonie and

Papueso Clinics: GHȼ6,239.00

Face lift of infrastructure

achieved and possible

prolonged useful life of

building

33

STRATEGY (VIII) Ensure Adequate Maintenance of Assets

Continue

Implementation of PPM

Schedules

Expenditure on maintenance of

assets as a percentage of non-

wage recurrent expenditure for

each facility was as follows:

Agogo Hospital: 4.8%

All other facilities: 5.2%

Maintenance of assets

ensured in the region of the

5% threshold of non-wage

recurrent expenditure

STRATEGY (IX) Improve Hospital/Customer/Community Relations

Hold Daily Education/

Interaction with Clients

at the OPD and in the

Wards

Daily education/interaction with

clients at OPD and on wards

held as part of daily morning

devotion

Improved hospital-client

relations

OTHER QUALITY OF CARE INDICATORS

COMPLICATED DELIVERIES

Number of Complicated Deliveries - 641

Caesarean Section - 584

Twin Deliveries - 57

CAUSES OF CAESAREAN SECTIONS

Compound Presentation - 19

Eclampsia - 9

Foetal Distress - 56

Cervical Dystocia - 4

Abruptio Placenta - 23

34

Placenta Praevia - 28

Antepartum Haemorrhage (APH) - 39

Face Presentation - 3

Post Maturity - 2

Cord Prolapse - 18

Elective C/S - 45

Previous C/S - 75

OPP - 10

Cephalopelvic Disproportion (CPD) - 83

Obstructed Labour - 17

Breech Presentation - 13

Pregnancy Induced Hypertension - 15

Foot Presentation - 4

Raptured Uterus - 71

Delayed 2nd Stage - 21

IUFD - 29

35

MATERNAL DEATHS

Number Recorded - 7 (All Audited)

CAUSES

Eclampsia - 3

Irrevesible shock 2° Sev. Haemorrhage

from a raptured uterus - 1

Acute pulmonary Oedeme 2° Sickle Cell

Cardiomyopathy - 1

Pulmonary Ebolism - 1

HIV Encephalopathy - 1

36

NEONATAL DEATHS

Number Recorded - 34

CAUSES

Prematurity - 16

Foetal Distress - 3

Neonatal Sepsis - 4

Severe Asphysia - 10

Broncho Pneumonia - 1

37

STILLBIRTHS

Number Recorded - 65

CAUSES

Preterm - 10

I U F D - 25

Cord Prolapse - 3

Delayed 2nd Stage - 4

Ruptured Uterus - 2

Breech Presentation - 10

Prolonged Labour - 3

Foetal Distress - 6

P I H - 2

38

MEASURES TO REDUCE MATERNAL DEATHS,

NEONATAL DEATHS AND STILLBIRTHS

• Intensify education on the need to refer cases early

• Regular interaction among the Hospital and referring institutions through

their District Directors of Health Services

• Involvement of Medical Superintendents of referring institutions in

Mortality Audits

• Continuous education by the PHC on the essence of antenatal and

postnatal attendances

• Enforce the use of Pathograph to monitor labour

• Increase staff strength (Midwives) and motivate them

39

MEASURES TO REDUCE MATERNAL DEATHS,

NEONATAL DEATHS AND STILLBIRTHS (Cont’d)

• Adequate stocking of the Blood Bank

2009 2010 2011 2012 2013

• No of pints of blood stocked: 1289 1634 1824 1796 1736

• No of pints of blood used: 1271 1633 1741 1640 1639

• Ensure availability at all times of adequate obstetric/gynaecological emergency

packs for:

• Antepartum Haemorrhage

• Pregnancy Induced Hypertension

• Eclampsia

• Retained Placenta

• Postpartum Haemorrhage

40

41

OBJECTIVE 3: IMPROVE FINANCIAL AND HUMAN RESOURCE

MOBILIZATION

ACTIVITY OUTPUT OUTCOME

STRATEGY (I) Strengthen Internal Income Generation System

Continue/Initiate

Income Generation

Activities

Agogo Hospital:

Mortuary Operations:

No. of bodies deposited:614

No. of bodies collected: 594

Total Revenue: GHȼ141,925.00

Total Exp.: GHȼ62,397.70

Gross Margin: GHȼ79,527.70

Hospital’s share of 45%:

GHȼ35,787.29

Agogo PHC:

GHȼ3,750.00 was realized from

the Unit’s Guest House

Additional income of

GHȼ35,787.29 was

available to the hospital for

utilization

42

Intensify Supervisory

Checks on Revenue

Collectors and Health

Insurance Billing

Officers

Institutional IGFs (GHȼ):

Agogo Hospital: 6,040,205.31

Agogo PHC: 241,651.25

Assin Praso H/C: 437,782.74

Assin Nsuta H/C: 606,810.50

Kwahu Praso H/C: 275,113.90

Enchi PHC: 604,398.43

Total: GHȼ8,205,962.13

10.7% increased in IGF

over 2012 total of

GHȼ7,409,983.79

Implement Development

Levy

GHȼ154,885.75 realized from

Development Levy – Agogo

Hospital

Additional income

available to the hospital for

developmental projects

STRATEGY (II) Provide Residential Accommodation for Staff

Rent Additional

Accommodation for

Staff

Agogo Hospital:

Accommodation was rented for

senior staff and other newly

posted staff at GHȼ33,986.39

Morale of beneficiary staff

boosted

43

STRATEGY (III) Recruit Needed Technical and Professional Staff and Ensure

Retention

Recruit Needed Staff to

fill vacancies

Staff recruited - Agogo Hospital:

1 Stenographer

2 Technical Officers

1 Physiotherapy/Orthotics

Assistant

10 Staff Nurses

1 Accounts Officer

1 Finance Officer

5 Midwives

1 Gynaecologist/Obstetrician

6 Community Health Nurses

14 Enrolled Nurses

1 Dental Technician

1 Driver

Improved technical/

professional staff strength

44

Identify and Recruit

Needed Staff

Assin Praso H/C

1 Physician Assistant

3 Comm. Health Nurses

2 Enrolled Nurses

1 Health Assistant

1 Laboratory Assistant

Enchi PHC

3 Health Extension Workers

2 Community Health Nurses

1 Biostatistics Records

Assistants

1 Physician Assistant

1 Enrolled Nurse

Improved staff strength

Reduced workload

45

Promote Deserving Staff

Staff promotions – Agogo

Hospital:

1 Prin. Nursing Officer

1 Senior Physiotherapist

1 Principal Accountant

2 Snr. Nursing Officers

21 Senior Staff Nurse

5 Senior Staff Midwife

1 Snr. Physician Assistant

(Anaesthesia)

2 Snr. Medical Assistant

(Medical)

2 Snr. Medical Officers

2 Snr. Pharmacy Technicians

Improved staff morale

46

Implement Existing

Incentive Packages for

Staff and Introduce

Feasible new ones

Expenditures on staff Internal

Allowances (GHȼ):

Agogo Hospital:

Rural Allow: 704,957.22

Locum Allow: 9,998.48

Call/Night Allow: 27,543.70

Snack Allow: 24,630.94

Parting Gift: 10,430.12

End of Year Bonus: 10,430.00

Total: GHȼ805,510.46

Improved staff morale

Staff shortage contained

47

Provide Uniform and

Protective Clothing to

Staff

Uniform provided at a total cost of

GHȼ6,615 for all category of staff in

Agogo Hospital

Staff morale boosted

Promote Staff

Development and

Growth through

Sponsorship with

Bonding

Agogo Hospital:

Training sponsorship or study leave

with pay provided for:

1 Snr. Lab Technician for BSc.

Medical Lab Technician (Sandwich)

2 Snr. Staff Nurse for Advanced

Diploma in Ophthalmic Nursing

1 Snr. Staff Nurse for Advanced

Diploma in Nurse Anaesthesia

1 Snr. Staff Nurse for Advanced

Diploma in Public Health

1 Snr. Health Aide for Diploma in

Dental Surgery Assistant (Sandwich)

Critical human resource

capacity building

embarked on

48

Promote Staff

Development and

Growth through

Sponsorship with

Bonding

Agogo Hospital:

Training sponsorship or study leave

with pay provided for:

1 Snr. Staff Nurse for Certificate in

Paediatric Nursing

1 Kitchen Supervisor for HND in

Hotel Catering and Institutional

Management

Enchi PHC:

Registered General Nurse – 3

Midwifery - 1

Critical human resource

capacity building

embarked on

49

OBJECTIVE 4: INCREASE EFFICIENCY IN RESOURCE UTILIZATION

ACTIVITY OUTPUT OUTCOME

STRATEGY (I) Prepare and Implement Plans and Budget

Prepare and Implement

Annual/Quarterly

Programme of Work

Based on Three Year

Strategic Plan

Annual and quarterly budgets

prepared

Performance of quarterly

budgets monitored on quarterly

basis by Income and

Expenditure Account to track

and analyse variances

Annual Income and Expenditure

Accounts prepared

Budget overruns checked

Income surplus of

GHȼ1,042,782.86 recorded

in 2013

50

Participate in Annual

Ministry of Health/

CHAG/GoG Plans and

Budget Preparation

Seminars

Two (2) seminars on Plan and

Budget preparation organized

by CHAG and MOH attended

by core budget team

Hospital budget captured

in CHAG and MOH

budgets

STRATEGY (II) Intensify Supervision, Monitoring and Evaluation

Prepare Activity

Reports Quarterly and

Discuss at all Heads of

Departments/IMC

Meeting

Three (3) out of four (4)

Quarterly Activity Reports

prepared and discussed at IMC

meetings

Improved supervision,

monitoring and evaluation

of hospital’s activities

Prepare Quarterly

Activity Reports for

Discussion by Area

Board

The first three quarters activity

reports prepared by all facilities

and discussed at Area Board

meetings

Improved supervision,

monitoring and evaluation

51

Participate Actively in

MOH/GHS Half-Year

and Annual

Performance Reviews

Regional GHS Half-Year and

Annual Performance Review

meetings attended by Hospital

DHMT Half-Year and Annual

Performance meetings attended

by each Health Centre and PHC

programme

Stewardship accounted to

MOH/GHS

52

STRATEGY (III) Improve the Existing Health Management Information System

Develop/Update Staff

Data Base on

Continuous Basis

Staff database updated on

continuous basis

Easy referencing, retrieval

and reporting on staff

Easy manpower budgeting

STRATEGY (IV) Strengthen Internal Communication

Hold Monthly IMC

Meetings

Agogo Hospital/PHC:

14 IMC meetings held to

discuss general management and

administrative issues

Three (3) out of fourteen (14)

IMC meetings held to discuss

Quarterly Activity Reports

Number of IMC meetings

attended by:

Assin Praso H/C: 6

Enchi PHC: 10

Team spirit enhanced

Emerging challenges

identified and dealt with

promptly

53

Hold Monthly General

Manager, Medical

Administrator and

Clinical in-charges

Meeting – Agogo

Hospital

Eight (8) out of twelve (12)

meetings held

Clinical Heads have

opportunity to contribute

to management decision

making processes

Inter-departmental

relationship and

complementation enhanced

Hold Quarterly Staff

Durbars/Meetings

Three (3) staff durbars were

held in Agogo Hospital

Assin Praso H/C: Five (5) staff

meeting held

Assin Nsuta H/C: Two (2) staff

meetings held

Enchi PHC: Two (2) staff

meetings held

Management/staff

interaction and mutual

trust promoted

Industrial harmony

maintained throughout the

year

54

Install Public Address

System (PAS) Linked to

all Departments/Units of

the Hospital

Public Address System installed

at the Medical Records

Ease of communication

between staff and patients

STRATEGY (V) Improve on Existing Procurement System

Make Available Policy

Guidelines and

Procedure for

Procurement

Policy Guidelines and Procedure

for procurement made availableProcurement streamlined

Hold Quarterly

Procurement Meeting

Three (3) procurement meetings

held at Agogo Hospital

Procurement Act adhered

for efficiency and

transparency

55

OBJECTIVE 5: IMPROVE MATERNAL AND CHILD HEALTH CARE

ACTIVITY OUTPUT OUTCOME

STRATEGY (I) Intensify Reproductive Health Care

Provide Focus Antenatal

Services

5,489 antenatal registrants

recorded in all facilities

5.1% decrease in antenatal

registrants compared to 2012

figure of 5,782

Conduct Supervised

Deliveries

A total of 3,142 supervised

deliveries conducted in all

facilities

5.5% decrease in supervised

deliveries compared to 2012

total of 2,978

Provide Postnatal

Services

2,833 postnatal registrants

recorded in all facilities

16.5% decrease in postnatal

registrants compared to 2012

total of 3,393

56

Run Child Welfare

Clinic (0 – 23 months)

7,878 registrants were

recorded in all facilities

15.5% increase in child welfare

services compare to 2012 total

of 6,820

Carry out School Health

Services

Agogo PHC: 4,181 pupils

examined

Assin Praso: No – 2,266

Assin Nsuta: No – 1,124

Minor illnesses were detected

and treated

Major illnesses referred to

hospital

Distribute Insecticide

Treated (Bed) Nets

(ITNs)

ITNs supplied and

distributed

Agogo PHC – 3,412

Beneficiaries had protection

against malaria

57

Distribute Vitamin “A”

Capsules to Postnatal

Mothers and Children

(6 – 59 months)

Vitamin “A” capsules

administered to children

Agogo PHC – 5,786

Assin Nsuta – 972

Assin Praso - 634

Prevention of morbidity and

mortality

Carry out Maternal

Mortality Audits and

give Feedback

Seven (7) Maternal deaths

recorded in Agogo Hospital,

all audited

Causes of the maternal deaths

were:

Eclampsia – 3, Irrevesible shock

2° Sev. Haemorrhage from a

raptured uterus – 1, Acute

pulmonary Oedeme 2° Sickle

Cell Cardiomyopathy – 1,

Pulmonary Ebolism – 1, HIV

Encephalopathy – 1

Provide Family

Planning Services

7,879 acceptors were

recorded in all facilities

50.8% increase in family

planning acceptor rate

compared to 2012 figure of

5,224

58

STRATEGY (II) Intensify Child Health Services

Provide Immunization

Services

Coverages recorded for the

various antigens were as

follows (2012 coverages in

brackets):

BCG: 124.0% (103.7%)

Measles: 140.6% (84.8%)

Penta III: 120.0% (90.0%)

OPV III: 122.7% (92.4%)

Y F: 113.0% (108.4%)

TT2++: 176.6% (128.0%)

Significant improvement over

2012 coverage

No vaccine preventable

disease was recorded in any of

the facilities

Feed Children on

Admission

All children on admission are

fed once a day at a total cost

of GHȼ10,578.00 – Agogo

Hospital Improved child health

services

Screening of the New-

Born within 48 Hours

All new-born babies screened

with 48 hours – Agogo

Hospital

59

STRATEGY (IV) Prepare for Obstetric Emergencies

Provide Obstetrics

Emergency Packs

Emergency packs available at

all times in adequate

quantities for:

Ante Partum Haemorrhage

Post Partum Haemorrhage

Pregnancy Induced

Hypertension

Eclampsia

Retained Placenta

Improved management of

obstetric emergencies

STRATEGY (V) Ensure Community Participation

Organize Community

Durbars

Three community durbars

were organized in three

different communities in

Assin Praso

Community participation in

RCH activities secured for

improved service delivery

60

OBJECTIVE 6: PREVENT AND CONTROL NON-COMMUNICABLE DISEASES

ACTIVITY OUTPUT OUTCOME

STRATEGY (I) Promote Non-Communicable Disease Control and Prevention

Establish/Run Non-

Communicable Disease

Clinics

23,808 attendances

recorded at Hypertensive

Clinic,

4,918 at Diabetic Clinic,

417 at Sickle Cell Clinic,

making a total of 29,143

attendances at non-

communicable disease

clinics at Agogo Hospital

6.1% decrease in attendances at

non-communicable disease

clinics compared to 2012 figure

of 31,042

61

OBJECTIVE 7: TO CONTROL THE INCIDENCE OF MALARIA, HIV/AIDS,

STI/TB TRANSMISSION AND OTHER COMMUNICABLE DISEASE

ACTIVITY OUTPUT OUTCOME

STRATEGY (I) Improve Disease Control and Prevention

Provide Health

Education

Assin Praso H/C:

Health education given:

Expired Products

Regenerative Health

Signs and Symptoms of

TB

Malaria Prevention

The Use of ITN

Child Survival

NID &

HIV Prevention

Increased awareness of disease

transmission, prevention and

control

Reduced disease burden

62

Provide Health

Education

Assin Nsuta H/C

Health education given:

Misconception about

family planning

Prevention of Cholera/

diarrhoea and management

Personal hygiene

Prevention of home

accident

Care of new born baby

Importance of

breastfeeding

Hand washing with soap

and clean water

Import of family planning

Benefit of facility delivery

Increased awareness of disease

transmission, prevention and

control

Reduced disease burden

63

Treat and Manage

Infected and Affected

People

Assin Nsuta H/C: 8 TB

Clients were referred from

Fosu Hospital for

supervision

Reduction in morbidity

Train CBSV on Current

Health Issues

Refresher course on Buruli

Ulcer for 40 CBSV and 30

Health Staff of Agogo PHS

Reduced disease burden

STRATEGY (II) Ensure Universal Precautionary Measures

Train Staff on Infection

Prevention and Control

Assin Praso H/C: All newly

engaged staff trained on

Infection Prevention and

Control

Enchi PHC: 5 staff trained

on infection prevention and

control

Reduced disease burden

64

STRATEGY (III) Promote Malaria and TB Control Programme

Follow Established

Treatment Guidelines on

Malaria and TB Control

Malaria:

Total number of lab confirmed

malaria cases at OPD: 15,656

Total number of admissions

due to lab confirmed malaria

cases (all ages): 1,855

Total number of deaths due to

lab confirmed malaria cases (all

ages): 16

Total number of admissions

due to malaria (<5 years): 1,200

Total number of deaths due to

malaria (<5 years): 9

Increased in laboratory

confirmed malaria

admissions (all ages) from

9.1% of total admissions in

2012 to 14.3% in 2013

65

Follow Established

Treatment Guidelines on

Malaria and TB Control

TB:

Total number of cases: 186

Cases under treatment: 75

Defaulters: 21

Deaths: 11

Treatment failure: 0

Transfer Out: 3

16.3% increase in

number of TB cases

compared to 160 in 2012

4.5% reduction in

defaulters rate compared

to 22 in 2012

Provide ITNs for All

Hospital Beds

All 223 beds in use in Agogo

Hospital have ITNs

All inpatients protected

against ward-acquired

malaria

Educate Clients on Daily

Basis at the OPD on

Malaria and TB

Prevention and Control

Daily morning devotion at OPD is

followed by health education of

clients on various topics including

malaria and TB prevention and

control

Clients knowledge on

malaria and TB

prevention and control

improved

66

OBJECTIVE 8: TO SPREAD THE GOSPEL THROUGH HEALTH SERVICE

DELIVERY

ACTIVITY OUTPUT OUTCOME

STRATEGY (I) Intensify Chaplaincy Activities

Make the Chaplain a

Member of the Clinical

Team – Agogo Hospital

Chaplain is an active

member of the clinical

team; takes part in daily

review of cases in the

Accident and Emergency

Department

Presence of the Chaplaincy

Department much felt in the

hospital through counselling of

clients

Draw and Implement a

Devotional Plan for

Clients and Staff

Yearly devotional plan

drawn for clients and staff,

Agogo Hospital

Number of Lay Preachers

enlisted: 16

Good News preached to

Patients/clients and staff on a

continuous basis to increase

their faith in the Lord

67

Draw and Implement a

Devotional Plan for

Clients and Staff

Number of devotional

services held for clients per

week:

Medical Ward: 5

Main OPD: 5

Eye OPD: 5

Antenatal Clinic: 2

Two (2) devotional services

held for staff per week in

the Hospital Chapel

Good News preached to

Patients/clients and staff on a

continuous basis to increase

their faith in the Lord

Carry out Daily Bedside

Visitations

Average number of Bedside

visitations per month by

Chaplain: 27

Theatre visitations by

Chaplain in the year: 2

Patients’ hope of recovery

boosted

Patients apprehension allayed

to undergo surgery

68

Organize Counselling

for Clients and Staff –

Agogo Hospital

Number of patients/clients

counselled during year: 8

Number of staff counselled

during year: 5

Alcoholic patients counselled

stopped drinking

Patients with suicidal

tendencies were helped to cope

with the difficulties they were

going through

Patients who declined surgery

initially were emboldened to

undergo the procedure

successfully

Organize End of Year

Carols Night Events

Carols night was

successfully organized on

20th December, 2013, at

Agogo Hospital

Impressive attendance by staff/

relatives and patients

The significance of Christmas

made real

69

Organize Social Support

for Needy Clients, Agogo

Hospital

Number of Needy Clients

supported: 5

Nature of support:

Free Treatment

Feeding

Transportation

Expenditure involved:

GHȼ2,684.00

Improved health of needy

clients

70

OBJECTIVE 9: IMPROVE COLLABORATION AND NETWORKING WITH

MOH/GHS/CHAG AND OTHER STAKEHOLDERS

ACTIVITY OUTPUT OUTCOME

STRATEGY (I) Deepen Existing Relations

Attend Quarterly

DHMT Meetings

DHMT meetings attended:

Agogo PHC: 4

Assin Nsuta H/C: 4

Sustained collaboration

Institutions kept up-to-date on

information from MOH/GHS

and vice-versa

Attend CHAG Annual

Delegates Meetings

CHAG Annual Delegates

conference attended by:

Agogo Hospital

Agogo PHC

Assin Praso H/C

Assin Nsuta H/C

Enchi PHC

Sustained collaboration

Institutions kept up-to-date on

information from CHAG

71

Attend Quarterly

General Manager’s

Meetings

Two (2) meetings were

attended by the General

Manager

Common challenges

discussed by all General

Managers for better service

delivery

Attend Association

Meetings for the various

Professional Groups

Annual meetings of the

following professional

groups/associations attended:

Pharmaceutical Society of

Ghana

Nurse Anaesthetist Group

Association of

Physiotherapists

Medical Assistants

Association

Paediatric Society of Ghana

Public Health Nurses Group

Staff updated on current

issues affecting their

respective professional

bodies for enhanced service

delivery

72

Collaborate with

Traditional Councils for

Quality Health Delivery

Traditional council still

represented on Area BoardSustained collaboration

Collaborate with

Malaria Vaccine Trial

Group

The third phase (MAL 055)

Has ended with no adverse

effect seen

MAL 063 also begun in May

2012

MAL 055 final result is yet

to be published

MAL 063 is on-going

30% of generator fuel cost

borne by Malaria Vaccine Trial

Group

Fuel cost burden lessened

73

Collaborate with

Foreign Partners for

Quality Health Delivery

The sixth seconded Doctor

(Dermatologist) from the

German Army started her six-

month tour of duty in July

Dermatological care

enhanced

Placement of eleven (11)

students from Medical Schools

in the Netherlands, Germany,

Australia, Switzerland,

England, for clinical elective

training

GHȼ4,090.00 realized from

clinical elective fee payments

Training successfully

completed

International recognition of

Agogo Hospital as

accredited centre for clinical

electives

74

Collaborate with

Foreign Partners for

Quality Health Delivery

Installation of donated

Transformer and Electrical

materials by Volketswil

Congregation, Switzerland,

through the collaborative

effort of the Ghana-Swiss

Technician Group completed

February 2013

Stable power supply ensured

Life span of Hospital

Equipment prolonged

Collaborate with

Training Institutions to

offer Practical Training

to Students

35 trainees from 25 training

institutions were given training

attachment/orientation by

Agogo Hospital

Contribution of hospital to

human resource

development of the country

OBJECTIVE: TO IMPROVE QUALITY OF CARE

Build Modern Toilet

for the OPD to replace

an old KVIP

Agogo HospitalLack of reliable source of water for the

project

Establish Assets

Replacement FundsAll Facilities

Cash flow problems throughout the

year as consequence of delayed

payment of health insurance claims

made this impossible

Build Staff

AccommodationAll Facilities Lack of funds

75

PLANNED ACTIVITIES NOT EXECUTED AND REASONS FOR NON-

PERFORMANCE

76

Complete the

Construction of the

new site to vacate the

current rented

premises

Assin Nsuta

Lack of funds

Agencies contacted did not respond

favourably to the request for financial

assistance

OBJECTIVE: INCREASE EFFICIENCY IN RESOURCE UTILIZATION

Establish LAN for

Clinical and Other

Relevant Departments

Agogo Hospital Project will commence early next year

Computerize Stores All Facilities Lack of funds

77

Carry out Yearly Peer

Review of PHS Sister

Institutions

Agogo Hospital

Exercise was not accorded priority

attention for 2013

Carry out Field Trips

to Facilities Acclaimed

as Centres of

Excellence

Undertake Annual

Management RetreatLack of funds

BIOSTATISTICS

SERVICE OUTPUTS

SERVICE

2013 TARGET 2013 ACTUAL

HOSP.

PHCs/

Health

Centres

TOTAL HOSP.

PHCs/

Health

Centres

TOTAL

OPD Attendance 155506 127348 282854 134758 146677 281435

Admissions 11208 - 11208 12930 - 12930

Surgical Op (Gen) 3500 - 3500 3366 - 3366

Surgical Op (Eye) 900 - 900 859 - 859

Sup. Deliveries 2080 829 2,909 2144 998 3142

Lab. Invest. 97592 21347 118939 84556 13855 98411

X-Ray Invest. 6800 - 6800 7056 - 7056

Ultrasound Inv. 3500 300 3800 4012 - 401278

SERVICE

2013 TARGET 2013 ACTUAL

HOSP.

PHCs/

Health

Centres

TOTAL HOSP.

PHCs/

Health

Centres

TOTAL

Antenatal Visits 13930 12000 25930 2092 3397 5489

Postnatal Visits 2130 1271 2520 1429 1404 2833

Neonatal Deaths - - - 34 - 34

Maternal Deaths - - - 8 - 8

Stillbirths - - - 65 - 65

Total Deaths - - - 380 - 380

HIV SCREENING: - - - -

Patients - - - 1038 - 1038

No. Positive - - - 226(21.8%) - 226(21.8%)

Donors - - - 2983 - 2983

No. Positive - - - 192(6.4%) - 192(6.4%)

Buruli Ulcer - - - 47 - 47

SERVICE OUTPUTS

79

OUTPATIENT ATTENDANCE - TREND

INSTITUTION 2009 (%) 2010 (%) 2011 (%) 2012 (%) 2013 (%)

Agogo Hospital

Assin Praso

Assin Nsuta

Kwahu Praso

Agogo PHC

Enchi PHC

Kom Clinic

125668 (60.2)

12544 (6.0)

18262 (8.8)

12693 (6.1)

4982 (2.4)

34467 (16.5)

-

167739 (58.4)

18733 (6.5)

42741 (14.9)

11706 (4.1)

4484 (1.6)

41944 (14.6)

-

144068 (52.7)

25250 (9.2)

51141 (18.7)

-

3225 (1.2)

49763 (18.2)

-

149230 (55.8)

24609 (9.2)

45007 (16.8)

-

3930 (1.5)

44666 (16.7)

-

134758(47.9)

30997 (11.0)

40571(14.4)

25919(9.2)

4107(1.5)

33741(12.0)

11342 (4.0)

TOTAL 208616 287347 273447 267442 28143580

OUTPATIENT ATTENDANCE - TREND

208616

287347273447 267442

281435

0

50000

100000

150000

200000

250000

300000

350000

2009 2010 2011 2012 2013

81

ADMISSIONS - TREND

INSTITUTION 2009 2010 2011 2012 2013

Agogo Hospital 9719 11449 11748 12092 12930

82

ADMISSIONS - TREND

0

2000

4000

6000

8000

10000

12000

14000

2009 2010 2011 2012 2013

9719

11449 11748 1209212930

83

ANTENATAL REGISTRANTS - TREND

INSTITUTION 2009 (%) 2010 (%) 2011 (%) 2012 (%) 2013 (%)

Agogo Hospital

Assin Praso

Assin Nsuta

Kwahu Praso

Agogo PHC

Enchi PHC

Kom Clinic

1784 (32.9)

844 (15.5)

559 (10.3)

383 (7.1)

727 (13.4)

1131 (20.8)

-

1985 (34.0)

680 (11.6)

803 (13.7)

384 (6.6)

423 (7.2)

1568 (26.8)

-

2067 (39.9)

747 (14.4)

835 (16.1)

-

443 (8.5)

1094 (21.1)

-

2216 (38.3)

616(10.7)

713(12.3)

-

596 (10.3)

1641 (28.4)

-

2092 (38.1)

604 (11.0)

726 (13.2)

-

594 (10.8)

1124 (20.5)

349 (6.4)

TOTAL 5428 5843 5186 5782 5489

84

ANTENATAL REGISTRANTS - TREND

4800

4900

5000

5100

5200

5300

5400

5500

5600

5700

5800

5900

2009 2010 2011 2012 2013

5428

5843

5186

5782

5489

85

SUPERVISED DELIVERIES - TREND

INSTITUTION 2009 (%) 2010 (%) 2011 (%) 2012 (%) 2013 (%)

Agogo Hospital

Assin Praso

Assin Nsuta

Kwahu Praso

Agogo PHC

Enchi PHC

Kom Clinic

1713 (62.7)

300 (11.0)

297 (10.9)

167 (6.1)

181 (6.6)

75 (2.7)

-

1906 (64.7)

324 (11.0)

303 (10.3)

138 (4.7)

156 (5.3)

118 (4.0)

-

2085 (64.9)

442 (13.8)

366 (11.4)

-

178 (5.5)

140 (4.4)

-

2099 (70.5)

286 (9.6)

246 (8.3)

-

234 (7.9)

113 (3.8)

-

2144 (68.2)

281 (8.9)

383 (12.2)

-

140 (4.5)

70 (2.2)

124 (3.9)

TOTAL 2733 2945 3211 2978 3142

86

SUPERVISED DELIVERIES - TREND

2400

2500

2600

2700

2800

2900

3000

3100

3200

3300

2009 2010 2011 2012 2013

2733

2945

3211

2978

3142

87

POSTNATAL REGISTRANTS - TREND

INSTITUTION 2009 (%) 2010 (%) 2011 (%) 2012 (%) 2013 (%)

Agogo Hospital

Assin Praso

Assin Nsuta

Kwahu Praso

Agogo PHC

Enchi PHC

Kom Clinic

1387 (43.5)

338 (10.6)

297 (9.3)

167 (5.2)

727 (22.8)

276 (8.6)

-

1420 (45.5)

345 (11.0)

358 (11.5)

338 (10.8)

180 (5.8)

482 (15.4)

-

1622 (50.0)

441 (13.6)

606 (18.7)

-

175 (5.4)

399 (12.3)

-

1521 (44.8)

307 (9.1)

345 (10.2)

-

687 (20.3)

533 (15.7)

-

1429 (50.4)

337 (11.9)

396 (14.0)

-

194 (6.8)

353 (12.5)

124 (4.4)

TOTAL 3192 3123 3243 3393 2833

88

POSTNATAL REGISTRANTS - TREND

2500

2600

2700

2800

2900

3000

3100

3200

3300

3400

2009 2010 2011 2012 2013

31923123

3243

3393

2833

89

REPRODUCTIVE AND CHILD HEALTH ACTIVITIES

(FAMILY PLANNING)

INSTITUTION 2009 (%) 2010 (%) 2011 (%) 2012 (%) 2013 (%)

Agogo PHC

Assin Praso

Assin Nsuta

Kwahu Praso

Enchi PHC

Kom Clinic

3238 (47.8)

818 (12.1)

883 (13.0)

1158 (17.1)

678 (10.0)

-

2074 (40.0)

342 (6.6)

912 (17.6)

1103 (21.3)

749 (14.5)

-

2334 (53.8)

450 (10.4)

1398 (32.2)

-

154 (3.6)

-

2630 (50.3)

1278 (24.5)

1044 (20.0)

-

272 (5.2)

-

2900 (35.8)

1535 (19.5)

829 (10.5)

-

541 (6.9)

2074 (26.3)

TOTAL 6775 5180 4336 5224 7879

90

REPRODUCTIVE AND CHILD HEALTH ACTIVITIES

(FAMILY PLANNING)

0

1000

2000

3000

4000

5000

6000

7000

8000

2009 2010 2011 2012 2013

6775

51804336

5224

7879

91

REPRODUCTIVE AND CHILD HEALTH ACTIVITIES

(CWC 0 – 23 MONTHS)

INSTITUTION 2009 (%) 2010 (%) 2011 (%) 2012 (%) 2013 (%)

Agogo PHC

Assin Praso

Assin Nsuta

Kwahu Praso

Enchi PHC

Kom Clinic

3238 (53.7)

729 (12.1)

657 (10.9)

976 (16.2)

434 (7.2)

-

3525 (55.8)

586 (9.3)

583 (9.2)

1060 (16.8)

565 (8.9)

-

3297 (71.2)

513 (11.1)

365 (7.9)

-

458 (9.9)

-

4528 (66.4)

542 (8.0)

776 (11.4)

-

974 (14.3)

-

4759 (60.4)

526 (6. 7)

379 (4.8)

-

1413 (17.9)

801 (10.2)

TOTAL 6034 6319 4633 6820 7878

92

REPRODUCTIVE AND CHILD HEALTH ACTIVITIES

(CWC 0 – 23 MONTHS)

0

2000

4000

6000

8000

2009 2010 2011 2012 2013

6034 6319

4633

6820

7878

93

SURGERIES – AGOGO HOSPITAL

TYPE 2009 2010 2011 2012 2013

General:

Major

Minor

821

1213

816

1297

628

1375

621

1375

642

1569

Sub-Total 2034 2113 2003 1996 2078

O & G:

Major

Minor

535

399

528

351

720

511

887

728

743

646

Sub-Total 934 879 1231 1615 1389

Eye:

Major

Minor

869

241

853

254

843

178

785

163

746

113

Sub-Total 1110 1107 1021 948 8 59

Grand Total 4078 4099 4255 4559 4326

94

SURGERIES - TREND

3800

3900

4000

4100

4200

4300

4400

4500

4600

2009 2010 2011 2012 2013

4078 4099

4255

4559

4326

95

LABORATORY INVESTIGATIONS - TREND

TYPE 2009 2010 2011 2012 2013

Serology

Biochemistry

Parasitology

Bacteriology

Haemotology

Others

18472

18700

23805

1595

30255

1424

22291

15274

28159

1182

31934

1821

20830

13897

21668

952

25666

2063

18768

16383

22423

788

22408

1812

19792

23742

21534

899

16667

1922

TOTAL 94251 100661 85076 82582 84556

96

LABORATORY INVESTIGATIONS - TREND

0

20000

40000

60000

80000

100000

120000

2009 2010 2011 2012 2013

94251100661

85076 82582 84556

97

X-RAY INVESTIGATIONS - TREND

TYPE 2009 2010 2011 2012 2013

Skull/Mandible/Sinuses

Chest

Upper Extremities

Lower Extremities

Abdomen

Hip & Pelvis

Spinal Column

Histerosalpingogram

222

3513

610

852

314

259

407

189

315

3579

708

769

345

424

539

188

242

3316

665

999

244

360

444

191

284

3018

670

718

240

261

433

166

283

3953

712

905

262

312

485

144

TOTAL 6366 6867 6461 5790 7056

98

X-RAY INVESTIGATIONS - TREND

0

1000

2000

3000

4000

5000

6000

7000

8000

2009 2010 2011 2012 2013

63666867

6461

5790

7056

99

ULTRASOUND INVESTIGATIONS - TREND

INSTITUTION 2009 2010 2011 2012 2013

Agogo Hospital 1531 1618 2380 4323 4012

100

ULTRASOUND INVESTIGATIONS - TREND

0

500

1000

1500

2000

2500

3000

3500

4000

4500

2009 2010 2011 2012 2013

1531 1618

2380

4323

4012

101

MORTALITY - TREND

TYPE 2009 2010 2011 2012 2013

Maternal Deaths

Stillbirths

Neonatal Deaths

All other Deaths

6

60

54

204

5

71

49

215

8

62

86

225

6

75

36

243

7

65

34

274

TOTAL 324 340 381 360 380

102

MORTALITY - TREND

290

300

310

320

330

340

350

360

370

380

390

2009 2010 2011 2012 2013

324

340

382

360

380

103

DEATHS BY CLINICAL DEPARTMENT

DEP’T 2009 (%) 2010 (%) 2011 (%) 2012 (%) 2013 (%)

A &E

Surgical

Medical

Obst./Gynae

Paediatrics

89 (27.5)

22 (6.8)

109 (33.6)

7 (2.2)

97 (29.9)

96 (28.2)

25 (7.4)

112 (32.9)

5 (1.5)

102 (30.0)

106 (27.8)

9 (2.4)

120 (31.5)

9 (2.4)

137 (36.0)

84 (23.3)

41 (11.4)

118 (32.8)

8 (2.2)

109 (30.3)

94 (24.7)

15 (3.9)

166 (43.7)

9 (2.4)

96 (25.3)

TOTAL 324 340 381 360 380

104

MALARIA CASES - AGOGO HOSPITAL

OUT-PATIENT DEPARTMENT

2009 2010 2011 2012 2013

Total No. of Cases

Total No. of Cases < 5 yrs

% of Cases < 5 yrs

15423

3632

23.6

17117

4245

24.8

15475

3745

24.2

13165

3525

26.8

15656

4058

25.9

105

MALARIA CASES - AGOGO HOSPITAL

IN-PATIENT DEPARTMENT (ADMISSIONS)

2009 2010 2011 2012 2013

Total No. of Cases

Total No. of Cases < 5 yrs

% of Cases < 5 yrs

2441

1229

50.4

2304

1247

54.1

1639

941

57.4

1099

629

57.2

1855

1200

64.7

106

MALARIA CASES - AGOGO HOSPITAL

DEATHS

2009 2010 2011 2012 2013

Total No. of Deaths

Total No. of Deaths < 5 yrs

% of Deaths < 5 yrs

18

13

72.2

7

4

57.1

12

8

66.7

8

7

87.5

16

9

56.3

107

TUBERCULOSIS - AGOGO HOSPITAL

2009 2010 2011 2012 2013

Total No. of Cases

Cases Under Treatment

Defaulters

Deaths

Treatment Failure

Relapses

Transfer Out

Cure

Completed

119

62

12

6

-

9

3

-

-

156

51

37

9

1

-

2

-

-

154

51

32

12

2

12

2

16

41

160

95

22

4

1

-

1

9

28

186

75

21

11

-

-

3

22

54

108

EXPANDED PROGRAMME ON IMMUNIZATION (EPI) COVERAGE

B C G

TARGET

POP

NO.

IMM.

%

COV.

AGOGO PHC 2164 2574 118.95

ASSIN PRASO 339 319 94.10

ASSIN NSUTA 477 470 98.53

KOM CLINIC 112 177 158.04

ENCHI357

536 150.14

109

-

20.0

40.0

60.0

80.0

100.0

120.0

140.0

160.0

PERCENTAGE IMMUNIZED

150.6

82.2

101.1

158.0

81.0

AGOGO PHC

ASSIN PRASO

ASSIN NSUTA

KOM CLINIC

ENCHI

110

EXPANDED PROGRAMME ON IMMUNIZATION (EPI) COVERAGE

MEASLES

TARGET

POP

NO.

IMM.

%

COV.

AGOGO PHC 2164 1991 92.9

ASSIN PRASO 339 246 72.57

ASSIN NSUTA 477 344 72.12

KOM CLINIC 112 347 309.82

ENCHI 357 556 155.74

111

-

50.0

100.0

150.0

200.0

250.0

300.0

350.0

PERCENTAGE IMMUNIZED

103.9

58.3

97.4

309.8

87.4

AGOGO PHC

ASSIN PRASO

ASSIN NSUTA

KOM CLINIC

ENCHI

112

EXPANDED PROGRAMME ON IMMUNIZATION (EPI) COVERAGE

PENTA III

TARGET

POP

NO.

IMM.

%

COV.

AGOGO PHC 2164 2062 95.29

ASSIN PRASO 339 226 66.67

ASSIN NSUTA 477 406 85.12

KOM CLINIC 112 234 208.93

ENCHI 357 515 144.26

113

-

50.0

100.0

150.0

200.0

250.0

PERCENTAGE IMMUNIZED

100.3

74.3

92.5

208.9

92.8

AGOGO PHC

ASSIN PRASO

ASSIN NSUTA

KOM CLINIC

ENCHI

114

EXPANDED PROGRAMME ON IMMUNIZATION (EPI) COVERAGE

OPV 3

TARGET

POP

NO.

IMM.

%

COV.

AGOGO PHC 2164 2062 95.29

ASSIN PRASO 339 234 69.03

ASSIN NSUTA 477 406 85.12

KOM CLINIC 112 234 208.93

ENCHI 357 554 155.18

115

-

50.0

100.0

150.0

200.0

250.0

PERCENTAGE IMMUNIZED

100.3

75.0

101.3

208.9

92.8

AGOGO PHC

ASSIN PRASO

ASSIN NSUTA

KOM CLINIC

ENCHI

116

EXPANDED PROGRAMME ON IMMUNIZATION (EPI) COVERAGE

YELLOW FEVER

TARGET

POP

NO.

IMM.

%

COV.

AGOGO PHC 2164 1991 92.01

ASSIN PRASO 339 247 72.86

ASSIN NSUTA 477 344 72.12

KOM CLINIC 112 193 172.32

ENCHI 357 556 155.74

117

-

20.0

40.0

60.0

80.0

100.0

120.0

140.0

160.0

180.0

PERCENTAGE IMMUNIZED

103.9

144.8

97.4

172.3

87.4

AGOGO PHC

ASSIN PRASO

ASSIN NSUTA

KOM CLINIC

ENCHI

118

EXPANDED PROGRAMME ON IMMUNIZATION (EPI) COVERAGE

T T 2

TARGET

POP

NO.

IMM.

%

COV.

AGOGO PHC 2164 3159 145.98

ASSIN PRASO 339 684 201.77

ASSIN NSUTA 477 762 159.75

KOM CLINIC 112 - -

ENCHI 357 710 198.88

119

-

20.0

40.0

60.0

80.0

100.0

120.0

140.0

160.0

180.0

PERCENTAGE IMMUNIZED

167.6

55.0

163.9

-

125.6

AGOGO PHC

ASSIN PRASO

ASSIN NSUTA

KOM CLINIC

ENCHI

120

BED UTILIZATION INDICES - AGOGO HOSPITAL

INDEX 2009 2010 2011 2012 2013

Average Daily Bed

Occupancy164 163 167 165 164

Occupancy Rate 73.4% 73.1% 75.1% 74.0% 73.4

Average Length of Stay 6 Days 5 Days 5 Days 5 Days 5 Days

Turnover Per Bed 43 Pts 51 Pts 52 Pts 54 Pts 58 Pts

Turnover Interval 2 Days 2 Days 2 Days 2 Days 2 Days

Death Rate 3.4% 3.0% 3.3% 3.0% 3.0%

121

MORBIDITY AND MORTALITY STATISTICS

TOP TEN (10) OPD CASES – AGOGO HOSPITAL

NO.

2012 2013

DISEASENO. OF

CASES

% OF

ALL

CASES

DISEASENO. OF

CASES

% OF

ALL

CASES

1 Malaria 13165 9.15 Malaria 15491 13.90

2 Acute Eye Infection 12129 8.43 Cough/Cold (URTI) 9535 8.56

3 Cough & Cold (URTI) 10415 7.24 Acute Eye Infections 6312 5.66

4 Gynae. Conditions 4291 2.98 Gynecological Conditions 4146 3.72

5 U. T. I. 4130 2.87 Acute Urinary Tract Inf. 4028 3.61

6 P. U. D. 3670 2.55 PUD 3662 3.29

7 Skin Diseases & Ulcer 2752 1.91 Skin Diseases & Ulcers 2801 2.51

8 Preg. & Related 2486 1.73 Acute Ear Infection 1566 1.41

9 Lower Abdominal Pain 2052 1.43 Anaemia 1456 1.31

10 Road Traffic 1489 1.03 Lower Abdominal Pain 1452 1.30

122

TOP TEN (10) CAUSES OF ADMISSION – AGOGO HOSPITAL

NO.

2012 2013

DISEASENO. OF

CASES

% OF

ALL

CASES

DISEASENO. OF

CASES

% OF

ALL

CASES

1 Malaria 1397 10.78 Malaria 1977 15.77

2 Skin Diseases & Ulcer 919 7.09 Gynecological Cond. 720 5.74

3 Hypertension 777 6.00 Hypertension 701 5.59

4 Gynae. Conditions 604 4.66 Skin Diseases & Ulcers 642 5.12

5 Cataract 586 4.52 Cataract 630 5.03

6 Septicaemia 502 3.87 Septicaemia 554 4.42

7 Pneumonia 502 3.87 Preg. Related Compl. 527 4.20

8 Preg. & Related 492 3.80 Severe Pneumonia 489 3.90

9 Prematurity 442 3.41 Anaemia 358 2.86

10 Anaemia 388 2.99 Malnutrition 303 2.42

123

TOP TEN (10) COMMUNICABLE – AGOGO HOSPITAL

NO.

2012 2013

DISEASENO. OF

CASES

% OF

ALL

CASES

DISEASENO. OF

CASES

% OF

ALL

CASES

1 Malaria 13165 93.64 Malaria 15491 94.28

2 HIV/AIDS 439 3.12 HIV/AIDS 355 2.16

3 Viral Hepatitis 187 1.33 Tuberculosis 240 1.46

4 Chicken Pox 122 0.87 Viral Hepatitis 162 0.99

5 Buruli Ulcer 52 0.37 Chicken Pox 89 0.54

6 Tuberculosis 31 0.22 Buruli Ulcer 36 0.22

7 Schistosomiasis 26 0.18 Typhoid Fever/Perf. 26 0.16

8 Typhoid Fever/Perf. 16 0.11 Measles 10 0.06

9 Intestinal Worm 16 0.11 Schistosomiasis 9 0.05

10 Other Meningitis 5 0.04 Intestinal Worm 9 0.05

124

TOP TEN (10) CAUSES OF DEATH – AGOGO HOSPITAL

NO.

2012 2013

DISEASENO. OF

CASES

% OF

ALL

CASES

DISEASENO. OF

CASES

% OF

ALL

CASES

1 Pneumonia 54 15.00 Sev. Pneumonia 45 11.84

2 Anaemia 23 6.39 Septicaemia 35 9.21

3 Liver Cirrhosis 23 6.39 Anaemia 29 7.63

4 Tuberculosis 20 5.56 Tuberculosis 27 7.11

5 C V A 19 5.28 Liver Cirrhosis 22 5.79

6 Cardiac Diseases 17 4.72 HIV/AIDS 20 5.26

7 Prematurity 15 4.17 Cardiac Diseases 17 4.47

8 HIV/AIDS 14 3.89 Severe Malaria 16 4.21

9 Malaria 12 3.33 C V A 16 4.21

10 Hypertension 9 2.50 Prematurity 15 3.95

125

CASE FATALITY RATE – AGOGO HOSPITAL

NO

2012 2013

DISEASE RATE DISEASE RATE

1 Pneumonia 10.76 Sev. Pneumonia 56.25

2 Anaemia 5.93 Septicaemia 6.32

3 Liver Cirrhosis 40.35 Anaemia 8.10

4 Tuberculosis 14.18 Tuberculosis 14.10

5 C V A 8.48 Liver Cirrhosis 28.95

6 Cardiac Diseases 24.64 Hiv/Aids 10.58

7 Prematurity 3.39 Cardiac Diseases 45.95

8 HIV/AIDS 8.05 Severe Malaria 0.81

9 Malaria 0.86 C V A 6.72

10 Hypertension 1.16 Prematurity 15.15

126

MORTALITY RATIOS – AGOGO HOSPITAL

2009 2010 2011 2012 2013

Maternal Mortality (per 100,000

Life Births)414 264 381 290 329

Neonatal Mortality (per 1,000 Life

Births)32.0 25.9 40.9 17.4 16.0

Stillbirths (per 1,000 Births) 34.3 36.2 28.7 34.9 29.7

Death Rate (% of all Admissions) 3.4 3.0 3.3 3.0 3.0

127

OTHER PERFORMANCE INDICATORS

UTILIZATION INDICATORS – AGOGO HOSPITAL

INDICATOR 2009 2010 2011 2012 2013

OPD COVERAGE: OPD

visits per capita0.74 0.94 0.78 0.79 1.72

INPATIENT COVERAGE:

Hospital Admissions per

1000 – coverage population

56.88 64.80 64.30 63.64 165.37

PROPORTION of Hospital

Deliveries as a % of

Expected Deliveries in

Catchment Population

25.08 27.02 28.50 27.62 11.82

128

INDICATOR 2009 2010 2011 2012 2013

Average Monthly

Admissions per Doctor43 50 52 53 49

Average Patient-Day

Equivalents per Nurse per

Day

2.61 2.93 1.70 1.68 1.90

Average Patient-Day

Equivalents per Staff

Member per Day

0.72 0.82 0.58 0.57 0.33

WORKLOAD INDICATORS – AGOGO HOSPITAL

129

QUALITY INDICATORS – AGOGO HOSPITAL

INDICATOR 2009 2010 2011 2012 2013

CAESARIAN COVERAGE:

Caesarian Sections as a % of

total expected deliveries in

catchment area

5.6 6.4 6.2 8.1 3.2

LABORATORY TEST:

Per Admission

Per 3 OPD Visits9.7

2.3

8.8

1.8

7.2

1.8

6.8

1.7

6.5

1.9

X-RAYS:

Per Admission

Per 3 OPD Visits

0.7

0.2

0.6

0.1

0.5

0.1

0.48

0.12

0.55

0.16

Ratio of Surgical Cases per

Admission0.4 0.4 0.4 0.38 0.34

130

FINANCE

INCOME & EXPENDITURE ACCOUNT

INCOME ITEMS

2013 BUDGET (GH¢) 2013 ACTUAL (GH¢)

HOSPITAL

PHCS/

HEALTH

CENTRES

TOTAL HOSPITAL

PHCS/

HEALTH

CENTRES

TOTAL

Govt. Subvention:

Salaries/Allow. 6,000,000.00 494,113.00 6,494,113.00 5,939,123.40 529,636.28 6,468,759.68

Service/Adm - 9,975.60 9,975.60 - 3,809.60 3,809.60

Electricity 80,0000.00 - 80,0000.00 - - -

Water 15,000.00 - 15,000.00 - - -

Fees/Other Charges 2,295,725.00 644,141.85 2,939,866.85 2,550,802.49 759,180.00 3,309,982.59

Sale of Drugs 3,050,000.000 1,008,400.00 4,058,400.63 3,261,848.39 1,159,213.26 4,421,061.65

Local Donations 22,000.00 23,600.00 45,600.00 15,624.40 29,750.59 45,374.40

Part/Fri. Overseas 10,000.00 29,004.64 39,004.64 600.00 11,700.59 12,300.59

Miscellaneous 211,500.00 12,666.65 224,166.65 227,554.43 247,363.46 474,917.89

TOTAL 11,684,225.00 2,221,902.37 13,906,127.37 11,995,553.11 2,740,653.29 14,736,206.40

131

Salaries/Allow.

43.90%

Service/Adm

0.03%

Fees/Other

Charges

22.46%

Sale of Drugs

30.00%

Local Donations

0.31%

Part/Fri.

Overseas

0.08%

Miscellaneous

3.22%

INCOME

132

EXPENDITURE

ITEMS

2013 BUDGET (GH¢) 2013 ACTUAL (GH¢)

HOSPITAL

PHCS/

HEALTH

CENTRES

TOTAL HOSPITAL

PHCS/

HEALTH

CENTRES

TOTAL

Govt. Sal./Allow. 6,000,000.00 494,113.00 6,494,113.00 5,939,123.40 529,636.28 6,468,759.68

Church Sal./Allow. 1,541,849.50 440,147.86 1,981,997.36 1,690,673.82 405,560.09 2,096,233.91

Staff Med. Subsidy 11,600.00 8,573.08 20,173.08 20,278.58 1,057.20 21,335.78

P & S Subsidy 9,060.00 4,772.48 13,832.48 10,578.00 3,183.90 13,761.90

Drugs 1,823,000.00 887,083.52 2,710,083.52 1,827,474.97 671,975.62 2,499,450.59

Med. Consumables 872,625.00 172,584.44 1,045,209.44 780,159.85 135,633.69 915,793.54

Maint. (Assets) 211,300.00 18,781.49 230,081.49 180,559.51 69,186.80 249,746.31

Fuel & Lubricants 86,000.00 44,025.20 130,025.20 93,016.60 44,721.70 137,738.30

Staff Trg. & Dev. 43,400.00 27,889.55 71,289.55 58,972.50 10,975.00 69,947.50

Utilities 63,175.00 20,108.15 83,283.15 29,329.06 5,947.22 35,276.28

Miscellaneous 538,096.50 262,071.02 800,167.52 517,670.88 201,237.85 718,908.73

Depreciation of Assets - - - 268,056.09 198,414.93 466,471.02

TOTAL 11,200,106.00 2,380,149.79 13,580,255.79 11,415,893.26 2,277,530.28 13,693,423.54

SURPLUS/DEFICIT 484,119.00 -158,247.42 325,871.58 579,659.85 463,123.01 1,042,782.86

133

Govt. Sal./Allow. 47.24%

Church Sal./Allow.

15.31%

Staff Med. Subsidy 0.16%

P & S Subsidy 0.10%

Drugs 18.25%

Med. Consumables

6.69%

Maint. (Assets) 1.82%

Fuel & Lubricants

1.01%

Staff Trg. & Dev. 0.51%

Utilities 0.26% Miscellaneous

5.25%Depreciation of

Assets 3.41%

EXPENDITURE

134

INCOME ITEM BUDGET ACTUAL

VARIANCE

AMOUNT %

Govt. Subvention:

Salaries/Allow. 6,494,113.00 6,468,759.00 -25,353.32 -0.39

Service/Adm 9,975.60 3,809.60 -6,166.00 -61.81

Electricity 80,000.00 - -80,000.00 -100.00

Water 15,000.00 - -15,000.00 -100.00

Fees/Other Charges 2,939,866.85 3,309,982.59 370,115.74 12.59

Sale of Drugs 4,058,400.63 4,421,061.65 362,661.02 8.94

Local Donations 45,600.00 45,374.40 -225.60 -0.49

Part/Fri. Overseas 39,004.64 12,300.59 -26,704.05 -68.46

Miscellaneous 224,166.65 474,917.89 250,751.24 111.86

TOTAL 13,906,127.37 14,736,206.40 830,079.03 5.97

135

EXPENDITURE ITEM BUDGET ACTUALVARIANCE

AMOUNT %

Govt. Sal./Allow. 6,494,113.00 6,468,759.68 25,353.32 0.39

Church Sal./Allow. 1,981,997.36 2,096,233.91 -114,236.55 -5.76

Staff Med. Subsidy 20,173.08 21,335.78 -1,162.70 -5.76

P & S Subsidy 13,832.48 13,761.90 70.58 0.51

Drugs 2,710,083.52 2,499,450.59 210,632.93 7.77

Med. Consumables 1,045,209.44 915,793.54 129,415.90 12.38

Maint. (Assets) 230,081.49 249,746.31 -19,664.82 -8.55

Fuel & Lubricants 130,025.20 137,738.30 -7,713.10 -5.93

Staff Trg. & Dev. 71,289.55 69,947.50 1,342.05 1.88

Utilities 83,283.15 35,276.28 48,006.87 57.64

Miscellaneous 800,167.52 718,908.73 81,258.79 10.16

Depreciation - 466,471.02 -466,471.02

TOTAL 13,580,255.79 13,693,423.54 -113,167.75 -0.83

SURPLUS/DEFICIT 325,871.58 1,042,782.86 716,911.28 219.9

136

DESCRIPTION INSTITUTIONAMOUNT

(GH¢)

SOURCE OF

FUNDING

Constructional Works

(Rehabilitation)

Agogo Hospital

Assin Praso H/C

Enchi PHC

225,067.78

1,270.00

6,239.00

IGF

IGF

IGF

SUB-TOTAL 232,576.78

Constructional Works

(New Projects)

Assin Nsuta H/C

Assin Praso H/C

12,187.00

10,558.90

IGF

IGF

SUB-TOTAL 22,745.90

SUMMARY OF DEVELOPMENT EXPENDITURE

137

Acquisition of New

Medical Equipment

Agogo Hospital

Assin Praso H/C

Enchi PHC

110,766.45

21,700.00

9,530.00

IGF

IGF

IGF

SUB-TOTAL 141,996.45

Acquisition of Non-

Medical Equipment/

Plant

Agogo Hospital

Assin Praso H/C

Assin Nsuta H/C

Enchi PHC

77,358.45

230.00

2,900.00

5,000.00

IGF

IGF

IGF

IGF

SUB-TOTAL 85,488.45

138

Major Rehabilitation of

Equipment, Plants,

Vehicles

Agogo Hospital 153,978.81 IGF

SUB-TOTAL 153,978.81

Acquisition of New

VehiclesAgogo Hospital 121,920.00 IGF

SUB-TOTAL 121,920.00

Acquisition of Furniture

Agogo Hospital

Assin Praso H/C

Enchi PHC

15,199.50

356.00

200.00

IGF

IGF

IGF

SUB-TOTAL 15,755.50

GRAND TOTAL 774,461.86

139

OPERATIONAL EFFICIENCY INDICATORS

AGOGO HOSPITAL2009

(GH¢)

2010

(GH¢)

2011

(GH¢)

2012

(GH¢)

2013

(GH¢)

Average Revenue per

OPD Attendance

Average Expenditure

per OPD Attendance

Margin

Average Revenue per

In-Patient Day

Average Expenditure

per In-Patient Day

Margin

10.65

9.74

0.91 (9.3%)

31.94

29.21

2.73 (9.3%)

9.82

8.55

1.27 (14.9%)

29.46

25.66

3.80 (14.8%)

23.82

20.14

3.68 (15.5%)

71.45

60.41

11.03 (15.4%)

50.62

48.20

2.42 (5.0%)

151.87

144.60

7.27 (5.0%)

69.12

65.78

3.34 (5.1%)

207.36

197.34

10.02(5.1%)

140

OPERATIONAL EFFICIENCY INDICATORS

141

ASSIN PRASO H/C2009

(GH¢)

2010

(GH¢)

2011

(GH¢)

2012

(GH¢)

2013

(GH¢)

Average Revenue per OPD

Attendance

Average Expenditure per

OPD Attendance

Margin

9.34

4.88

4.46

(91.4%)

9.94

7.43

2.51

(33.8%)

11.83

3.99

7.84

(66.2%)

18.81

10.57

8.24

(78.0%)

22.57

18.79

3.78

(20.1%)

OPERATIONAL EFFICIENCY INDICATORS

142

ASSIN NSUTA H/C2009

(GH¢)

2010

(GH¢)

2011

(GH¢)

2012

(GH¢)

2013

(GH¢)

Average Revenue per OPD

Attendance

Average Expenditure per

OPD Attendance

Margin

9.28

8.44

0.84

(47.5%)

8.50

6.30

2.20

(34.9%)

9.92

7.64

2.26

(22.8%)

16.60

14.47

2.13

(14.7%)

19.54

16.43

3.11

(18.9%)

OPERATIONAL EFFICIENCY INDICATORS

143

KWAHU PRASO H/C2009

(GH¢)

2010

(GH¢)

2011

(GH¢)

2012

(GH¢)

2013

(GH¢)

Average Revenue per

OPD Attendance

Average Expenditure per

OPD Attendance

Margin

-

-

-

4.16

5.78

(1.62)

-

-

-

-

-

-

10.61

7.61

3.0

(39.4%)

144

OPERATIONAL EFFICIENCY INDICATORS

ENCHI PHC2009

(GH¢)

2010

(GH¢)

2011

(GH¢)

2012

(GH¢)

2013

(GH¢)

Average Revenue per

OPD Attendance

Average Expenditure per

OPD Attendance

Margin

9.81

8.99

0.82

(9.1%)

8.28

13.94

-5.66

(-41.6)

20.46

13.40

7.06

(34.5%)

17.25

13.38

3.87

(28.9%)

18.02

20.01

-1.99

(-9.9%)

IMPLEMENTATION OF NATIONAL HEALTH INSURANCE

SCHEME

AGOGO HOSPITAL/EYE

Total No. of Cases

No. of Insured Cases

% of Insured Patients

Total IGF

Revenue from Insured

As a % of IGF

Total Reimbursement

Outstanding Reimbursement

134,758

123,136

91.4

GHȼ6,040,205.31

GHȼ4,291,702.23

71.1

GHȼ3,203,190.20

GHȼ1,088,512.03

145

IMPLEMENTATION OF NATIONAL HEALTH INSURANCE

SCHEME

146

ASSIN PRASO HEALTH CENTRE

Total No. of Cases

No. of Insured Cases

% of Insured Patients

Total IGF

Revenue from Insured

As a % of IGF

Total Reimbursement

Outstanding Reimbursement

30,997

27,274

88.0

GHȼ437,782.74

GHȼ380,184.79

86.8

GHȼ252,721.48

GHȼ127,463.31

IMPLEMENTATION OF NATIONAL HEALTH INSURANCE

SCHEME

147

ASSIN NSUTA HEALTH CENTRE

Total No. of Cases

No. of Insured Cases

% of Insured Patients

Total IGF

Revenue from Insured

As a % of IGF

Total Reimbursement

Outstanding Reimbursement

40,571

37,750

93.0

GHȼ606,810.50

GHȼ454,766.12

74.9

GHȼ271,459.71

GHȼ183,306.41

IMPLEMENTATION OF NATIONAL HEALTH INSURANCE

SCHEME

148

ENCHI PHC

Total No. of Cases

No. of Insured Cases

% of Insured Patients

Total IGF

Revenue from Insured

As a % of IGF

Total Reimbursement

Outstanding Reimbursement

33,741

31,757

94.1

GHȼ604,398.43

GHȼ405,262.89

67.1

GHȼ196,277.99

GHȼ208,984.90

AGOGO HOSPITAL

Acquisition of a Brand new Land Cruiser Prado

Establishment of a Dental Clinic

Renovation and extension of the Houseman flat to convert into a twin

bungalow to house two families

Repair works at the children’s ward which included roof leakages,

replacement of locks, louvre blades and frames, mosquito nets and

repair of cabinets

Renovation of Eye Theatre & Eye Ward by installation of glazing

windows and glass swing doors

149

MAIN ACHIEVEMENTS

150

AGOGO HOSPITAL

• On-going massive renovation of the Pharmacy block into an ultra-

modern facility (about 70% complete)

• Changing of Laboratory windows and doors to a glazing type and

swing door to meet international standards

• Donation of a mobile ultrasound machine worth €3,500.00 by Dr.

Lutz

• Donation of assorted medical equipment through the MoH

Equipment Replacement Programme

151

AGOGO PHC

• Staff actively participating in the malaria vaccine trial

• Buruli Ulcer cases reduced by 30%

• A new outreach point has been opened at Hwidiem to increase CWC

coverage

• Community Health Officers have been assigned to each electoral

area in Agogo. This has intensified School Health Activities and

Home Visits to trace defaulters

152

ASSIN PRASO HEALTH CENTRE

• Posting of Physician Assistant from CHAG to improve staffing

and to reduce workload on the sole Retired Physician assistant.

• Drilling and Mechanization of Borehole offering the facility self

sufficiency in water supply

• Acquisition of ultrasound machine to improve service delivery

• Major maintenance works on facility buildings

• Donation of medical equipment from USAid worth GH¢3,885.00

153

KWAHU PRASO HEALTH CENTRE

• Completion of Staff Bungalow for the Physician Assistants

• Acquisition of a Generator for the Centre

• Running of Eye Outreach Program with Agogo Presby Hospital

• Completion of staff bungalow and acquisition of laboratory

equipment through the support of Agogo Hospital

• Creation of a male ward and furnished with new hospital beds,

side lockers, etc

• Painting of all buildings of the facility

• Purchase of a new modern delivery bed for the maternity

154

ASSIN NSUTA HEALTH CENTRE

• Construction of nurses’ quarter in progress

• Construction of a pavilion to reduce congestion at the CWC

• Improved staff strength as two Health Assistants have been

posted to the facility

155

ENCHI PHC

• Posting of a Disease Control Officer and an Enrolled Nurse

• Purchase of a slit lamp for the eye unit

• Renovation of Amonie Presby Clinic completed and ready for

use

156

KOM CLINIC

• Average daily OPD attendance improved from 30 to 100 due to

the posting of a Physician Assistant to the clinic

• Kom Clinic in collaboration with Agogo Hospital Eye Unit

undertook 50 eye surgeries and 547 eye OPD attendances under

the outreach programme

• Payment of electricity bill by government as a financial relief

• Few nurses now posted to the clinic through Health Co-

ordination office

• Extension of water supply system to all staff quarters through

the support of the Health Co-ordination office

MAIN CONSTRAINTS/CHALLENGES

COMMON CHALLENGES/CONSTRAINTS

• Cash flow problem as a result of health insurance scheme delayed

claims payment

• Shortage of professional staff especially Nurses and Midwives

• Difficulty in obtaining financial clearance for mechanization of staff

to free IGF for development

• Shortage of staff accommodation compounded by increasing

numbers of Rotation Nurses and newly posted staff

157

158

AGOGO HOSPITAL

• Single spine salary imposing high financial burden of

unmechanised salaries/wages

• Lack of accommodation for doctors and other critical staff

159

AGOGO PHC

• Inadequate funds to run all activities

• Over aged vehicles especially the Toyota Land Cruiser

• Unmotorable roads in the sub-municipality contributing to

frequent breakdown of the vehicles

• Lack of CHPS compounds

160

ASSIN NSUTA HEALTH CENTRE

• General accommodation problem as the facility faces ejection

• Congestion of clients at the OPD

161

ENCHI PHC

• Lack of Staff Nurses/Midwives for Papueso and Amonie CHPS

compounds

• Both vehicles for the programme have broken down

• Inadequate accommodation leading to high expenditure on rent

162

KOM CLINIC

• Lack of accommodation for critical staff

• Majority of staff unmechanized draining the IGF

• Lack of equipment, office accommodation and wards

• Laboratory not accredited by NHIA affecting quality of service

delivery

163

WAY FORWARD

DEALING WITH CROSS-CUTTING CHALLENGES FROM

GENERAL MANAGER’S OFFICE

• Work through Health Co-ordination office and CHAG to get staff

on unmechanized payroll mechanized for financial relief

• Apply for national service personnel with health (nursing and

midwifery in particular) background

164

AGOGO HOSPITAL

• Computerization of the OPD system (including Medical

Records Department), principally to reduce waiting time

• Collaborate with Asante-Akim North and Central Assemblies

to assist in the construction of staff accommodation

• Possibly construct accommodation units from own resources

165

166

167

AGOGO PHC

• Liaise with the Presby Health Coordinator’s office, the Hospital

and the District Assembly to establish CHPS compounds in all

CHPS zones (especially Bebome)

• Intensify progress on all PHC activities

• Organize an EPI mop up in our hard to reach communities during

the dry season

ASSIN PRASO HEALTH CENTRE

• Expand facility to accommodate the increasing level of clients

168

ASSIN NSUTA HEALTH CENTRE

Seek funds to construct permanent buildings for the centre at new

site as a long-term solution to the problem of inadequate space at

current location

KWAHU PRASO HEALTH CENTRE

• Collaborate with stakeholders and NGOs to assist in acquisition of

vehicle or possibly contract a loan to acquire one.

• To empower staff in communication skill through workshops to

enhance staff patient relationship to improve OPD attendance

169

ENCHI PHC

• Computerize pharmacy operations

• Commence construction of a Doctors bungalow

• Start process of upgrading the Enchi Health Centre to a Polyclinic

status

KOM CLINIC

• Run 24-hour emergency services

• Construct male and female wards for detention of critically ill

patients

• Migration of un-mechanized staff to single spine salary structure

• Seek posting of more professional staff (eg Nurses and Midwives)

170

BEST PRACTICES/INNOVATIONS

Review of all cases at Accident and Emergency Department

by entire Clinical Team first thing every morning

Holding of clinical meeting every Thursday throughout the

year

Display of printed Clinical and Infection Prevention

Protocols in all departments of the hospital

Provision of insecticide treated nets for all beds in the

hospital

171

Availability at all times of adequate obstetric emergency

packs for:

Ante-Partum Haemorrhage

Pregnancy Induced Hypertension

Eclampsia

Retained Placenta

Post-Partum Haemorrhage

24-hour theatre services every day

Use of improvised incubators in the Nursery manufactured

by the Hospital’s Maintenance department

Provision of oxygen concentrator in Accident and Emergency

Department, Children’s Ward and Medical Ward

Screening all new-borns within 48 hours

ACKNOWLEDGEMENT

The contributions and support in various forms of the following institutions,

bodies, organizations and individuals are hereby thankfully acknowledged.

• Government of Ghana through MOH/GHS

• The Moderator and General Assembly Council of the Presbyterian

Church of Ghana

• The Director of Development and Social Services, PCG

• The Chairman and Members, Committee on Health and Environment

of the PCG

• The Health Coordinator, PCG

• Chairman and Members of the Area Board, Asante-Akyem Presby

Health Services

• CHAG National Secretariat

• Rev. Ernst Peyer Memorial Foundation, Switzerland

• World Vision Ghana

• Asante Akim North Municipal Assembly

172

APPENDIX I (a)

USER SATISFACTION SURVEY AT OPD (AGOGO HOSPITAL)

INDICATOR2011 2012

2013

Proportion of patients: JUN DEC

1 Seen promptly within 2 hours 57 30 57 68

2 Seen without unnecessary delay 78 90 62 100

3 Examined by Doctor 76 97 97 100

4 Told their diagnosis 69 59 90 72

5 Given instructions about illness by Doctor 53 56 90 90

6 Told whether to return 80 82 72 74

7 Having privacy during consultation 99 100 98 100

8 Receiving all drugs prescribed 93 98 78 98

9 Understanding instruction from the Pharmacy 100 100 98 100

10 Perceiving staff attitude to be very good 84 95 89 100

11 Perceiving hospital to be clean 80 99 92 96

12Seeking emergency treatment in previous 6

months who were seen promptly100 67 42 71

13 Feeling very satisfied with their visit 92 100 96 100173

0

20

40

60

80

100

120

1 2 3 4 5 6 7 8 9 10 11 12 13

Jun-11

Jun-12

Jun-13

Dec-13

174

APPENDIX I (b)

INPATIENTS DEPT. USER SATISFACTION SURVEY

(AGOGO HOSPITAL)

INDICATORS 2011 20122013

JUN DEC

1 Proportion of patients given bed within 30 mins. 93 100 85 84

2Proportion of patients given bed without

unnecessary delay45 99 100 94

3 Proportion of patients visited by a Doctor daily 94 100 80 100

4Proportion of patients examined by Doctor on

each visit83 100 80 100

5Proportion of patients receiving all prescribed

drugs in the hospital75 96 90 67

6Proportion of patients served regularly their

medication97 100 100 100

7Proportion of patients receiving privacy while on

admission42 100 90 98

175

8aProportion of patients admitted with

emergency condition34 12 65 42

8b Proportion of patients given prompt attention 71 67 77 90

9Proportion of patients perceiving staff attitude

to be very good84 100 100 96

10aProportion of patients needing other services

(e.g. x-ray, lab etc)82 89 80 86

10bProportion of patients given prompt attention

at the lab, x-ray etc.94 59 81 91

11Proportion of patients receiving receipt for

each payment100 96 100 100

12Proportion of patients perceiving ward to be

clean90 98 95 98

13Proportion of patients able to pay for all

services95 100 100 96

14 Proportion of patients told to return for review 86 97 90 100

15Proportion of patients feeling very satisfied

with services95 100 80 100

176

0

20

40

60

80

100

120

1 2 3 4 5 6 7 8a 8b 9 10a 10b 11 12 13 14 15

Jun-11

Jun-12

Jun-13

Dec-13

177

APPENDIX I (c)

USER SATISFACTION SURVEY AT OPD

(ASSIN PRASO HEALTH CENTRE)

INDICATOR 2012 2013

Proportion of patients: JUN DEC JUN DEC

1 Seen promptly within 1 hours or less 80 90 100 95

2 Seen without unnecessary delay 85 89 100 99

3 Examined by Doctor 95 99 75 100

4 Told their diagnosis 90 100 60 100

5 Told how to take treatment 100 100 50 100

6 Told whether to return 99 100 80 100

7 Having privacy during consultation 100 100 90 75

8 Receiving all drugs prescribed 100 100 100 100

9 Understanding instruction from the Pharmacy 90 85 90 85

10 Perceiving staff attitude to be very good 99 100 98 90

11 Perceiving clinic to be clean 99 98 100 95

12Seeking emergency treatment in previous 6

months who were seen promptly100 100 100 100

13 Feeling very satisfied with their visit 99 99 95 98178

0

20

40

60

80

100

120

1 2 3 4 5 6 7 8 9 10 11 12 13

Jun-12

Dec-12

Jun-13

Dec-13

179

APPENDIX I (d)

USER SATISFACTION SURVEY AT OPD

(ASSIN NSUTA HEALTH CENTRE)

INDICATOR2011 2012 2013

Proportion of patients:

1 Seen promptly within 1 hours or less 90 86 86

2 Seen without unnecessary delay 90 88 88

3 Examined by Doctor 94 98 74

4 Told their diagnosis 100 100 100

5 Told how to take treatment 100 100 100

6 Told whether to return 100 100 100

7 Having privacy during consultation 74 80 76

8 Receiving all drugs prescribed 100 100 100

9 Understanding instruction from the Pharmacy 100 100 100

10 Perceiving staff attitude to be very good 84 98 98

11 Perceiving clinic to be clean 96 100 100

12Seeking emergency treatment in previous 6

months who were seen promptly100 100 100

13 Feeling very satisfied with their visit 100 98 90180

0

20

40

60

80

100

120

1 2 3 4 5 6 7 8 9 10 11 12 13

2011

2012

2013

181

APPENDIX I (e)

USER SATISFACTION SURVEY AT OPD

(KWAHU PRASO HEALTH CENTRE)

INDICATOR2009 2010

Proportion of patients:

1 Seen promptly within 1 hours or less 100 100

2 Seen without unnecessary delay 100 100

3 Examined by Doctor 100 80

4 Told their diagnosis 100 80

5 Told how to take treatment 100 100

6 Told whether to return 100 32

7 Having privacy during consultation 100 100

8 Receiving all drugs prescribed 100 100

9 Understanding instruction from the Pharmacy 100 100

10 Perceiving staff attitude to be very good 100 100

11 Perceiving clinic to be clean 96 100

12Seeking emergency treatment in previous 6 months

who were seen promptly100 34

13 Feeling very satisfied with their visit 100 100 182

0

20

40

60

80

100

120

1 2 3 4 5 6 7 8 9 10 11 12 13

2009

2010

183

APPENDIX I (f)

USER SATISFACTION SURVEY AT OPD

(ENCHI PRIMARY HEALTH CARE)

INDICATOR2012 2013

Proportion of patients:

1 Seen promptly within 1 hours or less 50 60

2 Seen without unnecessary delay 58 81

3 Examined by Doctor 87 90

4 Told their diagnosis 47 51

5 Told how to take treatment 64 60

6 Told whether to return 74 62

7 Having privacy during consultation 89 95

8 Receiving all drugs prescribed 80 94

9 Understanding instruction from the Pharmacy 80 99

10 Perceiving staff attitude to be very good 95 95

11 Perceiving clinic to be clean 87 88

12Seeking emergency treatment in previous 6 months

who were seen promptly71 100

13 Feeling very satisfied with their visit 89 100 184

0

20

40

60

80

100

120

1 2 3 4 5 6 7 8 9 10 11 12 13

2012

2013

185

APPENDIX II

RATIONAL DRUG PRESCRIPTION INDICATORS (AGOGO HOSPITAL)

INDICATOR

AGOGO HOSPITAL STANDARD

1ST QTR

2013

2ND QTR

2013

3RD QTR

2013

4TH QTR

2013

ASH.

REGIONWHO

Diagnosis

No. of Drugs per

Prescription

Prescription

Generic Drugs

Antibiotics

Injections

Prescriptions

within EDL

96.0%

3.3

65.3%

23.1%

8.0%

89.7%

98.0%

3.7

68.4%

22.8%

5.3

87.2%

100.0%

3.1

70.2

31.2%

3.7%

75.5%

100%

3.4

54.9%

34.5%

2.0%

80%

100%

4

84%

40%

40%

100%

100%

2

100%

20%

20%

100%

186

APPENDIX III

PURCHASE OF MEDICAL EQUIPMENT (AGOGO HOSPITAL)

187

DESCRIPTION QUANTITYTOTAL COST

GHȼ

Delivery Bed

Digital Thermometer

Litman Stethoscope

PB Apparatus

Electric Boiler

Electrical Suction Machine

Drum (Sterilizing)

SUB-TOTAL

1

320

21

45

1

1

1

2,200.00

2,968.00

1,680.00

11,050.00

800.00

2,200.00

120.00

21,018.00

188

DESCRIPTION QUANTITYTOTAL COST

GHȼ

Oxygen Flometers

ORISCOPE

Selecta Flow meter

Weighing Scales

Dental Unit Assorted Medical Items

SUB TOTAL

GRAND TOTAL

15

10

5

8

5,585.00

5,000.00

4891.25

3,500.00

70,772.20

89,748.45

110,766.45

189

NAME OF INSTITUTION/ORGANIZATIONNO. OF

TRAINEES

Christian Service University College

Catholic University College

Grace Baptist University College

Kwame Nkrumah University of Science & Technology

Presby University College, Abetifi-Kwahu

University of Professional Studies

University of Cape Coast

University of Development Studies

All Nations University College, Koforidua

University of Ghana

1

2

1

2

2

1

3

3

1

2

APPENDIX IV

TRAINING ATTACHMENT OFFERED TO STUDENTS

190

NAME OF INSTITUTION/ORGANIZATIONNO. OF

TRAINEES

University of Education, Winneba-Kumasi Campus

Koforidua Polytechnic

Takoradi Polytechnic

Kumasi Polytechnic

Allied Health Professional Council, Korle-Bu

Medicare College of Applied Sciences, Kumasi

Ramseyer Vocational/Technical Institute

Physiotherapy Assistant Training School, Duayaw-Nkwanta

Bright College, Kukurantumi

Opoku Ware Girls’ Vocational/Technical Institute, Nkawie

Kwara State Polytechnic, Nigeria

Nerebehi ICCES of Vocational Institute

GIMPA

1

3

1

2

1

1

1

1

1

1

1

1

1

191

TOYOTA LAND

CRUISER PRADO

192

DISPENSING COUNTER

PHARMACY DEPARTMENT

193

INSIDE THE PHARMACY

DEPARTMENT

194

INSIDE THE PHARMACY

DEPARTMENT

195

RENOVATED PHARMACY

DEPARTMENT

196

INSIDE THE DENTAL UNIT

197

INSIDE THE DENTAL UNIT

198

FRONT VIEW FENCE WALL

THANK YOU

199