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THE REPUBLIC OF UGANDA
Annual Health Sector Performance Report
Financial Year 2003/2004
October 2004
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Foreword Uganda, frequently referred to as the Pearl of Africa, continues to demonstrate a high disease burden similar to other developing countries. As a result, the intricate relationship between poverty and ill–health becomes inescapable. The Government of Uganda and its Health Development Partners have been implementing the Health Sector Strategic Plan (HSSP) for the last four years under the Sector Wide Approach. The thrust of this policy implementation strategy is to contribute to the national Poverty Eradication Action Plan (PEAP) and the Millennium Development Goals (MDGs). The health sector has a big responsibility of exercising accountability at the national and international levels. This fourth consecutive Annual Health Sector Performance Report highlights the progress made during FY 2003/04 towards achieving the overall sector goal as well as the specific targets for the period under report. During this period under review FY 2003/04, the overall health sector resource envelope totalled Ugshs 374 billion. This, in real terms, represented only a 3% increase over the FY 2002/03. The health sector has however utilised these resources in accordance with the HSSP and PEAP priorities and has yet again registered significant improvement in performance. It is gratifying to note that the efforts expended in carrying out the mass measles campaign in October 2003 have yielded immediate results. Once again, the measles wards are empty. I urge all the districts and other partners to do all that is in their power to sustain and improve routine immunisation so that at the end of this FY we surpass the HSSP I target of 85% coverage. The utilisation of Outpatient services at government and NGO facilities has increased from 0.70 visits per person per year to 0.79. This is a sign that the population is developing more confidence in the health system and in turn, the utilisation continues to rise. The utilisation of the health facilities for safe deliveries registered a 20% performance improvement. This is a welcome development but we should strive to do better. The fight against the major killer, malaria, has continued to yield results mainly in the area of Home Based Management of Fever, Insecticide Treated Nets and their re-treatment and even in the quality of case management as demonstrated by the low case fatality rate of 3% at the Regional Referral Hospital level, where the more complicated cases are handled. The plans to use DDT for Indoor Residual Spraying are underway, while at the same time addressing the challenge of changing the mindset of the general population regarding its efficiency, effectiveness and safety. The strategic developments in drugs management through the introduction of credit lines for districts at the National Medical Stores and Joint Medical Stores have continued to yield tremendous results. The fight against the HIV/AIDS epidemic continues with the launch in June 2004 of the programme for Universal Access to Free Antiretroviral Treatment in Uganda while at the same time strengthening the ABC strategy. We are eagerly awaiting the results of the on-going HIV sero-prevalence study to provide information to further strengthen our HIV/AIDS strategies and services. The health sector is hosting the second National Health Assembly in October 2004 and in doing so fulfils the obligation of mobilising the leadership at all levels to advocate for the prioritisation of health investments in Uganda. On behalf of the Government and
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people of Uganda, I wish to express appreciation to all health sector stakeholders for the efforts put into the implementation of the HSSP during the year under Report. The District League Table has yet again provided a comparative performance assessment across the country. The district ranking has not remained the same as last year. I urge the district political and technical leadership to critically examine the factors that have affected the improvement or worsening of performance, address the prevailing constraints and use this competitive spirit to improve on the health of our people. Remember the famous adage that Health is Wealth. Hon. Brig. Jim Katugugu Muhwezi MP MINISTER OF HEALTH
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Towards better Health for the people of Uganda A message from the Director General of Health Services. This is the fourth Annual Health Sector Performance Report (AHSPR) for the current five-year HSSP I. It has been prepared side by side with the second Health Sector Strategic Plan (HSSP II) 2005/06-2009/10 and the revision of the PEAP (2004) for Uganda. The priorities and targets that are contained within are aligned with the Millennium Development Goals and the Vision 2025. From analysis of this AHSPR, it is gratifying to note that we have continued to make progress and our performance continues to improve as judged by the attainment and in many cases surpassing of our targets and indicators. During 2005 we will be due for another Health and Demographic Survey. The results of that Survey will be a reliable measure of the early impact of the success of the implementation of HSSP I and the PEAP and may call for readjustments in HSSP II. In spite of these promising developments, we need to be continuously reminded that Uganda is still one of the poorest countries with unacceptable indices and that action to address this is urgent. In the area of sustainable Health Systems Development, which is the central thrust of the National Health Policy and the HSSP, I am pleased to note that this year, we faced and overcame a number of challenges and shocks. The leading ones among these are Human Resources Management, management of global initiatives such as the Global Fund to Fight AIDS, TB and Malaria and PEFPAR, harmonizing roles with Civil Society Groups, the war in the North and North East, scaling up access to ARVs, reviewing the Malaria treatment policy and coordination with Health Development Partners. The ability of the health System to handle these challenges and to maintain cohesion and order is a source of encouragement as it has reasserted the importance of the stewardship role of a responsible government and bodes well for the future. During the year, the central Ministry of Health implemented a major change in the arrangements for supervision and support to district health services. This entailed a move from the Quality Assurance Supervision visits to more integrated Area Teams. The Quarterly Performance Review meetings experienced some delays but were still held. Improvement is called for in this area. Dr. F. Runumi now Commissioner of Health Services in charge of Planning, replaced Dr. P. Y. Kadama, who joined WHO, and I wish both of them well in their new positions. In respect to District Health Services, our Vision is to see the Local Authorities owning responsibility, taking leadership and having capacity to fulfil their roles in district health services delivery. Any support given to them from outside should be aimed at accelerating the achievement of that vision and the sooner this is achieved the better. The Constitution, the Local Authorities Act and the SWAp MoU are all in line with that vision. District health services have continued to improve. Many of the districts which had been ranked poorly in the previous year have shown some improvements and targeted action will be needed to support those which remain weak. Credit for this goes to the District political leaders, the Civil Servants and members of Civil Society. The Local Authorities Association has shown a lot of enthusiasm and responsibility in mobilizing its members to be champions for the Health Sector. This will become increasingly important as we all move towards Fiscal Decentralization. I would also like to see acceleration in the
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establishment and empowerment of communities and households through the Village Health Teams and the Parish Development Committees. In this way community ownership and responsibility for their own health will become entrenched as a way of life. This in turn will make the people’s health a high priority political issue and will also inevitably lead to improvements in the quality of health services within a strong and stable pro-poor health system. F. G. Omaswa DIRECTOR GENERAL OF HEALTH SERVICES.
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Table of Contents
Foreword ..................................................................................................................... i Towards better Health for the people of Uganda .............................................................. iii Acronyms ................................................................................................................... vi Illustrations ................................................................................................................. viii Executive Summary ............................................................................................................ xi Chapter 1: Introduction .................................................................................................................. 1
1.1 The Sector Framework .............................................................................................................. 1 1.2 The Annual Health Sector Performance Report FY 2003/04 ............................................ 3 1.3 Sources of Information .............................................................................................................. 3 1.4 Challenges and Planning for Future Reports ......................................................................... 4 1.5 Outline of the Report ................................................................................................................. 4
Chapter 2 Overview of Health Sector Performance FY 2003/04 ........................................ 5
2.1 Performance against HSSP Indicators .................................................................................... 5 2.2 Summary Financial Report for the FY 2003/04 .................................................................. 13
Chapter 3 Implementation of the Health Sector Strategic Plan ....................................... 24
3.1 Delivery of the Uganda National Minimum Health Care Package ....................... 24 3.1.1 Prevention and Control of Communicable Diseases .......................................................... 24 3.1.2 Maternal and Child Health ...................................................................................................... 42 3.1.3 Prevention and Control of Non-Communicable Diseases and conditions..................... 52 3.1.4 Health Promotion and Disease Prevention .......................................................................... 64
3.2 Integrated Health Sector Support Systems .................................................................... 74 3.2.1 Health Care Financing ............................................................................................................. 74 3.2.2 Human Resources for Health ................................................................................................. 86 3.2.3 Health Infrastructure Development and Management ...................................................... 91 3.2.4 Management of Medicines and Health Supplies .................................................................. 93 3.2.5 Monitoring and Mentoring of District Health Systems. .................................................. 100 3.5.6 Laboratory Support Services ................................................................................................ 103 3.2.7 Blood Transfusion Services ................................................................................................. 103 3.2.8 Health Information and Research ....................................................................................... 104 3.2.9 The Stewardship of the Health Sector. .............................................................................. 106
Chapter 4 The National Health Assembly and 9th Joint Review Mission .................. 111
4.1 The National Health Assembly ........................................................................................... 111 4.2 The 9th Government of Uganda/Development Partner Joint Review Mission .......... 112
Chapter 5 The 2nd Health Sector Strategic Plan (HSSP II) ............................................ 121
5.1 Priority Areas for HSSP II ................................................................................................... 122 5.2 Implementation Priorities ..................................................................................................... 122 5.3 Priority Outcomes for HSSP II. .......................................................................................... 122 5.4 Process for developing HSSP II .......................................................................................... 123 5.5 The costing and financing of HSSP II ............................................................................... 124
Annexes: Annex I: The District League Table......................................................................................... 125 Annex II: Health Sector Budget Performance FY 2003/04 .................................................. 128 Annex III: Human Resource Inventory FY 2003/04 .............................................................. 129 Annex IV: Hospital Performance Assessment FY 2003/04 ................................................... 132
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Acronyms ABC Abstinence, Be faithful, Condom use AFP Acute Flaccid Paralysis AHSPR Annual Health Sector Performance Report AIM AIDS Integrated Management ANC Ante Natal Care ARV Antiretroviral BCC Behaviour Change Communication BEmOC Basic Emergency Obstetric Care CB-DOTS Community based Directly Observed Treatment CDC Centre for Disease Control CDD Community based Drug Distributors CEmOC Comprehensive Emergency Obstetric Care CME Continuing Medical Education CYP Couple Years of Protection DDHS District Director of Health Services DOTS Directly Observed Treatment DPs Development Partners ENT Ear, Nose and Throat EPI Expanded Programme for Immunisation ESD Epidemiology and Surveillance Division FP Family Planning GFATM Global Fund for AIDS, TB and Malaria GoU Government of Uganda GTZ German Technical Cooperation HC Health Centre HDP Health Development Partners HMIS Health Management Information System HPAC Health Policy Advisory Committee HRD Human Resource Division HSSP Health Sector Strategic Plan HUMC Health Unit Management Committee IDSR Integrated Disease Surveillance and Response IEC Information, Education and Communication IMCI Integrated Management of Childhood Illnesses IPT Intermittent Presumptive Treatment IRS Indoor Residual Spraying IST In-service Training Strategy ITN Insecticide Treated Nets JRM Joint Review Mission KABP Knowledge, Attitude, Behaviour change, Practice KDS Kampala Declaration on Sanitation KPI Kampala Pharmaceutical Industries LLIN Long Lasting Insecticide Nets LSS Life Saving Skills LTPM Long Term Permanent Methods MAAIF Ministry of Agriculture, Animal Industries and Fisheries MCP Malaria Control Programme MDGs Millennium Development Goals MIP Malaria in Pregnancy MNT Maternal and Neonatal Tetanus MoES Ministry of Education and Sports MoH Ministry of Health MoU Memorandum of Understanding
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MRC Medical Research Council MTR Mid-Term Review NCD Non Communicable Diseases NCRL Natural Chemotherapeutics Research Laboratory NGO Non Government Organisation NHA National Health Assembly NHP National Health Policy NIDs National Immunisation Days NMS National Medical Stores NVS National Voucher Scheme OPD Outpatient Department OPV Oral Polio Virus PC Palliative Care PEAP Poverty Eradication Action Plan PEPFAR President’s (Bush) Emergency Plan for AIDS Relief PET Post Exposure Treatment PHC Primary Health Care PHC-CG Primary Health Care Conditional Grant PHP Private Health Practitioners PMTCT Prevention of Mother to Child Transmission PNFP Private Not-For Profit PPPH Public Private Partnership for Health PSI Population Services I QA Quality Assurance RIDs Rabies Immunisation Days SHI Social Health Insurance SHSSP Support to the Health Sector Strategic Plan SOP Standard Operating Procedures SRH Sexual and Reproductive Health and Rights SWAp Sector Wide Approach TASO The AIDS Support Organisation TBL TB and Leprosy TCMP Traditional and Complementary Medicine Practitioners TOT Training of Trainers TT Tetanus Toxoid UBTS Uganda Blood Transfusion Services UDHS Uganda Demographic and Health Survey UNBS Uganda National Bureau of Standards UNHCO Uganda National Health Consumers Organisation UNHRO Uganda National Health Research Organisation UNMHCP Uganda National Minimum Health Care Package UPHOLD Uganda Programme for Human and Holistic Development UVRI Uganda Virus Research Institute VACS Vitamin A Capsule Supplementation VCT Voluntary Counselling and Testing VPH Veterinary Public Health WHO World Health Organisation WP Wettable Powder Formulation
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Illustrations
Figures
Figure 1.1: Overview of the Sector Programme .................................................................. 2 Figure 2.1: Variation of New OPD Attendance by District FY 2003/04 ............................ 8 Figure 2.2: Variation of Pentavalent Vaccine Coverage by district FY 2003/04 .................. 9 Figure 2.3: Deliveries in health units by district FY 2003/04 ............................................ 10 Figure 2.4: District PHC-CG Releases against Allocation ................................................. 15 Figure 2.5: Relating health sector Inputs with Outputs ..................................................... 15 Figure 2.6: District Performance according to the League Table ....................................... 18 Figure 2.7: Change in overall district Performance ........................................................... 19 Figure 3.1: Comparison of the children <5years treated at health facility and by Community
Drug Distributors FY 2003/04 ....................................................................... 26 Figure 3.2: Comparison between OPD New Attendance for the under 5s for FY 2002/03
and FY 2003/04 ............................................................................................. 27 Figure 3.3: IPT2 coverage by district ................................................................................ 29 Figure 3.4: Number of Functional PMTCT sites by District ............................................. 34 Figure 3.5: Sites offering ART in Uganda ......................................................................... 35 Figure 3.6: TB Case Reporting by District ........................................................................ 38 Figure 3.7: Progress of Maternal and Neonatal Tetanus in Busoga Region ....................... 48 Figure 3.8: Measles morbidity and mortality trends FY 2003/04 ...................................... 50 Figure 3.9: Standard Unit of Output (SUO) by the Regional Referral Hospitals ............... 60 Figure 3.10: Comparison of Efficiency at the Regional Referral Hospitals .......................... 61 Figure 3.11: Comparison of Health Workers' Outputs at the Regional Referral Hospitals .. 61 Figure 3.12: Cumulative admissions in a sample of 65% of PNFP Hospitals ...................... 63 Figure 3.13: Cumulative Number of Deliveries is a sample of 65% of PNFP Hospitals ...... 63 Figure 3.14: Pit latrine coverage by district ......................................................................... 67 Figure 3.15: Completeness of weekly district and health unit reporting, Uganda 2003 ........ 72 Figure 3.16a Impact of mass campaigns for measles cases, Uganda 2003 ....................... 72 Figure 3.16b Impact of mass campaigns for measles cases, Uganda 2003 ....................... 73 Figure 3.17: Resource Projections for the Ugandan Health Sector ...................................... 74 Figure 3.18: Allocation of health sector budget FY 2003/04 .............................................. 77 Figure 3.19: FY 2003/04 Approved Budget Estimates and Releases (Bn Shs) .................... 77 Figure 3.20: Percentage expenditure in the public and private sector .................................. 79 Figure 3.21: Percentage expenditure on HSSP and Non HSSP inputs: ............................... 80 Figure 3.22: PNFP Health Sector – Trends in income structure: ........................................ 81 Figure 3.23: Relative sources of income over time – PNFP Hospitals: ............................... 82 Figure 3.24: Relative sources of income over time – PNFP LLUs ...................................... 82 Figure 3.25: Percentage of released funds that are spent in the different quarters. .............. 83 Figure 3.26: Total Health Expenditure in Uganda FY 1998/99 to FY 2000/01 .................. 84 Figure 3.27: Management of Health Sector Resources by Financing Agents ....................... 85 Figure 3.28: Performance against indicative budget FY 2003/04 ....................................... 96
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Tables
Table 2.1: Performance against the HSSP Monitoring Indicators. ..................................... 6 Table 2.2: Trends for the 5 PEAP indicators 1999/00 to 2003/04 .................................... 7 Table 2.3: Total Number of Deliveries in Government and PNFP Units .......................... 9 Table 2.4: Proportion of Approved Posts that are filled by appropriately trained health
workers .......................................................................................................... 12 Table 2.5: HSSP Funding for the FY 2003/04 ................................................................ 13 Table 2.6: Movements in & out of the Top and Bottom 10 of the League Table ............. 19 Table 2.7: Comparing Drug Management Performance and the League Table ................ 20 Table 2.8: Comparing District Performance on Pentavalent Vaccine Coverage and League
Table Ranking ................................................................................................ 20 Table 2.9: Performance of the Districts with marked Insecurity in FY 2003/04 .............. 21 Table 2.10: Performance of the New Districts in FY 2003/04 .......................................... 22 Table 2.11: Performance of the districts in the Karamoja Region ...................................... 22 Table 3.1: Performance against HSSP Malaria Indicators ................................................ 25 Table 3.2: The Status of HBMF Implementation in the districts ..................................... 25 Table 3.3: Partner Support in provision of HOMAPAK ................................................. 26 Table 3.4: Net sales in Uganda by type, 2002 to the 1st half of 2004. .............................. 29 Table 3.5: Performance against HSSP STD/HIV/AIDS Indicators ................................ 32 Table 3.6: Performance against HSSP TB Control Indicators .......................................... 36 Table 3.7: CB-DOTS Implementation Coverage ............................................................. 37 Table 3.8: District leprosy prevalence Rate ...................................................................... 39 Table 3.9: Performance against HSSP SRH Indicators .................................................... 42 Table 3.10: Results on a Needs Assessment for EmOC in 37 districts of Uganda ............. 43 Table 3.11: CYP Factors for each Family Planning Method. ............................................. 44 Table 3.12: Performance against HSSP IMCI Indicators ................................................... 45 Table 3.13: Performance against HSSP Immunisation Indicators ...................................... 46 Table 3.14: Selected AFP surveillance performance indicators .......................................... 48 Table 3.15: Performance against HSSP Nutrition Indicators ............................................. 51 Table 3.16: Mulago Hospital Service Outputs FY 2003/04 ............................................... 58 Table 3.17: Performance against the HSSP Health Education and Promotion Indicators .. 64 Table 3.18: Performance against HSSP Environmental Health Indicators ......................... 66 Table 3.19: Performance against HSSP IDSR indicators ................................................... 71 Table 3.20: Trends of GoU Budget Funding for the Health Sector FY 1999/00 to FY
2000/03 (Billion Ugshs.) ................................................................................. 75 Table 3.21: Donor Expenditure FY 2003/04 (US Dollars) ................................................ 79 Table 3.22: Global Funds approved against disbursed ....................................................... 80 Table 3.23: Sources of Funds Spent in the Health Sector (US $ per capita) ....................... 84 Table 3.24: Comparison of Health Expenditure in Other African Countries ..................... 85 Table 3.25: Current number of staff in the Health Sector – GoU/PNFP .......................... 86 Table 3.26: Analysis of Actual Number of Staff (excluding Non-medical staff) and
Minimum Staffing Norms – All Districts, GoU only. ...................................... 87 Table 3.27: Analysis of Actual Number of Clinical Staff and Minimum Staffing Norms – All
Districts, GoU only. ....................................................................................... 88 Table 3.28: Distribution of Clinical Staff in HC IIs (GoU) ................................................ 88 Table 3.29: Analysis of Actual Number of Technical Support Staff and Minimum Staffing
Norms – All Districts, GoU only. ................................................................... 89 Table 3.30: The projected and actual output of ECN and Enrolled Nurses and Midwives 90 Table 3.31: Summary of Health Facilities by level and ownership ...................................... 91 Table 3.32(a): Status of Medical Buildings at HC IIIs for the 39 Districts Surveyed .............. 92
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Tables contd:
Table 3.32(b): Status of Medical Buildings at HC IV's for the 39 District Surveyed ............... 92 Table 3.33: Medicines budget allocation FY 2003-04 (UGX billions) ................................ 94 Table 3.34: Analysis of Performance of National Medical Stores ...................................... 97 Table 3.35: Medicine availability by indicator drug FY 2002/03 and 2003/04 .................. 98 Table 3.36: Medicines availability by level of care, FY 2002/03 and 2003/04 .................... 99 Table 3.37: Research conducted by UNHRO .................................................................. 106 Table 3.38: Estimates of additional costs to enhance PNFP health worker salaries in the
medium term. ............................................................................................... 107 Table 4.1: Progress on the National Health Assembly Resolutions ................................ 113 Table 4.2: Progress on the Undertakings of the 9th Joint Review Mission ..................... 118
Boxes :
Box 3.1: TB Treatment Success: The story of Apac district .............................................. 37 Box 3.2: Improved Sanitation Coverage – The Success Story of Busia District .................. 68 Box 3.3: The strengths and weaknesses of the Area Team Strategy identified during the start
up phase............................................................................................................ 101 Box 3.4: Successful HMIS Management: The case of Gulu District ................................ 104
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Executive Summary The implementation process for the Health Sector Strategic Plan (HSSP), 2000/01–2004/05, has completed four years and in fulfilment of the provisions of the Memorandum of Understanding (MoU) that guides the partners in the implementation of the plan, the Ministry of Health presents the fourth Annual Health Sector Performance Report for FY 2003/04. This report is an assessment of health sector performance given previously agreed annual targets set in light of the overall HSSP Monitoring Framework. The report focuses on:
• Assessment of overall health sector performance against the 18 HSSP Indicators; • Information on individual district performance against 10 of the HSSP indicators,
and using this to build up a League Table ranking district performance • Progress on the delivery of the Uganda National Minimum Health Care Package
(UNMHCP) at the various levels; • Hospital performance as an integral component of the Minimum Health Care
Package • The performance of the Integrated Health Sector Support systems; • Progress in the implementation of the resolutions of the first National Health
Assembly and undertakings of the 9th Joint Review Mission (JRM) • Provision of a synopsis of the second Health Sector Strategic Plan (HSSP II)
Overall Health Sector Performance
Overall, the health sector has registered yet another year of improved performance. As in the past, the assessment is based on performance against HSSP indicators and agreed targets for the FY 2003/04. In particular performance against the 5 Poverty Erdication Action Plan (PEAP) indicators has been assessed and the performance trends noted over the four years of the HSSP. The analysis indicates that:
• New Outpatient (OPD) attendance has registered further improvement and at 0.79 visits per person per year has already exceeded the annual and the 2005 HSSP target of 0.7;
• The approved posts filled by trained health workers stands at 68% using HSSP norms excluding Nursing Assistants, and using HSSP minimum staffing norms is at 86%;
• Deliveries taking place at health facilities have registered a modest improvement from 20% to 24.4%.
• Couple Years of Protection (CYP) as a measure of effectiveness of Family Planning services over time has remained rather constant
• The achieved DPT3/HepBHib coverage of 83% is close to the target of 85% expected at the end of HSSP
• HIV national average sero-prevalence rates as determined from Antenatal Care (ANC) surveillance sites is estimated at 6.2%, this indicator has stabilised between 6 and 7% since the beginning of the HSSP.
The resource envelope available to the health sector during the period under report was Ugshs 385.54 billion, which is equivalent to US$ 7.83 per capita. This still remains far below the Health Financing Strategy estimate of US$ 28 per capita per year (excluding
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Anti-Retroviral Therapy and pentavalent vaccine). For the third year running, the GoU contribution to the sector resource envelope was higher than the donor project component. The actual releases to the sector amounted to Ugshs 361.25 billion, constituting 94% budget performance. The overall resources available to the sector increased by 11% over the FY 2002/03 levels. However, in real terms, there was only a marginal 3% increase taking into account the inflation and population growth factors. The formula for allocation of funds to the districts was further refined to improve equity and efficiency by taking into consideration project funding and hospital coverage. As a result, the districts most in need received more funds per capita than the richer ones.
District Performance and the League Table
For the second year running, performance of individual districts has been assessed using a set of HSSP management and service delivery indicators. The purpose of conducting this assessment and ranking the districts is several-fold:
• To bring to light the contributions of the various districts to the overall performance of the health sector;
• Providing information to enable analytical assessment of reasons behind good and poor district performance;
• Enable the process of planning for and offering preferential support to poor performers;
• To provide a basis for discussion of the district and overall health sector performance by the Local Government leadership and other stakeholders at the National Health Assembly.
• To provide a challenge and an incentive to the districts for improved performance
• To encourage good practices by recognising good performance, innovation and appropriate reporting.
For purposes of comparability, the League Table indicators used in the FY 2002/03 performance assessment were maintained. A number of districts have shown profound improvements in the rankings as compared to the previous reporting period. The League Table provides opportunity for districts to conduct a critical assessment of their performance and lay the appropriate strategies. The top 10 districts in order of ranking are; Gulu, Jinja, Adjumani, Moyo, Tororo, Rukungiri, Mpigi, Bushenyi, Kampala and Busia. The bottom 10 districts from the last are; Kotido, Pader, Yumbe, Kamwenge, Iganga, Wakiso, Masindi, Lira, Moroto and Mubende. The factors influencing performance include the management of the district, insecurity, infrastructure such as in the new districts and peculiar circumstances such as in the Karamoja Region. At individual district level, Gulu, Kampala, Mukono, Mbale and Apac show an improvement of more than 50%, whereas Luwero, Kaberamaido, Mubende, Ntungamo, Nebbi and Pallisa show a decline of more than 30%. As a general observation, during the period under review, the functionality of some Health Sub-districts and particularly the referral facilities at Health Centre IV level, was
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lower than expected. This largely affected the performance of individual districts. Unless there is improvement in the functionality of these Health Sub-Districts within the district health system, the sector is unlikely to register much difference in the attainment of district and sector targets.
The delivery of the National Minimum Health Care Package
The 12 elements of the Uganda National Minimum Health Care Package (UNMHCP) have been grouped into four clusters in the HSSP and also in this report as a move towards integrated assessment and analysis. Within the clusters, performance assessment for the package elements has been done with particular emphasis on HSSP indicators and targets. Activities carried out are related to the intended objectives of the programmes to determine whether the activity did actually contribute towards the objectives and therefore attainment of the targets. There is registered improvement in target setting, though some of the indicators have remained difficult to assess due to the nature of the sources of information. The following sector achievements in the FY 2003/04 are highlighted:
Malaria Control Prevention – the policy on Insecticide Treated Nets (ITNs) has shifted in favour of the poor and the most vulnerable through the provision of free nets. A recently conducted Net re-treatment exercise found that the household net coverage was higher than had been estimated. Case management – at community and facility level – Home Based Management of Fever (HBMF) is currently implemented in 43 out of 56 districts. The remaining districts are to be covered during FY 2004/05. The available results indicate high utilisation rates for the service; a Malaria Case Fatality Rate at hospital level that is in tandem with the HSSP target; the Anti-malarial Drug Policy, guided by research findings, is undergoing a transition; while the preventive treatment of malaria in pregnancy has fallen short of attaining the sector target.
STD/HIV/AIDS Control Voluntary Counselling and Testing (VCT) services are now available in all the 56 districts of Uganda, while Prevention of Mother-to-child-Transmission (PMTCT) services are now available at 71 sites in 49 districts and Anti-Retroviral Therapy at all the 11 Regional Referral Hospitals.
Immunisation The DPT3/HepBHib coverage at 83% is close to the HSSP target of 85% and other antigens showed similar performance. The success of the mass measles campaign is already evident in the weekly reports; TT2 for pregnant women at 50% was the same as for the previous year and fell short of the annual target of 59%.
Sexual and Reproductive Health and Rights This has been maintained as a sector priority and the proportion of mothers delivering in government and NGO facilities showed some improvement from 20% to 24.4% with evidence that more improvements could have been achieved. There is need to employ
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strategic thinking in order to improve on this service delivery area and the biggest challenge lies within the district health systems.
Environmental Health Advocacy for the Kampala Declaration on Sanitation (KDS) has been given priority and pit latrine coverage has improved from 47% to 57%.
Integrated Health Sector Support Systems
• The overall disbursement of the PHC Non-wage component to the districts was at 94.5%
• The human resources available to the sector registered minimal increment due to the limited resource envelope. Progress was made in the discussions with stakeholders in the improvement of the remuneration of the existing health sector workforce
• The Pull System, established to streamline drug procurement and management, was solidly established and most districts registered high rates of Credit Line utilisation. The per capita expenditure on drugs has therefore increased from US$ 1.2 per capita during FY 2002/03 to US$ 1.6 per capita during the period under review.
• Infrastructure development has ensured that 110 Operating Theatres are complete; equipment provided to 68 Theatres, 128 doctors’ houses completed and multi-purpose vehicles availed to about 50% of the Health Centre IV facilities.
• Information management has continued to register a steady improvement with timeliness and completeness of HMIS reports at 85% and 90% respectively.
• The various arms of health sector regulation have registered significant achievements especially in drugs, nursing and clinical practice.
Resolutions of the NHA and Undertakings of the 9th JRM
The resolutions of the first National Health Assembly, held in November 2003, focussed on improving the requisite sector inputs in order to realise meaningful outputs that will contribute to elevating the health status of the people of Uganda. In the course of FY 2003/04, the attention paid to these important national decisions earned greater results in the following areas;
• Improvement of drug supplies and management • Provision of better health services for the Internally Displaced Persons as
demonstrated by the performance of Gulu and other insecurity affected districts in the League Table
• Advocacy for Reproductive Health • Monitoring and mentoring of district health systems through the deployment of
Area Teams • Improved information management in terms of quantity and quality.
The National Health Assembly was followed by the 9th Government of Uganda/Development Partners Joint Review Mission (JRM) also held in November 2003. The progress made with respect to the Resolutions of the National Health
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Assembly and the 9th JRM Undertakings is summarised in Chapter 4 of this report. Most of the resolutions were adequately addressed and significant progress was made towards the achievement of the 9th JRM undertakings.
The second Health Sector Strategic Plan (2005/06-2009/10).
The preparation of the second Health Sector Strategic Plan (2005/06-2009/10) is nearing completion. The preparation of this plan has benefited from wide stakeholder consultations and therefore enjoys a very high level of ownership. Compared to HSSP I, the new strategic plan document is constructed to reflect more clearly, the maxim that the primary purpose of the National Health System (NHS) is to achieve improved health of the people. Individual programme outputs are seen as the means to achieving the desired health outcomes and not as an end in themselves. The programme overview has therefore been amended to show that implementing the Uganda National Minimum Health Care Package (UNMHCP) is the main approach for achieving the sector programme goal and development objective. This will be accompanied by a strong focus on health promotion and disease prevention. The focus of the plan remains on how to make maximum contribution to the national PEAP and the MDGs. Efforts have been made to better integrate services and programmes to enable efficiencies to be realised in both delivery and support. The October 2004 National Health Assembly and Joint Review Mission are expected to provide the final inputs into HSSP II before its presentation to cabinet for approval.
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Chapter 1: Introduction
1.1 The Sector Framework The overall objective of the health sector is to reduce morbidity and mortality from the major causes of ill–health and the disparities therein. The National Health Policy (NHP) and the Health Sector Strategic Plan (HSSP) based on the Poverty Eradication Action Plan (PEAP) provide the framework for facilitating this achievement. Figure 1.1 illustrates the contribution of the sector to reduced morbidity, mortality and fertility and thereby to the national goal of Expanded Economic Growth and Poverty Eradication. The HSSP has five outputs namely:
• Delivering the Uganda National Minimum Health Care Package (UNMHCP), deliberately and targeting the most vulnerable members of the population
• Strengthening the health care delivery system at the national, district and Health Sub-district levels
• Strengthening and operationalising the legal and regulatory framework • Strengthening integrated support systems for improved service delivery • Development of strategic policies, research and information management
systems that support effective planning and service delivery. Decentralisation of health services and the Sector Wide Approach (SWAp) are the focal implementation modalities for the HSSP. The different stakeholders in the sector have different mandates from the Constitution, the Local Governments Act and the NHP and HSSP. In particular there are different responsibilities for the Central and Local Governments. The core functions of the Central Government against which performance is determined are:
• Policy formulation, standard setting and quality assurance; • Resource mobilisation; • Training, Capacity development and Technical support; • Provision of nationally coordinated services, e.g. Epidemic Control; • Coordination of health services; • Monitoring and Evaluation of overall sector performance and
The responsibilities of the Local Governments (districts and delegated to Health sub-Districts) are:
• Implementation of national health policies; • Planning and management of district health services; • Provision of disease prevention, health promotion, curative and rehabilitative
services with emphasis on the UNMHCP; • Vector Control; • Health Education; • Ensuring provision of safe water and environment sanitation and • Health data collection, management, interpretation, dissemination and utilisation.
2
Figure 1.1: Overview of the Sector Programme
Programme Goal
Expanded Economic Growth Increased Social Development
Poverty Eradication
Programme Development Objective Reduced Morbidity and Mortality
from major causes of ill health and reduced disparity therein
Program output 1 Program output 2 Program output 3 Program output 4 Program output 5 Minimum Health Care Package implemented,
Health Care Delivery system strengthened
Legal and regulatory framework strengthened and operational
Integrated support systems strengthened and operational
Policy, planning & information management system operational; Research and development implemented
Elements
Elements Elements Elements Elements
1. Control of Communicable Diseases
- Malaria - STD/HIV/AIDS - TB
2. Integrated Management of Childhood Illness
3. Sexual and Reproductive Health & Rights
4. Immunisation 5. Environmental Health 6. Health Education and
Promotion 7. School Health 8. Epidemics and
Disaster Preparedness & Response
9. Nutrition 10. Interventions against
Diseases Targeted for Elimination or Eradication
11. Mental Health 12. Essential Clinical Care
Restructured Ministry of Health and support institutions Decentralised health care delivery system Partnership with private sector. Inter-sectoral linkages strengthened
Health Acts Professional Councils Private sector regulated Traditional practitioners regulated
1. Human Resources for Health
2. Health Care
Financing 3. Health Infrastructure 4. Laboratory Services 5. Procurement and
management of drugs, medical supplies and logistics
1. Policy & Planning 2. Quality Assurance 3. Health Information
System 4. Research and
Development
3
For each HSSP implementation year, and as part of the strategic thinking and planning process, the GoU and stakeholders in the sector, examine the performance of the health sector against set targets and for the different levels against their responsibilities. The analysis also takes into consideration the contributions of the sector in the overall context of poverty eradication and national development. The Annual Health Sector Performance for the FY 2003/04 forms the subject content for this report.
1.2 The Annual Health Sector Performance Report FY 2003/04
The period under report is the fourth year of HSSP implementation, the Financial Year 2003/04. The process of compiling this report has greatly benefited from the experiences of the previous years of HSSP implementation. As in the other preceding reports, the emphasis remains on assessing the implementation of the HSSP both in the perspective of the period under report and in relation to the overall sector achievements and strategic planning. Within this framework, efforts have been made to:
• Focus more on performance at the district level and making comparisons among the districts by use of a League Table
• Highlight the individual and collective contribution of the National and Regional Referral Hospitals as well as the PNFP hospitals at similar levels, into the broader picture of delivering the Uganda National Minimum Health Care Package.
• Include the donor expenditure analysis within the Financial Report • Review the progress made towards the specific commitments made at the last
National Health Assembly and Joint Review Mission • Take cognisance of the conceptual and operational changes that are expected
with the transition from HSSP I to HSSP II.
1.3 Sources of Information The compilation of this report relied heavily on the traditional sources of information enshrined in the Monitoring and Evaluation Framework of the HSSP and in particular the HMIS. There were deliberate attempts to obtain information from the districts to supplement and validate the HMIS. Use has also been made of information from undertakings of partners as well as their regular performance reports. The contribution of the central support sub-sector was mainly obtained from the quarterly and annual performance assessment reports. Other sources of information included:
• Reports of Undertakings sanctioned by the November 2003 JRM and National Health Assembly sessions.
• Research and other studies undertaken by various stakeholder institutions
4
1.4 Challenges and Planning for Future Reports The lessons learnt from the compilation of previous reports have gone a long way to improve on the quantity and quality of the information required for the process. The following areas have demonstrated significant improvements;
• The ability of the Resource Centre to analyse the information from the districts according to identified needs
• The provision of expertise by Integrated Disease Surveillance and Response (IDSR) to various programmes in the analysis of their data for national and sub-national surveillance purposes
• Involvement of district and hospital managers in the conceptualisation and data handling for this report
There is need for improvement in the following areas;
• The submission of monthly, quarterly and annual reports by the National and Regional Referral hospitals;
• The submission of the quarterly and annual performance reports by the districts • Central programmes and departments submitting their quarterly and annual
performance reports using the formats provided; • The culture of utilising the available data and information by the Central
programmes and departments • Donor Projects providing appropriate annual reports timely;
The overall picture points towards the attainment of the ultimate goal of obtaining the appropriate quantities of quality data and information in a timely manner so as to make the Annual Performance Reporting exercise easier and more meaningful and a crucial part of the Monitoring and Evaluation of the Sector.
1.5 Outline of the Report The Report is divided into five chapters. Chapter 1 of the Report is an Introduction; Chapter 2 covers an Overview of Sector Performance with national and district level performance against HSSP indicators. Chapter 3 is a more detailed discussion of Implementation of the HSSP looking at performance against different elements of the Uganda National Minimum Health Care Package (UNMHCP) and the Support systems to the UNMHCP. Chapter 4 recapitulates the deliberations of the first National Health Assembly with emphasis on the various resolutions, the actions taken to operationalise those resolutions and the way forward. The Chapter also looks at the Undertakings that were adopted at the 9th Joint Review Mission and provides a broad picture of the progress made during the period under report. Chapter 5 summarises the progress made in the strategic planning process at the national level and the status of the second Health Sector Strategic Plan.
5
Chapter 2 Overview of Health Sector Performance FY 2003/04
2.1 Performance against HSSP Indicators The health sector stakeholders agreed to a set of indicators for the monitoring of the HSSP at the national and the district levels. Targets for these indicators for the HSSP period were agreed, and annual targets have been derived from these. As part of a dynamic process, these benchmarks have undergone revision particularly in view of the fact that the resources required for the implementation of the HSSP have not been available in the quantities required. The targets for the national level indicators for the FY 2003/04 were reviewed and agreed upon at the Mid-Term Review of the HSSP (MTR) in April 2003. The performance against the 18 HSSP monitoring indicators for FY 2003/04 is shown in Table 2.1. In addition, this Report details out the variation of performance amongst districts and for the first time presents a framework for objective assessment of hospital performance. District performance is discussed in this section and more analytically under Chapter 2.3; with the help of a League Table while the hospital performance is discussed in detail in Chapter 3. The health sector performance has continued to improve as shown by a number of the indicators whose performance have surpassed FY 2002/03 levels (OPD attendance, the number of deliveries in health facilities, the proportion of approved posts filled by trained health workers, HMIS completeness and timeliness). There is no change registered in the DPT3/Pentavalent vaccine coverage (from 84% to 83%), and the proportion of indicative PHC-CG drug budget used for drugs has registered a decline (from 66% to 51%). Five indicators were previously chosen from the longer list of HSSP indicators to provide a global view of sector performance, and are used to measure sector performance at the level of the Poverty Eradication Action Plan (PEAP). These are included together with global development indicators and indicators of other sectors in the Poverty Monitoring and Evaluation Strategy (PMES). The trends in the performance for the PEAP indicators for the FY 1999/00 to FY 2003/04 as presented in Table 2.2 are used in this Report to assess overall Health Sector Performance in FY 2003/04, Year 4 of the HSSP, in relation to the previous years and in comparison to the HSSP 2005 targets. Other indicators are mentioned in this chapter, but more detailed discussion is available under the appropriate sections of the UNMHCP in Chapter 3 of this Report.
6
Table 2.1: Performance against the HSSP Monitoring Indicators.
Category
Indicator Purpose (What it measures)
Baseline (1999/00) National Value
2002 / 03 2003 / 04 Data source Target Achieved Target Achieved
1 Input Percentage of GOU budget allocated to health sector Commitment of GOU to health 7.3 % 9.6% 9.0% 10% 9.6% MoH/ MoFPED 2 Input Percentage of PHC CG funds released on time to the sector ( Non salary
recurrent and capital ) Level of Govt. honouring its commitment to the sector
100% 97% 100% HPD MoH MoFPED
3 Input Total public (GoU and donor) allocation to health per capita Equity of health resource allocation $ 4.80 $8.0 $ 7.2 $8.0 $7.83 MoH MoFPED
4 Process Percentage of disbursed PHC-CGs that are expended Absorption capacity at the district level
50 % 95% 100% Monitoring Reports
5 Process Proportion of districts submitting complete HMIS monthly returns to MOH in time
Management capacity for the reporting system
15.6 % 75% 70 % 85% 85% HMIS reports
6 Process Percentage of facilities without any stock-outs of chloroquine, ORS, cotrimoxazole and measles vaccine
Drug management protocols 29.1 % 60% 80% HMIS/ Records review
7. Process Percentage of population residing within 5 km of a health facility (public or PNFP) providing the MHCP by district
Equity and access (Implementation of the UNMHCP)
57 % 72% 72%* Mapping exercise
8 Output Percentage of children < 1 yr receiving DPT 3 according to schedule by district Utilisation (PEAP Indicator) 41.4 % 70% 84 % 85% 83%
9 Output Proportion of approved posts that are filled by trained health personnel Level of staffing implementation of HRD policy
33 %* 42% 66% 68%* HMIS/Staff Inventories
10 Output Contraceptive Prevalence Rate (CPR) Couple Years of Protection (CYP)
Utilisation 15 % NA NA 228,675
223,686
UDHS HMIS
11 Output Proportion of surveyed population expressing satisfaction with the health services Quality of care NA NA NA NA NA Community surveys
12 Output Urban / Rural specific HIV sero-prevalence rates HIV infection 10.9 % Urban 4.3 % Rural 6.8 %Average
5.8% 6.2% Average 6.2%** Average
ACP reports
13 Output Percentage of deliveries taking place in a health facility (Govt. and NGO ) Deliveries supervised by health workers
Utilisation ( PEAP )
25.2 % 38 % UDHS
28% 20.3 % 30% 24.4%
HMIS Reports
14 Output Total Govt. and NGO OPD utilisation per person per year Utilisation ( PEAP ) 0.40 0.65 0.72 0.7 0.79 HMIS Reports 15 Output Health facility level specific number of C/Sections per 1000 deliveries within the
catchment area of the facility Level of surgical obstetric care at HC IV
14.0 per 1000 live births
NA NA NA NA HMIS Records
16 Output Proportion of TB cases notified compared to expected Effectiveness of surveillance system 50 % 70% 99.7% 70% 49%*** NTLP Reports
17 Malaria case fatality rate among children < 5 yrs old Quality of case management 3% 3% **** Population. Surveys
18 Percentage of fever/uncomplicated malaria cases ( all ages ) correctly managed at health facilities
Access to effective malaria case management
NA NA NA NA NA Facility based surveys
*has not been updated since 2002/03;** 2002/03 & 2003/04 figures not really comparable to the baseline; *** the 2002/03 & 2003/04 figures not comparable as measurement changed; ****estimate from RRH
7
Table 2.2: Trends for the 5 PEAP indicators 1999/00 to 2003/04
Indicator Baseline 1999/00
2000/01 2001/02 2002/03
2003/04 2004/05 Target
OPD Utilisation
0.40 0.43 0.60 0.72 0.79 0.7
DPT 3/Pentavalent vaccine coverage
41% 48% 63% 84% 83% 85%
Deliveries at Health Facilities – GoU and PNFP
25.2% 22.6% 19% 20.3% 24.4% 35%
Approved Posts filled by Trained Health Workers
33% 40% 42% 66% 68% 52%
National Average HIV Sero–prevalence as captured from ANC Surveillance sites
6.8% 6.1% 6.5% 6.2% NA 5%
2.1.1 New Outpatient Attendance in Government and PNFP Health Units
New Outpatient Attendance (OPD) in Government and PNFP units is used as a measure of utilisation of health services, and therefore is a measure of the quality and quantity of services (supply side) and the health seeking behaviour of the population (demand side). There has been a steady increase in new OPD attendees since the launching of the NHP and HSSP. Per capita attendance has risen from 0.4 in FY 1999/00 to 0.79 in FY 2003/04, which is a 97.5% increase over the period. This level of achievement surpasses the FY 2004/05 target of 0.7. The increase is even more apparent using absolute figures with new OPD attendees increasing from 9.3 million in FY 1999/00 to 20.1 million in FY 2003/04 (116% increase). The large increases in OPD attendance can be attributed to:
• Improved sector management and advocacy at all levels; • Improvements in sector funding levels (budget) and management with increased
efficiency and equity; • The abolition of User Fees in public units (except for private wings in hospitals)
as of March 2001 and decreased fees in some of the PNFP units; • Improving geographical access to services with construction of new health units
especially in previously under-served areas; • The improved quality of services – more drugs and other health supplies, and
more trained health workers. The increased availability of drugs in the FY 2003/04 is likely to have played a particularly important role in maintaining and further increasing the high OPD utilisation rates.
The best five performing districts on this indicator are; Moyo, Adjumani, Gulu, Kabale and Kisoro while the least performing districts are: Kibale, Bugiri, Kotido, Iganga and Mubende districts (see Figure 2.1). All the five best performing districts are border districts, with the first two (Moyo and Adjumani) also playing host to large numbers of refugees1 while Gulu is characterised by Internally Displaced Populations concentrated in camps. The performance ranges from 0.46 attendances per person per year in Kibale to 1 outpatient attendance has previously been noted to be much higher amongst refugee compared to native populations
8
1.43 in Moyo and Adjumani. Last year (FY 2002/03) Kampala was the least performer with 0.4 visits per person per year in this indicator mainly due to incomplete reporting that has largely been corrected; hence the improved performance for FY 2003/04 of 0.65 visits per person per year. On the other hand the high utilisation of OPD services along the borders of the country especially in the North and West of the country, seems to indicate that people from the neighbouring countries come here seeking the better quality services. It is important to note the factors which may have worked in the opposite direction – decreasing OPD utilisation – which include the increasing coverage of Home Based Interventions especially Home Based Management of Fever (HBMF) in the country. The increasing number of children being managed for fevers in the community would imply that fewer of these children end up in health centres and hospitals for In-Patient and Out-Patient visits. Currently there are still gaps in the data of the number of children that have been treated under this programme – see Chapter 3. In some districts however this has already been related to declines in OPD attendance, as seen in Adjumani District.
Figure 2.1: Variation of New OPD Attendance by District FY 2003/04
0.00
0.20
0.40
0.60
0.80
1.00
1.20
1.40
1.60
Kiba
ale
Bug
iri
Kot
ido
Igan
ga
Mub
ende
Toro
ro
Kay
unga
Apa
c
May
uge
Nak
apiri
pirit
Kam
wen
ge
Ruk
ungi
ri
Mas
indi
Wak
iso
Kam
uli
Kam
pala
Lira
Kata
kwi
Mor
oto
Muk
ono
Pade
r
Mba
rara
Kanu
ngu
Luw
ero
Kibo
ga
Siro
nko
Sem
babu
le
Kapc
horw
a
Mba
le
Nat
iona
l
Ntu
ngam
o
Kye
njoj
o
Yum
be
Mas
aka
Bus
ia
Neb
bi
Kitg
um
Hoi
ma
Aru
a
Kum
i
Kas
ese
Bush
enyi
Kabe
ram
aido
Mpi
gi
Kab
arol
e
Sor
oti
Kala
ngal
a
Pal
lisa
Bund
ibug
yo
Nak
ason
gola
Jinj
a
Rak
ai
Kis
oro
Kaba
le
Gul
u
Adju
man
i
Moy
o
0.79
2.1.2 DPT 3/Pentavalent Vaccine Coverage
The Pentavalent Vaccine coverage (formerly DPT3 coverage) is used as a proxy measure for immunisation performance and general health sector performance. The national coverage for the reporting period is 83%, which is a 1.2% drop from last FY performance of 84%. This stagnation may be attributed to a plateau effect (more efforts may be needed to see equivalent increases that were seen at lower levels of coverage), and National Immunisation Days (NIDs) fatigue. At 83% the performance of the indicator has surpassed the annual target of 80% and it is still possible that the HSSP
9
target of 85% will be reached, however particular efforts will be needed to ensure this. A more detailed discussion on immunisation is in Chapter 3. The district performance against this indicator varies from 44% in Pader district to 139% in Mbale district (see Figure 2.2). The five best performing districts are; Mbale, Kumi, Sironko, Kalangala and Kabarole while the least performing districts are; Pader, Lira, Katakwi, Kitgum and Nakapiripirit. All the very poorly performing districts experience some insecurity and this is likely to be a major contributing factor to the low coverage. Figure 2.2: Variation of Pentavalent Vaccine Coverage by district FY 2003/04
0
20
40
60
80
100
120
140
160
Pade
r
Kitg
um Lira
Kat
akw
i
Nak
apiri
pirit
Kotid
o
Kapc
horw
a
Mas
indi
Luw
ero
Moy
o
Sem
babu
le
Kam
wen
ge
Kibo
ga
Yum
be
Wak
iso
Kyen
jojo
Hoi
ma
Mor
oto
Kiba
ale
Bugi
ri
Kam
pala
Igan
ga
Kiso
ro
May
uge
Kase
se
Adju
man
i
Toro
ro
Mub
ende
Mas
aka
Rak
ai
Ruk
ungi
ri
Mba
rara
Kabe
ram
aido
Arua
Nat
iona
l
Ntu
ngam
o
Kan
ungu
Jinj
a
Palli
sa
Bund
ibug
yo
Nak
ason
gola
Kaba
le
Apac
Kam
uli
Muk
ono
Kayu
nga
Mpi
gi
Busi
a
Neb
bi
Bush
enyi
Soro
ti
Gul
u
Kab
arol
e
Kala
ngal
a
Siro
nko
Kum
i
Mba
le
83%
2.1.3 Deliveries in Health Facilities
Whereas an improvement has been registered in performance against this indicator in the year under review as compared to FY 2002/03, the utilisation of the health facilities for safe deliveries remains unacceptably low. The proportion of expecting women who deliver in government and PNFP health units has risen by 20% from 20.3% to 24.4% between FY 2002/03 and FY 2003/04 (see Table 2.3). Table 2.3: Total Number of Deliveries in Government and PNFP Units
Financial Year 2001/02 2002/03 2003/04 % Increase between the years 2001/02 to 2002/03
2002/03 to 2003/04
Number of deliveries
214,083 262,633 303,799 20% 16%
Proportion of all expectant women delivering in GoU & PNFP units
19% 20.3% 24.4% 7% 20%
10
The coverage for this indicator shows marked variation across the country. A large proportion of the deliveries are contributed by a few districts on the right hand side of the national average as shown in Figure 2.3, while many districts are well below the national average of 24.4% to the left of the graph. Figure 2.3: Deliveries in health units by district FY 2003/04
0
10
20
30
40
50
60
70
Nak
apiri
pirit
Kotid
o
Kam
wen
ge
Kata
kwi
Kala
ngal
a
Kyen
jojo
Yum
be
Sem
babu
le
Kapc
horw
a
Mub
ende
Mor
oto
Bugi
ri
Kabe
ram
aido
Kaba
le
May
uge
Bund
ibug
yo
Kiba
ale
Apac
Siro
nko
Wak
iso
Mba
rara
Ntu
ngam
o
Arua
Kitg
um
Adju
man
i
Pade
r
Kanu
ngu
Rak
ai
Bush
enyi
Mas
indi
Moy
o
Mas
aka
Busi
a
Lira
Kayu
nga
Kase
se
Nak
ason
gola
Toro
ro
Kibo
ga
Nat
iona
l
Mba
le
Hoi
ma
Mpi
gi
Igan
ga
Luw
ero
Gul
u
Ruk
ungi
ri
Kam
uli
Muk
ono
Kaba
role
Kiso
ro
Pallis
a
Neb
bi
Soro
ti
Jinj
a
Kum
i
Kam
pala
24.4%
The best performing districts are Kampala, Kumi, Jinja, Soroti and Nebbi and the least performers are Nakapiripirit, Kotido, Kamwenge, Katakwi and Kalangala. All the best performing districts have at least 2 hospitals each, and apart from Nakapiripirit and Kotido, which are both in Karamoja where communities have peculiar cultural beliefs related to Reproductive Health, the other 3 least performers have no hospitals. The availability of hospital services is a major determinant for pregnant women’s choice to deliver in a health facility. It has been noted that in most districts over 30% of the deliveries in health facilities actually occur in the hospital(s). This may be a reflection of the failure to-date of the HC IV to take up their due function as centres for Comprehensive Emergency Obstetric Care (CEmOC) and HC IIIs for Basic Emergency Obstetric Care (BEmOC). It is interesting to note that Kampala has emerged the best performer for this indicator in the period under review. This is mainly as a result of the more complete data submitted by Kampala district for FY 2003/04 especially on deliveries from Mulago Hospital and the major PNFP hospitals (Nsambya, Rubaga and Mengo). More on this indicator is covered under Chapter 3 on Sexual and Reproductive Health and Rights. The reasons for the low turn up of mothers have been studied and include:
• Perceived poor quality of services particularly lack of equipment, supplies, water, light and privacy;
11
• Cost to the clients as quite often mothers are asked to bring gloves, cotton, and mackintoshes;
• Poor attitude of health workers, with midwives particularly reported to be rude to mothers;
• Cultural barriers and use of TBAs and other alternatives in the society; Reproductive health supplies are often lacking at the health units which can be attributed to general under-funding, but also due to the fact that these supplies are not prioritised by the health units, HSDs and districts. Discussions have been held at various fora on maternal health and in particular the low turn up of mothers for deliveries in health units despite good Antenatal Care attendance. The performance well below target shows that there is still a big need for improvement, particularly if the sector is to contribute to improvements in health outcomes like maternal and child mortality. This is discussed further under Sexual and Reproductive Health and Rights in Chapter 3 of the Report.
2.1.4 Approved Posts filled by Trained Health Workers
The availability of trained service providers is very crucial for the attainment of the HSSP objectives. A Health Workers Inventory (HWI), which has been long overdue and was emphasised as an essential undertaking by the HSSP Mid Term Review, was compiled in the FY 2002/03. The data is regularly updated. The HSSP baseline of 33% was based on the Uganda National Human Resource Requirements for HC II, III, and IV Report compiled by MoH (January 1999), which excluded Hospitals. The staffing standards in the report differ from the HSSP staff norms in the following ways:
• Nursing Assistants were not included in the standards used in 1999; • 1999 staff standards were more generous with 1 Clinical Officer, 1 Enrolled
Nurse and I Enrolled Midwife at the HC II against 1 Enrolled Comprehensive Nurse in the HSSP norms.
The staffing level of 68% reflected as the HSSP Indicator in Tables 2.1 and 2.2 is based on the HWI as of October 2004 and compares the staffing norms with actual numbers of health staff (non-medical staff are not included) excluding Nursing Assistants. As highlighted in Table 2.4 when Nursing Assistants are included in the calculations the staffing level improves to 86%. The staffing levels in the AHSPR of FY 2002/03 have since been updated. These estimates (FY 2002/03 and FY 2003/04) differ from previous estimates in that:
• The inventory over the last two years has been exhaustive, whereas previous figures seem to have been under-estimates, as some districts were indicated with as few staff as 10;
• There has been recruitment over the four years of the HSSP; • The centralised payroll has improved capture of information about health
workers and has been used to validate the inventory.
12
Table 2.4: Proportion of Approved Posts that are filled by appropriately trained health workers
Type of Norms HC II HC III HCIV Total PHC level
District Hospital
Total
HSSP staff norms (GoU) 90% 78% 92% 85% 91% 86% HSSP norms, exclude Nursing Assts. (GoU)
109% 58% 75% 69% 66% 68%
HSSP norms include PNFPs 98% 84% 93% 90% 94% 91% There has hardly been any improvement in this indicator with 66% performance in FY 2002/03 and 68% in the FY 2003/04. This is not surprising since there was hardly any recruitment in FY 2003/04. The changes are more likely to be due to more complete data (see Annex III and Chapter 3 for more details on Human Resources for Health). The best performing districts are Kampala, Adjumani, Kalangala, Ntungamo and Arua. The least performers are Kamwenge, Pader, Kanungu, Sironko and Kabale. Apart from Kabale all the least performers for this indicator are new districts. This is because new districts may not have as many Health units, usually lack hospitals and may not be in a position to attract health workers. This is important to note for future resource allocation. The challenges for human resources management in the sector in the FY 2003/04 centred on discussion with other sector stakeholders including MoFPED, MoPS and health workers representatives. The improvement in health workers’ salaries had implications on the wage bill and as such did not make it possible to recruit health workers by the different districts. The HWI has highlighted inequities for example the proportion of staff positions filled by appropriately trained health workers ranges from 40% in Kamwenge to 265% in Kampala district (including Nursing Assistants). Affirmative action is urgently required during resource allocation to enable the poorly covered districts to catch up. Many of the districts with poor performance against this indicator have previously failed to attract health workers even when provided with a budget for recruitment. An incentive package to attract health workers to these districts was proposed by the MoH and presented to MoPS. The MoPS indicates that a comprehensive approach to human resource management is being pursued.
2.1.5 National Average HIV Sero-prevalence
The national HIV sero-prevalence (from ANC Sentinel sites) has stabilised between 6% and 7% for the last 4 years. It was recognised that there is need to have an estimate that is more representative of the general population. Hence, the MoH commissioned an HIV sero-survey and data collection is currently ongoing. More information regarding the STD/HIV/AIDS programme appears in Chapter 3 of this Report. It is recognised that other sectors contribute to the performance of this indicator. The health sector retains the responsibility of collecting information and reporting on it while the responsibility for performance is at the level of the PEAP. However, given the increased availability of Anti-Retroviral Therapy it is recognised that different indicators may need to be used to track any changes in prevalence/incidence that may occur as a result of this.
13
2.2 Summary Financial Report for the FY 2003/04
2.2.1 The financing target and the HSSP Resource Envelope
The Health Financing Strategy (HFS) estimated that the total annual cost of the HSSP, in the medium term, as US$ 28 per capita. In order to maximise efficiency, the bulk of this financing would be channelled through the GoU budget as this has been shown to enable the sector to target funding against set priorities. Despite inflation rates and some adjustments in the composition of the UNMHCP2, it is estimated that the US$ 28 per capita remains a realistic target and the HFS outlined a strategy to achieve this financing goal by the FY 2019/20. The HFS is being updated in the HSSP II formulation process. The Uganda National Health Accounts for the 1998/99 to 2000/01 completed in FY 2003/04 have shown that when all sources of funding for the health sector are considered, Total Health Expenditure (THE) is slightly less than US $20 per capita - see Chapter 3 Health Financing Section for more detail. Most of the expenditure is by the households and within the private sector, where the spending is not necessarily on HSSP priorities. Public sources (GoU and donor) contribute less than 50% of Total Health Expenditure.
2.2.2 FY 2003/04 Budget Performance and Management
In FY 2003/04, the approved budget including donor projects was Ugshs 385.54 billion, equivalent to US$ 8.4 per capita. Of this, a total of Ugshs 361 billion is estimated to have been spent equivalent to US$ 7.83 per capita. This is an improvement from the FY 2002/03 during which an estimated US$ 7.2 per capita was spent in the health sector by government and donors. This expenditure remains much less than the requirement of US$ 28 per capita. Table 2.5 and Chapter 3 provide more information. Performance against the budget was 94% with the government budget showing performance of 95% and the donor projects 92%3. As in FY 2002/03 the GoU budget including donor budget support exceeded donor project funding. Table 2.5: HSSP Funding for the FY 2003/04
Source Budget Expenditure Performance Comment
GoU budget
218.84 207.99 95% Compiled from government expenditure documents
Donor Projects
166.7 153.26 92% Estimated from submission from 8 donors
Total 385.54 361.25 94%
The health sector has made efforts to use the available resources in the most efficient and equitable manner. The increasing channelling of most resources through the budget has enabled the use of the government and SWAP procedures for management of these resources. The Health Sector Working Group is mandated to make resource allocation proposals, which are then concretised in the Budget Framework Paper. For the FY
2 Particularly regarding the wide scale provision of anti-retroviral drugs for HIV, the Pentavalent vaccine and Home Based Management of Fever 3 Donor Project performance is 92% against the MTEF figures of 166.7 billion of July 2003/04
14
2003/04 the sector policy priorities and spending priorities as highlighted in the Budget Framework Paper were to address efficiency and equity in the bid to contribute to Poverty Eradication. In the FY 2003/04 this was operationalised in the following ways: Allocating resources to target the poor and most vulnerable members of society in line with the PEAP – was done by continuing to allocate more financial resources at the Primary Health Care level where most of the poor in the country obtain their services. Funds to districts were allocated after putting into consideration a number of factors including: need for health care; availability of other sources of health care funding like: donor projects and availability of other vertical funding like to hospitals. In addition, in order to further decrease cost to the users, the budget for PNFP hospitals and health units was increased to enable these providers provide good quality services at a lower cost to the community. Efforts were made to target health care inputs with a large impact on quality of services especially drugs and supplies. For the FY 2003/04 both the level of funding for drugs and supplies and the mode of funding were targeted. The drug credit lines previously introduced in FY 2002/03 were scaled up in magnitude and in addition included General and Regional Referral Hospitals. In terms of programme priorities, the need to increase availability of Reproductive Health services led to the emphasis on infrastructure – HC IVs, HC IIIs and multipurpose vehicles- that would facilitate the provision of these services. The sector sought and was granted PAF status for the general hospitals, which is likely to improve budget performance at this level and also better synchronisation with the rest of the district health services. For National and Regional Referral Hospitals the emphasis was on preparation of appropriate Costed Business Plans to enable due prioritisation and accountability. Annex II and Chapter 3 provide more detail on the GoU budget performance. The wage component realised 98% performance, non-wage component 98% and Domestic Development 84%. Mulago Hospital had the highest budget performance at 112% and the Regional Referral Hospitals the lowest at 82%.
Disbursement of Budget Funds to the Local Governments
The performance of MoH, MoFPED and Local Governments in disbursing PHC funds was not as good as in FY 2002/03. The analysis from 22 districts that submitted complete data showed that the disbursement performance was good for the PHC-CG Non-wage grant (utilised by the DDHS and HSD for management and service delivery) and the NGO grant – at 89%. This was followed by the wage grant performance at 88% and the lowest performance was noted for the PHC-CG Development performance at 72% (see Figure 2.4). The budget performance in these 22 districts seems to be lower that the national averages in Annex II. This illustrates the variations across the country. The variation in performance is usually due to the variations in submitting reports and requests for PHC funds.
15
Figure 2.4: District PHC-CG Releases against Allocation
88%94% 95%
89%
72%
35%
0%10%20%30%40%50%60%70%80%90%
100%
PHC wage DDHS HSDs NGOs PHC Dev. Loc. Gov't
Relating Inputs with Outputs The reforms undertaken by the health sector continue to achieve results. When the improvements in the sector outputs (represented by OPD attendance) are plotted against the GoU budget for the health sector, it is apparent that with every increase in the budget the curve grows even steeper – Figure 2.5. This is in agreement with observations that the sector is improving utilisation of its infrastructural and human resources by availing more drugs and supplies. This has attracted more Ugandans to the health centres, thus improved efficiency all around. Figure 2.5: Relating health sector Inputs with Outputs
Ugandan health financing reforms delivering output results
0
5
10
15
20
25
0 50 100 150 200 250
GoU Budget Expenditure (Billions of Shillings 2003/04 Prices)
Out
-pat
ient
atte
ndan
ces
(mill
ions
)
2001/02
1997/981998/99
1999/00 2000/01
2002/03
2003/04The increasing gradient of this graph proves that the the sector is becoming more efficient at turning its budget into health care outputs
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2.2.3 Financial Management
Ministry of Health Headquarters - Programme 9 Tracking Study
In accordance with an undertaking from the October 2002 Joint Review Mission a Tracking Study was performed during FY 2002/03 on the MoH’s PAF funds allocated to Programme 9: National Service Delivery Programmes. The health sector stakeholders have discussed the Report and follow up actions were agreed and are being implemented including: sorting out delays in the release of funds within the MoH due to various bottlenecks; decreased reallocation between programmes at the MoH: and countering the low levels of reporting and accountability on Programme 9 and other funds from the various sub-programmes
Districts – Financial Management Monitoring
The Monitoring for the PHC-CG has shown improvements in financial management at district and lower levels. However there are still some challenges particularly with compliance with guidelines. The following have been observed:
• Proportion of budget to be spent on various areas: this is still a challenge as shown using the 50% indicative budget for drugs – see under Drug Management.
• Poorer performance on timeliness and completeness of reporting in FY 2003/04 compared to FY 2002/03. This has in turn led to delayed release of funds by MoFPED. For example in Quarter 1 of FY 2003/04 in 18 districts studied, only 59% of the funds expected were released. This improved to 82% in the second quarter.
• Inaccurate information in Quarterly Reports: the reports submitted for consideration by the MoH before funds can be released for the subsequent quarter, may differ from the information in the book of accounts. In particular the expenditure is often overstated to create the impression that the funds are exhausted.
• Handling of Capital Development Funds: in most districts construction and training of Nursing Assistants have taken off very slowly because the funds come in small instalments, and the complicated tender procedures. This has been worsened by poor release of funds by MoFPED against this the PHC Development Grant.
2.3 Measuring District Performance against the HSSP Indicators This report (FY 2003/04) is the second time that an assessment of individual districts’ performance against the agreed district HSSP Monitoring Indicators has been carried out with the help of a District League table. The information from this assessment is used to rank districts. For the FY 2003/04 report it was agreed that the same indicators for the League Table as for FY 2002/03 report be used to allow for fair comparison between the years. It has been easier this time round to assemble the necessary data to make up the League Table, which as a result is more complete than the previous one. Some districts however did not provide information on some of the indicators such as drug procurement (especially in the Private-for-Profit sub-sector) and financial management. This has counted against these districts.
17
What makes up the League Table?
A number of both HSSP and non-HSSP district monitoring indicators have been used for the league table. These are:
• Information Indicators: District population; Number of HSDs and Number of hospitals.
• Management Indicators: Management of the PHC-CG – measured by timeliness of reporting/requests; Management of health data – measured by completeness and timeliness of HMIS reporting; Expenditure on key inputs – measured by proportion of indicative PHC-CG budgets spent on drugs; and Management of inputs – proportion of staff norms appropriately filled.
• Service Delivery Output Indicators: Pentavalent vaccine coverage; OPD new attendances per capita; Proportion of expectant mothers delivering in GOU and PNFP units; Proportion of expected TB cases that are notified; Proportion of pregnant women receiving the 2nd dose of Fansidar in Pregnancy (IPT2); and Pit Latrine coverage.
The information indicators are not accorded a score as these are not determined by the district but by historical circumstances, central level, and development partners. However these indicators do influence outputs and therefore are included for perspective. The magnitude of contribution for each of the indicators has been determined mainly by 3 factors: • Importance of factor in terms of its contribution to the overall health outcomes - For
example the indicator on drugs scores 10, whereas timeliness of HMIS is 5. • Magnitude of district influence on the performance of the indicator - For example
the indicator on staff norms although very important, the contribution by the district is relatively small thus the score of 5.
• The HSSP indicators that are also used as PEAP indicators are awarded the highest scores of 12.5 each.
The Purpose of the League Table
The League Table has been put in place to facilitate the following: • Compare sector performance between districts and therefore determine good and
poor performers; • Provide information to facilitate the analysis of circumstances behind good and poor
performance at the district level, and thus enable appropriate corrective measures which may range from increasing the amount of resources (such as funds, infrastructure, equipment or staff) or more frequent and regular support supervision;
• Increase Local Government ownership for achievements – the AHSPR is discussed at the NHA where political, administrative and technical leadership of the districts will be in attendance;
• Encourage good practices – good management, innovations and timely reporting. The League Table is not meant to embarrass Local Governments of poorly performing districts, but rather to make them question why their district is performing poorly, and considering ways in which that performance can improve. The districts that have shown marked improvement or decline are assisted to see how they are performing against other districts.
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The League Table Scores
The top 10 districts in order of ranking are: Gulu, Jinja, Adjumani, Moyo, Tororo, Rukungiri, Mpigi, Bushenyi, Kampala and Busia. The bottom 10 districts from the last are: Kotido, Pader, Yumbe, Kamwenge, Iganga, Wakiso, Masindi, Lira, Moroto and Mubende. The detailed League Table is included in this Report as Annex I and Figure 2.6 is a map highlighting the top 10 and the bottom 10 performers. The good and poor performers are spread across the country.
Figure 2.6: District Performance according to the League Table
When the League Tables for FY 2002/03 and for FY 2003/04 are compared it is noted that the overall score in FY 2002/03 was higher (63.1 compared to 60.2) and this has been contributed to by lower scores on top of the table (the top score was 85 in FY 2002/03 compared to 77.6 in FY 2003/04) and the bottom districts did worse in FY 2002/03 compared to FY 2003/04 (7 districts in FY 2003/04 scored less than 41.7 the least score in FY 2002/03). This indicates when the aggregate PEAP indicators are considered, an improvement is noted but when the output and some management indicators are analysed at the district level, a decline is noted. At individual district level Gulu, Kampala, Mukono, Mbale and Apac show an improvement of more than 50%, whereas Luwero, Kaberamaido, Mubende, Ntungamo, Nebbi and Pallisa show a decline of more than 30% (see Figure 2.7). The stakeholders and particularly the districts concerned should note the factors causing movement up or down the League Table. Three of the worst 10 performers in the FY 2002/03 League
19
Table have made remarkable improvements and are no longer in the bottom bracket (see Table 2.6). These are Kampala from 47th to 9th position, Bundibugyo from 51st to 35th position, Apac from 54th to 25thposition and Katakwi from 53rd to 44th position. Figure 2.7: Change in overall district Performance
-70
-50
-30
-10
1030
5070
Gul
u
Kam
pala
Muk
ono
Apa
c
Kab
ale
Bun
dibu
gyo
Bus
heny
i
Bus
ia
Toro
ro
Kye
njoj
o
Adj
uman
i
Hoi
ma
Mba
le
Siro
nko
Kat
akw
i
Nak
ason
gola
Mpi
gi
Sor
oti
Nak
apiri
pirit
Kitg
um
Mas
aka
Ruk
ungi
ri
Sem
babu
le
Mas
indi
Pad
er
Kas
ese
Jinj
a
Bug
iri
Kot
ido
Moy
o
Kam
uli
Kib
aale
Yum
be
May
uge
Kib
oga
Mba
rara
Rak
ai
Wak
iso
Kab
arol
e
Kum
i
Lira
Aru
a
Igan
ga
Kap
chor
wa
Kis
oro
Kan
ungu
Kay
unga
Kal
anga
la
Mor
oto
Kam
wen
ge
Pal
lisa
Neb
bi
Ntu
ngam
o
Mub
ende
Kab
eram
aido
Luw
ero
Table 2.6: Movements in & out of the Top and Bottom 10 of the League Table
Top 10 Bottom 10
Stayed in the same group
Jinja, Moyo, Rukungiri Kotido, Masindi, Pader, Yumbe
New Entrant in Group Adjumani, Bushenyi, Busia, Gulu, Kampala, Mpigi, Tororo
Iganga, Kamwenge, Mubende, Lira, Moroto, Wakiso
Factors Influencing District Performance
In order to begin to determine the likely reasons behind good and poor performance some cross analyses have been done. This analysis considered the following variables; a) Performance against Management Indicators – for example the proportion of
indicative drug budget spent b) Performance against Service Delivery/Output Indicators particularly immunisation c) Peculiar circumstances which include:
Districts with insecurity in FY 2003/04 New districts since 2000; and Karamoja Region – the nomadic culture
District Management Performance
Overall district management practices can be represented by some proxies. Study of both League Tables – FY 2002/03 and 2003/04, shows that good performance on the League Table tends to be closely linked to drug management as shown by the proportion of the indicative budget for drugs that has actually been spent on drugs in the FY under review.
20
Table 2.7: Comparing Drug Management Performance and the League Table
District Proportion of Indicative PHC Budget used for drugs
Drug Funding Rank
League Table Score
League Table Rank
Kitgum 120% 1 44.8% 29 Moyo 109% 2 72.1% 4 Adjumani 102% 3 72.5% 3 Gulu 102% 3 77.6% 1 Tororo 96% 4 67.6% 5 Nakasongola 93% 5 61.1% 17 Kyenjoojo 92% 6 61.3% 16 Busia 86% 7 66.0% 10 Sironko 85% 8 53.1% 30 Soroti 83% 9 58.3% 24 As shown in Table 2.7, five of the top 10 performers on the League Table are among the top 10 performers in drug management. The proportion of the drug budget spent on drugs is likely to affect district performance through improved availability of drugs, and therefore more utilisation of services by the population. It is hence likely that well managed district health services in all other aspects are likely to coincide with the appropriate emphasis on providing the necessary inputs.
Service Delivery Capacity:
The indicator “Proportion of children <1 receiving 3 doses of pentavalent vaccine according to schedule” was closely related to overall good performance as shown in Table 2.8. This suggests that districts which have high immunization coverage, measured by Pentavalent vaccine coverage, are likely to be good performers overall. This indicator could therefore be used as a proxy indicator for overall district performance except in cases where the population numbers are questionable. A successful immunisation programme involves a lot of planning and management skills and hence districts that excel in this are likely to apply the same skills across all services leading to high overall performance. Table 2.8: Comparing District Performance on Pentavalent Vaccine Coverage
and League Table Ranking
District
Pentavalent Vaccine Coverage
% Rank
League Table Score
League Table Rank
Mbale 139 1 54.1 14 Kumi 125 2 60.0 20 Sironko 118 3 53.1 30 Kalangala 114 4 59.7 21 Gulu 110 5 77.6 1 Kabarole 110 6 65.3 11 Soroti 103 7 58.3 24 Bushenyi 102 8 66.7 8 Nebbi 99 9 55.5 28 Busia 96 10 66.0 10
21
Districts with marked Insecurity
Among the 7 districts of Northern and North Eastern Uganda which suffered marked insecurity and displacement of persons in the FY 2003/04, Gulu performed best, followed by Soroti in 1st and 24th positions respectively on the League Table and are in the top half of the League Table. The rest are in the bottom half with Lira and Pader districts at 49th and 55th position respectively in the bottom 10 districts on the League Table (see Table 2.9). Table 2.9: Performance of the Districts with marked Insecurity in FY 2003/04
District District with Insecurity
Rank League Table
Score Rank Gulu 1 77.6 1 Soroti 2 58.3 24 Kitgum 3 54.8 29 Kitgum 4 48.6 38 Katakwi 5 44.7 45 Lira 6 42.5 49 Pader 7 35.7 55
The performance of Gulu district particularly needs special mention. A number of factors contributed to the spectacularly good performance in Gulu district. These include:
• The majority of the people live in Internally Displaced People’s Camps or within the Municipality. This has enabled service delivery as most IDP Camps have health units;
• Good management of the district health services which can be illustrated by the good information management (see later under HMIS) and use of the drug budgets to procure drugs;
• Support by partners in addressing the population needs; On the other hand Pader is still close to the bottom of the League Table and this can be attributed to:
• Persistent insecurity – leading to migration of health workers from the district and a mobile population;
• Being a new district, Pader still has limitations in terms of human, logistic and infrastructural capacity.
The health sector stakeholders agreed to a resolution regarding districts with insecurity at the 1st National Health Assembly. The follow-up to this is reported in Chapter 4.
New Districts
Districts that have only been in existence for less than 4 years are likely to be more disadvantaged in terms of infrastructure, logistics and human resource, since marginalisation was the justification for the creation of most of these districts. In the FY 2002/03 analysis was done to see the best performing and the worst performing amongst the new districts. In FY 2002/03, Kaberamaido was the best performer, followed closely by Kanungu and Kyenjojo, with Pader, Yumbe and
22
Nakapiripirit in the bottom positions. This situation has not changed much; except for the decline by Kaberamaido (was overrun by insecurity for a number of months) and the climb by Sironko from 7th to 3rd Only Kyenjojo and Kanungu districts are in the top half of the League Table. The rest are in the bottom half of the League Table with Wakiso, Kamwenge, Yumbe and Pader holding 4 of the bottom 6 position of the Table (see Table 2.10). The poor performance of Wakiso district is a concern given that there is no obvious disadvantage such as poor infrastructure or logistical capacity. Table 2.10: Performance of the New Districts in FY 2003/04
District
New Districts FY 2002/03
Rank
New Districts FY 2003/04
Rank League
Table Score Rank Kyenjojo 3 1 61.3 16 Kanungu 2 2 58.4 23 Sironko 7 3 53.9 30 Kaberamaido 1 4 48.6 38 Mayuge 5 5 48.3 40 Kayunga 4 6 46.6 43 Nakapiripirit 9 7 45.7 44 Wakiso 8 8 41.3 51 Kamwenge 7 9 39.6 53 Yumbe 10 10 39.3 54 Pader 11 11 35.7 55
Karamoja Region:
The Karamoja Region is characterised by peculiarities which have implications for health service delivery. These include nomadism whereby a large proportion of the population, particularly the young males are very mobile, travelling with the animals looking for pasture. The cultural norms of the Karamojong are very negative towards women having deliveries in health units and the use of latrines for faecal disposal. This is illustrated by the poor performance of the Karamoja districts against the key HSSP indicators such as OPD utilisation, deliveries in health units and latrine coverage (see Table 2.11). Table 2.11: Performance of the districts in the Karamoja Region
District Latrine coverage Deliveries in health units
OPD utilisation District League Table
Score Rank Score Rank Score Rank Overall Score
Rank
Nakapiripirit 3% 55 3% 56 0.62 46 45.7 44 Moroto 10% 53 12% 45 0.69 37 43.3 48 Kotido 2% 56 7% 55 0.51 54 30.6 56 Ranked 44th out of 56 in the League Table, Nakapiripirit district is the best performer of the three districts. This level of performance shows that special effort has to be made if the people of Kamaroja are to enjoy the same health services and standards as the rest of the country.
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The Future of the League Table
The District League Table although only introduced in the AHSPR for the first time in 2002/03 has been of immense value in unpacking health sector performance and highlighting the variations between districts. Although no Gold Standard has been used, just comparing districts amongst each other helps to show areas for improvement. However as sector Monitoring and Evaluation matures, and during the development of HSSP II, there is need to judge whether there is scope for further improvement of the League Table as a Monitoring and Evaluation tool. The Joint Review Mission of October could be a forum for this discussion. Among the issues to be discussed should be the following: Should the League Table maintain the same indicators in future? If not which indicators should be discarded and which new ones should brought on board. There have been some proposals for these, which include:
• New indicators to consider: Couple Years of Protection (CYP) and Malaria Case management – possibly use of Case Fatality Rate;
• Indicators to get out – HMIS timeliness and completeness – as they are approaching 100%; Human Resources for Health – as a scored indicator, to an information indicator as the district can do little to make changes in this;
A different concern though is the linkage between good performance on the League Table and the health status of the population. Is there any relationship? Should there be a relationship? What about the data from National and Regional Referral Hospitals – should this continue to be included in its entirety under the districts these hospitals are situated in?
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Chapter 3 Implementation of the Health Sector Strategic Plan
3.1 Delivery of the Uganda National Minimum Health Care Package The Uganda National Minimum Health Care Package (UNMHCP) addresses the priority components of the national disease burden. The 12 elements of the UNMHCP constitute the most cost effective interventions considered to have the highest impact on decreasing population morbidity and mortality. For purposes of demonstrating integration at the implementation level, the elements have been clustered into the following sub-packages;
i) Prevention and Control of Communicable Diseases ii) Maternal and Child Health iii) Prevention and Control of Non-Communicable Diseases iv) Health Promotion and Disease Prevention
For each element within the sub-package, there is a review of the annual targets, an assessment of the achievements made at the national and district levels and the challenges and constraints encountered. Specific efforts are made to relate the reported activities to the expected outputs.
3.1.1 Prevention and Control of Communicable Diseases The Burden of Disease Study of 1995 indicated that communicable diseases contributed more than 65% of the national disease burden. The HMIS data analysed over the years indicate that this continues to be the case. The main focus of the HSSP is on malaria, HIV/AIDS and TB as indicated by their contribution to the national disease burden.
(1) Malaria
Malaria remains the number one cause of morbidity and mortality among the population of Uganda with serious economic and social consequences. During FY 2003/04, malaria accounted for 52% of the OPD attendance while over 400,000 cases were treated by the Community Drug Distributors (CDDs) as part of Home Based Management of Fevers. Malaria still accounts for 30% of inpatient admissions and 9-14% of inpatient deaths (20- 23% of deaths of children under 5 years of age). The focus for Malaria Control is:
• Prompt and effective malaria case management at the health facility, community and household levels
• Vector control including insecticide treated mosquito nets (ITNs), indoor residual insecticide spraying (IRS) and environmental management
• Malaria in pregnancy care including intermittent preventive treatment (IPT). • Malaria epidemic preparedness and response including the prediction, early
detection and containment of epidemics The performance for FY 2003/04 is indicated in the Table 3.1. Key indicators such as the utilisation of ITNs have been difficult to monitor because the data can only be obtained from surveys. The performance indicator positions have therefore been derived from nationally representative surveys and are elaborated on in the various sections.
25
Table 3.1: Performance against HSSP Malaria Indicators
Indicator Baseline Value
Achieved 2002/03
Target 2003/04
Achieved 2003/04
Target 2005
1 The proportion of the population that receive effective treatment for malaria within 24 hrs of onset of symptoms
30% 48%* 55% 60%
2 Proportion of pregnant women who receive protection against malaria through IPT with SP
0% 20.3% 40% 24% 60%
3 The proportion of children under five protected by ITNs
5% 3.8%** 25% 50%
4 Reduced malaria Case Fatality at hospital level to below baseline levels
5% - 3% 3%*** 3%
*Valid for children in HBMF district as at June 2003 **Valid for 6 HBMF districts as at June 2003 ***This is derived from data covering 10 Regional Referral Hospitals
Effective Malaria Case Management:
This strategy is two-pronged, targeting case management at the facility and community levels. Community Level Implementation of the home-based management of fever (HBMF) strategy is at various stages of implementation in 43 out of 56 districts (see Table 3.2). The HBMF strategy shall be initiated in the remaining 13 districts in FY 2004/05. The dispensing of HOMAPAK at community level is ongoing in 33 districts with district–wide coverage in 27 districts and partial coverage in 6 districts. It is envisaged that by the end of FY 2004/05, there shall be district-wide coverage in all districts with the support of the Global Fund. Table 3.2: The Status of HBMF Implementation in the districts
Step Output Districts
1. Sensitization and planning at district level
Supportive district leaders & a district implementation plan
43
2. Training of district trainers District trainers/supervisors of drug distributors
43
3. Orientation of health workers Supportive health workers & health facilities
33
4. Sensitization and planning at sub-county level
Supportive leaders & Community mobilisers
33
5. Sensitization of communities at level LC I level and selection of volunteers to be trained as drug distributors
Sensitized communities and volunteers to be trained as drug distributors
33
6. Training drug distributors Trained drug distributors 33 7. Treatment of children by trained
volunteers (drug distributors) Children with fever being treated 33
8. Supervision of drug distributors Supervised drug distributors
33
26
During the course of the year, procurement and distribution of 8,582,724 doses of HOMAPAK to the implementing districts was supported by various partners as indicated in Table 3.3. Table 3.3: Partner Support in provision of HOMAPAK
Partner
Doses of HOMAPAK
Support to the HSSP (ADB) in 11 districts of Northern Uganda
3,500,000
UPHOLD (USAID) in 20 districts 1,582,724 Malaria Consortium/DfID covering IDP camps 3,500,000 Total 8,582,724
The reports from some of the districts which have attained full HBMF coverage indicate that a substantial number of children with fever have been treated by the community drug distributors. Figure 3.1 compares the children treated at health facilities with those treated by the drug distributors for the districts of Rukungiri, Nakasongola, Kyenjojo, Gulu and Adjumani for FY 2003/04. Figure 3.1: Comparison of the children <5years treated at health facility and by
Community Drug Distributors FY 2003/04
Comparison of number of children <5yrs treated at health facility and by drug distributors 2003/04
66811
145174
43384
34014
34374
46942
133978
53215
19026
44798
0 20000 40000 60000 80000 100000 120000 140000 160000
Adjumani
Gulu
Kyenjojo
Nakasongola
Rukungiri
Dis
tric
t
Number of Children
No. treated at H/U No.treated by Drug Distributors
Under 5s OPD Attendance and the HBMF strategy
According to the data available from 8 HBMF districts, there has been a general increase in OPD attendance of children <5yr over the past 2 years. Figure 3.2 shows the trends in <5yr OPD attendance for 2 consecutive years (FY 2002/03 to FY 2003/04). This increase could be attributed to the following factors;
• Increased availability of drugs with consequent increased utilization of services.
27
• Increased access to services through opening up of new health centres in remote areas.
• HBMF intervention may be reaching the hard-to-reach population, which had previously engaged in self-medication and hence despite the high number of children treated, there is little or no impact on OPD attendance.
• Improved completeness in reporting. Figure 3.2: Comparison between OPD New Attendance for the under 5s for FY
2002/03 and FY 2003/04
107534
72031 66444
252054
81689
161234
7620062352
212715
4810444161
137906
43543
102865
4461648068
0
50000
100000
150000
200000
250000
300000
Adjumani Gulu Kabarole Kiboga Kumi Kyenjojo Nakasongola Rukungiri
District
No.
of n
ew a
tt. u
nder
4yr
s
2002/20032003/2004
Studies done in Rukungiri district indicate a high level of community knowledge of HBMF and community satisfaction with the programme. The community drug distributors (CDDs) are motivated by the trust the communities have put in them in appreciation of their services. Analysis of data from the initial 10 HBMF implementing districts reveals a relatively well-established system. There is a high rate (79%-99%) of recovery of the treated children, >52% children are treated within 24 hours of onset of fever, <0.3% of the children seen died and the attrition rate of drug distributors ranges from 1.5%-21.2%. The major challenges in implementation of HBMF which need immediate attention are; a weak reporting system, inadequate supervision of the CDDs, logistical problems in the delivery of drugs to the CDDs, low community support and attrition of CDDs.
Facility Level The health facility provides a continuum of care from the community level, and during the period under review, the following were done to strengthen effective malaria case management.
• Training workshops on management of severe malaria were conducted for the hospitals that remained uncovered during FY 2002/03
• On-site sensitisation of health workers on the issues of the antimalarial drug policy
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• Ensuring a constant supply of antimalarials at the health facility level
Antimalarial Drug Policy Change.
Since 1997, MCP has been collecting data on antimalarial drug efficacy at 8 sites that are geographically and epidemiologically representative of the malaria ecological strata in Uganda. Data from these sites was used in revision of the antimalarial drug policy in 2000 and 2004. In May 2004, the Case Management Working Group (CMWG) of the ICC for Malaria reviewed antimalarial drug efficacy data from these sites. These data showed a mean treatment failure for CQ/SP after 14 days of follow-up of 21.4% (range 3-45%), which is higher than the 15% level at which WHO recommends a change in the drug policy. The CMWG hence recommended that CQ/SP should be replaced by Artemether-Lumefantrine (Coartem) as 1st line treatment for uncomplicated malaria, oral Quinine as Second line treatment and parenteral Quinine for the treatment of severe and complicated malaria. A proposal to fund this change in policy was submitted to Round 4 of the Global Fund and has been provisionally approved. Plans for rolling out the new policy in the last quarter of 2005 are underway.
Malaria in Pregnancy (MIP)
The strategy aims at all pregnant women receiving 2 doses of SP as intermittent preventive treatment for malaria. The emphasis during the year was to ensure availability of SP at the health unit level, to build an environment of provider confidence to deliver the services and to mobilise communities to utilise ANC services where IPT is provided. The overall coverage for IPT2 for FY2003/04 was 24% (see Figure 3.3). Although this is an increase (of 4%) from FY 2002/03 levels, it is very much below the FY 2003/04 target of 40%. The performance range for the indicator is from 55% for Moyo to 7% for Kampala. The best performers are Moyo, Gulu, Nebbi, Soroti and Kamwenge. The least performers are Kampala, Nakapiripirit, Katakwi, Kibale and Lira. During the course of the year, the following were achieved;
• Training of district trainers/supervisors in 12 districts in addition to the 40 districts already covered.
• Sensitisation of district leaders to MIP in last 12 districts. • Monitoring the supplies of SP to the health units through the PHC and credit
line purchase systems and the Area Team monitoring process • Piloting pragmatic indicators for monitoring of MIP in the districts of Luwero
and Soroti in collaboration with WHO. The pilot was evaluated and recommendations made will influence the Monitoring and Evaluation of MIP in Sub-Saharan Africa.
• Piloting of the community MIP strategy to increase ANC attendance and IPT uptake in the district of Mubende.
29
Figure 3.3: IPT2 coverage by district
0
10
20
30
40
50
60
Kam
pala
Nak
apiri
pirit
Kata
kwi
Kiba
ale
Lira
Kotid
o
Wak
iso
Mas
aka
Bund
ibug
yo
Sem
babu
le
Kiso
ro
Kanu
ngu
Kapc
horw
a
Pallis
a
Kayu
nga
Ruk
ungi
ri
Nak
ason
gola
Mub
ende
Igan
ga
Kitg
um
Ntu
ngam
o
Mba
le
Apac
Mba
rara
Kala
ngal
a
Kabe
ram
aido
May
uge
Mor
oto
Bugi
ri
Mas
indi
Kibo
ga
Nat
iona
l
Mpi
gi
Kaba
role
Kaba
le
Kyen
jojo
Pade
r
Rak
ai
Yum
be
Bush
enyi
Jinj
a
Hoi
ma
Luw
ero
Kase
se
Kam
uli
Siro
nko
Toro
ro
Busi
a
Muk
ono
Adju
man
i
Arua
Kum
i
Kam
wen
ge
Soro
ti
Neb
bi
Gul
u
Moy
o
24%
Insecticide Treated Nets (ITNs) Use of Insecticide treated nets (ITNs) is one of the most cost effective methods of malaria prevention in highly endemic areas. The target is to have all children under 5 years and pregnant women sleeping under ITNs. Following the release of the GFATM funds to Uganda, a decision was taken to distribute all the ITNs free of charge to the target groups. The mechanisms for distributing the free nets are still being worked out. ITNs sales and distribution: In 2003 a total of 467,081 nets were sold/distributed, an increase of almost 187,000 nets or 67% compared to 2002 figures and a more than doubling of the 2001 totals (see Table 3.4). Of these 51% were long-lasting nets, 34% nets bundled with an insecticide treatment kit and only 15% were untreated nets. No exact figures are available for nets sold in the informal sector (drug sellers/drug shops). In the period January to June 2004, 280,470 nets of all types have been sold, of which 67 % are LLIN. The number of re-treatments sold in the 1st 6 months of 2004 was 501,314. Table 3.4: Net sales in Uganda by type, 2002 to the 1st half of 2004.
Period 2002 2003 Half 2004 Item Number % Number % Number % Untreated nets 73,000 26 70,000 15 25,962 9 ITN Bundled* 130,412 46 158,997 34 65,750 23 Long-Lasting Insecticide Treated Nets (LLIN)** 77,883 28 238,084 51 188,758 67 Total (All types) 281,295 100 467,081 100 280,470 100 *ITN Bundled nets are untreated mosquito nets bundled together with one treatment dose **LLIN are nets that are factory treated and may not require re-treatment during its lifespan.
30
The ITNs Subsidy Scheme in Northern Uganda by PSI is on-going whereby ITNs (Smartnet) are sold at Ugshs 5,000 to the general population. Net Coverage: Based on various data sources, the mean net coverage in FY 2000/01 was 9.9% in rural areas and 33.3% in urban areas. In the same areas estimates for FY 2003/04 were 23.5% in rural and 48.8% in urban areas. This represents a 2.8 fold increase of net coverage in rural and 1.7 fold increase in urban areas within the last 3 years. Clear estimates of the true coverage will be available after the UDHS 2005. The National Mass Net Re-treatment exercise was conducted in 20 districts in April to early June 2004 with a total of 481,800 out of the targeted 650,000 nets (74%) re-treated. Net re-treatment picture Indoor Residual Spraying: Insecticide for Indoor-Residual-Spraying (IRS) was distributed as wettable powder formulation (WP) and included lambdacyhalothrin and deltamethrin. A total of 11,272 units (each unit represents about 200m²) were distributed. IRS was conducted in various institutions such as boarding schools within FY 2003/04. Malaria Epidemic Preparedness and Response: The Highland Malaria (HIMAL) project, which started in September 2002 and is expected to last 4 years, is being implemented in Kabale and Rukungiri districts with data collection in 5 sentinel Health Centres (HCs) per district. At an intensive sentinel site in each district, clinical outpatient morbidity and inpatient morbidity and mortality, entomological and parasitogical data is collected, while at the other non-intensive sites only clinical outpatient morbidity and inpatient morbidity and mortality data is collected. An automatic weather station has been established in 2 intensive sentinel HCs, Bufundi HC III in Kabale and in Kebisoni HC IV in Rukungiri District which automatically collects data on rainfall, temperature and relative humidity.
31
Data analysis and feedback to participating sentinel HCs on a weekly basis is fully operational. The same data is sent to the MCP, the London School of Hygiene and Tropical Medicine, various offices in the MoH and to WHO Country Office. The surveillance system is now fully operational and able to detect early any malaria upsurges/epidemics in the two districts. During this year, we have experienced the expected seasonal upsurges throughout the country but there were no epidemics.
Challenges in malaria control
Resource Limitations • Even though significant gains have been registered especially in the areas of
HBMF and IPT, serious challenges remain in the provision of the required supplies at the facility and community levels. There are high stock-outs of SP as the available SP is used for both IPT and management of clinical malaria.
• At the subsidised rate of Ugshs 5,000, the cost of ITNs remains out of reach of the intended beneficiaries.
• Kampala Pharmaceutical Industries (KPI) is failing to meet current demands for manufacture of Homapack for the 33 districts. This is likely to be more problematic with scaling up to cover the entire country.
Supervision and Monitoring
• The current HMIS tools do not capture some of the information needed to monitor malaria interventions (e.g. IRS and ITN).
• There is inadequate analysis of the HBMF data recorded by the drug distributors and the HMIS at all levels.
• Capacity to supervise the community interventions (e.g. HBMF, ITN re-treatment and use) is inadequate in some districts.
• There is a high attrition of drug distributors, who are volunteers, as their demands for incentives are yet to be addressed.
(2) STD/HIV/AIDS
Almost two decades after the first reported case and HIV/AIDS still remains a significant public health challenge contributing significantly to morbidity and mortality in Uganda. Significant achievements have been made in the last decade in addressing the problem with reported epidemic contraction and sexual behavioural change. The STD/AIDS Control Programme in the health sector is part of the multi-sectoral strategy for HIV/AIDS prevention and control in Uganda and is responsible for implementing the public health response to the epidemic. The objectives of the programme are:
• To prevent the further transmission of the STD/HIV/AIDS epidemic • To mitigate the impact of HIV/AIDS through the provision of care and support
to the infected and affected • To strengthen capacity for HIV/AIDS prevention and control at the national,
district and community levels.
32
In order to achieve the above objectives, a number of interventions are being implemented. The outputs achieved as a result of these interventions during the FY 2003/04 are summarised in Table 3.5 below. Table 3.5: Performance against HSSP STD/HIV/AIDS Indicators
Indicator Baseline Value 1999/00
Achieved 2002/03
Target 2003/04
Achieved 2003/04
Target 2005
1 Antenatal HIV sero-prevalence rates 6.8 % 6.2 % N/A 5.1 % 2 Knowledge of two methods of
prevention of HIV transmission 85 % 90 % N/A 95 %
3 Condom availability at central level (millions)
80 80 60 80 120
4 Condom use at last sex with a non-regular partner
50 % 60 % N/A 75 %
5 Median age at first sex (Years) 16 16 N/A 17 6 Proportion of STI patients who are
appropriately managed according to guidelines
21 % 25 % N/A 50 %
7 Number of districts with at least one VCT outlet
33 54 56 56 56
8 Number of districts with at least one PMTCT outlet
3 31 46 49 56
9 Number of Regional Referral Hospitals providing ART services
1 11 11 11 11
IEC/Behaviour Change Communication
IEC strategies in Uganda remain the backbone of HIV/AIDS prevention and control interventions in the absence of an effective cure for the disease. The IEC activities implemented continue to focus on creating awareness, knowledge and subsequently behavior change. The following were the key IEC outputs for the period of reporting:
• In line with the revised IEC strategy, advocacy materials were developed for VCT, PMTCT, Infection Control under Universal Precautions and promotion of ABC preventive options.
• IEC messages disseminated through Radio and Television Talk Shows
Condom promotion, distribution and Use
Condom promotion, distribution and use is one of the three elements (ABC) of the Uganda HIV/AIDS prevention and control strategy. Condom promotion and distribution is done through the public sector by the MoH working together with social marketing groups and private distributors. In FY 2003/04:
• The National condom policy was finalised and the printing process started • Condom promotion is ongoing through IEC and social marketing groups. • 80 million pieces of condoms were procured through the World Bank
HIV/AIDS control project. 60 million pieces of condoms (ENGABU) were distributed by the MoH and NGOs, 30 million pieces were distributed through social marketing groups and 5 million through private vendors.
33
• A national condom distribution plan together with guidelines was developed. Mapping of distribution sites to make condoms more available and accessible is in progress.
Voluntary Counselling and Testing
Voluntary Counselling and Testing (VCT) is an important component of the comprehensive strategy to address HIV/AIDS in Uganda. Knowledge of one’s serostatus helps the individual to make an informed decision on sexual and social behavioural patterns. It is important for the health sector to meet the demands for quality VCT services and to ensure that they are accessible and being utilised. During the reporting period, the following outputs were achieved:
• The 4 remaining districts (Kanungu, Bugiri, Nakapiripirit and Bundibugyo) were facilitated to start VCT services, thus covering all the districts in the country.
• VCT policy implementation guidelines were developed, adopted and disseminated. They are being reviewed for legal implications of offering VCT services to children and how a consensus position could be reached.
• In FY 2003/04; approximately 560,000 people were tested for HIV in VCT centres around the country (compared to 150,000 people tested in FY 2002/03) and 280,000 HIV testing kits were procured for use in VCT service provision
• 300 new counsellors and 250 laboratory staff were trained for VCT service provision. 50 new static VCT sites and 100 outreach sites were started.
Prevention of Mother to Child Transmission (PMTCT)
The transmission of HIV from mother to child is the second most common means of transmission of the virus in this country. There has been a lot of effort from the national and international community to focus on this modality of HIV control. At the national level MoH is promoting a four pronged strategy that consists of primary prevention of HIV/AIDS, prevention of unintended pregnancies among HIV positive women, use of a comprehensive package that includes ARV drugs in HIV infected pregnant mothers to reduce Mother to Child transmission of HIV and comprehensive care to the mother and her family. During the reporting period the following key outputs were achieved:
• Access to services increased from 71 sites in 31 districts in FY 2002/03 to 140 sites in 49 districts in FY 2003/04, an increase of almost 100%. The sites are spread across the country (see Figure 3.4).
• About 101,195 out of the 176,368 pregnant women who were offered counselling at PMTCT sites (57%) accepted to take the HIV test. Approximately 10% of those tested turned out to be positive for HIV.
• About 5,486 of the HIV positive mothers were given antiretroviral drugs for prevention of mother to child transmission of HIV.
34
Figure 3.4: Number of Functional PMTCT sites by District
Infection Control: The STD/AIDS control programme infection control interventions are conducted to complement the efforts of the Clinical Services and Quality Assurance Departments. This component involves preventing transmission of nosocomial infections, with special emphasis on blood borne pathogens. In FY 2003/04, the following were the main achievements:
• Infection control practice and on job training was done following an outbreak in Mbarara Hospital
• Based on the initiative from Mbale and Kayunga Hospitals, infection control practice was carried out and 60 health workers were trained from both hospitals.
• 74 members of the Federation of Uganda Employers (FUE) were sensitised on universal precautions.
Care and Support including Anti-retroviral Therapy (ART)
The MoH has continued to provide a package of Care services including clinical management, psychosocial support (counselling) and home based care across a continuum. During FY 2003/04, 58 health facilities in 20 districts from both the public and private sectors have been accredited to provide antiretroviral drugs. 48 of these facilities are currently providing ART (see Figure 3.5). An estimated 24,500 patients are currently accessing ART from the different public outlets. The public sector ART programme was officially launched in June 2004 with drugs for treating 2,700 adults that were procured under the World Bank funded Uganda AIDS Control Project. The drugs were distributed to 26 health facilities, including all the 11
35
Regional Referral Hospitals. To facilitate the programme, 381 doctors, 63 clinical officers, 238 nurse/ midwives, 200 laboratory staff, 1,000 counselors and 60 nursing assistants were trained in HIV/AIDS management including ART and 96 trainers, 330 supervisors and 390 community volunteers were trained for Home Based Care Figure 3.5: Sites offering ART in Uganda
* Several Private for profit Facilities are not captured in the Map
Monitoring and Evaluation including Surveillance
The STD/AIDS control programme keeps track of the progress of the HIV/AIDS epidemic through a series of surveillance activities. These activities include sentinel surveillance and KABP surveys for behavioural data collection within the concept of second generation surveillance. Additional data on STD/HIV/AIDS is obtained from collaborating partners like MRC, Rakai Project, GTZ, AIC, and CDC. This enables the programme to compile a comprehensive database. The following were the key outputs during the FY 2003/04;
• New sentinel sites were opened up to complement the existing ones and to improve the rural representation. There are currently 25 operational sites in the country.
• National sero-behavioural survey preparations were completed and the survey is currently on-going
36
Challenges
The challenges to reducing the prevalence of HIV in Uganda are well demonstrated by the findings of the Multi-Country AIDS Project assessment conducted in 19 districts (October – November 2003). The salient findings point to issues of misconceptions, mismatch between behaviour and knowledge levels and issues of geographical and financial accessibility. The knowledge levels about the benefits of VCT are still considerably low (47% for men and 39% for women). This has implications on the utilisation of these services. There is also a clear disconnect between knowledge and behaviour, more so in men than in women. Despite the knowledge levels indicated above, only 14% of both the men and women had taken an HIV test. The main reasons cited by the men are poor accessibility, the costs and the unpredictable response of the family members to the results of the test. The women on the other hand cited fear of the outcome of the results, were afraid to be seen by the community members attending the service and the unpredictable response from the spouse. Other challenges include;
• Of the mothers attending antenatal clinics, 81% knew the risk of MTCT. However, only 38% were counselled and only 13% took the HIV test. The predominant reasons given for failing to take the test are the fear of broken marriages in case of positive results and the belief that knowing that one is HIV positive leads to a quicker death due to frustrations
• Regarding the youth (15–24), 52% knew two of the ABCs but only 25.5% reported to have always used a condom. Similarly, only 51% of the men (15-54) had ever used a condom
(3) TB and Leprosy Control
TB and leprosy are closely associated with poverty and the TB situation is compounded by the common occurrence of the dual TB/HIV infection. Control of TB and Leprosy using Directly Observed Therapy Short-course (DOTS) and Multi-Drug Therapy (MDT) respectively is a well-known cost effective intervention. On average a TB patient loses 4 months of work per year while untreated leprosy patients end up in destitution. Treatment and rehabilitation of the affected population groups improves productivity and quality of life in line with the national Poverty Eradication Action Plan.
TB Control:
The objective of the National TB/Leprosy Control Programme is to control these diseases through early diagnosis and treatment. During the FY 2003/04, the national Case Finding rate was 49% of the expected smear positive cases against the global target of 70%. Table 3.6 provides the performance of the TB control programme against the HSSP indicators. Table 3.6: Performance against HSSP TB Control Indicators
Indicator Baseline Value
Achieved 2002/03
Target 2003/04
Achieved 2003/04
Target 2005
1 Coverage with Community DOTS
60% 100% 82% 100%
2 Attained TB Cure Rate levels
52% 85% 62% 85%
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Community DOTS:
As a means to TB disease control, the community based TB care using the Directly Observed Treatment Short-course (DOTS) strategy continues to be embraced and expanded to achieve a wider coverage as shown in Table 3.7. Community DOTS is now available in 46 out of the 56 districts. Table 3.7: CB-DOTS Implementation Coverage
This is a 21% improvement over the 34 districts registered the previous FY. A lot still needs to be done to attain the HSSP target and also to improve on
coverage in the districts with partial implementation. Whereas the districts of Kiboga and Rakai continue to register satisfactory CB–DOTS implementation, this is not the case for some districts such as Mpigi, Wakiso and Hoima.
TB Treatment Success Rates:
Treatment success rates have been adversely affected by population movements, especially in urban and semi-nomadic populations. The other limiting factor is accessibility to laboratory services. However, the single major factor affecting treatment success is the default rate of 19% in FY 2003/04, which shows little change from the 20% registered in FY 2002/03. This is attributable to the problems of community mobilisation and access to diagnostic and treatment centres. In districts practicing community DOTS, default rates have been minimised and treatment success rates are significantly high. However, only one district, Apac, has attained a treatment success rate above 90% and a cure rate close to the HSSP 2005 target (see Box 3.1).
Box 3.1: TB Treatment Success: The story of Apac district
DOTS Implementation Level
Number of Districts
1 Full Implementation 12 2 Partial Implementation 28 3 Start up Phase 7 4 Not Yet Started 9
Apac district, with a population of 700,000 (Projection for FY 2003/04), has registered significant success in attaining high cure rates for Pulmonary Tuberculosis. According to the District TB and Leprosy Supervisor, the secret lies in involving all service providers at health unit level, strong commitment and conducting effective support supervision. The district implements CB–DOTS through out all the 22 Sub-counties and each sub-county has a CB–DOTS supervisor who is either a TBL Assistant, a Health Assistant, an active CHW or a Nursing Assistant. These are supervised by the 5 HSD CB–DOTS focal persons. The former are provided with bicycles and the latter with motorcycles to facilitate their movements. The HSD focal persons ensure that quarterly meetings are held regularly. Similarly, performance assessment meetings are held at the district level on a quarterly basis. The above efforts have led to the following achievements in TB control for the FY 2003/04 that is above the national averages: Case Detection Rate 51.3 % Cure Rate 82.5 % Success Rate (Cure Rate + Completion Rate) 92 % Default Rate 0 % The high treatment success rates have been sustained for the last FOUR years.
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TB Case Reporting: The performance range of this indicator in FY 2003/04 is very wide ranging from 227% for Kampala to 13% for Kotido (see Figure 3.6). The best performers are Kampala, Kalangala, Gulu, Masaka and Lira while the least performers are Kotido, Kapchorwa, Bugiri, Pallisa and Nakasongola. Figure 3.6: TB Case Reporting by District
0
50
100
150
200
250
Kotid
o
Kapc
horw
a
Bugi
ri
Pallis
a
Nak
ason
gola
Kiso
ro
Kam
uli
Yum
be
Kase
se
Igan
ga
Wak
iso
Bund
ibug
yo
Kata
kwi
Pade
r
Kyen
jojo
Arua
Neb
bi
Moy
o
Busi
a
Muk
ono
Hoi
ma
Siro
nko
Kaba
le
Sem
babu
le
Mas
indi
Kayu
nga
Kam
wen
ge
Kum
i
Kibo
ga
Mub
ende
Kiba
ale
May
uge
Mpi
gi
Toro
ro
Adju
man
i
Nat
iona
l
Kitg
um
Apac
Bush
enyi
Ruk
ungi
ri
Mba
le
Kabe
ram
aido
Mor
oto
Soro
ti
Nak
apiri
pirit
Rak
ai
Luw
ero
Ntu
ngam
o
Jinj
a
Kaba
role
Kanu
ngu
Mba
rara
Lira
Mas
aka
Gul
u
Kala
ngal
a
Kam
pala
49%
Opportunities for scaling Up TB Control: A number of opportunities are being exploited to scale up the implementation of the various TB control measures;
• Funds from the Global Fund, targeting the strengthening of diagnostic capacity • A 3 year programme funded by WHO supporting DPTS expansion and already
covering 43 districts • Support from CIDA to procure laboratory equipment and supplies and also
quality control • Intensified Support and Action Countries (ISAC) Initiative. This is an emergency
initiative targeting 9 selected countries, to expand DOTS implementation with the aim of attaining the global targets by December 2005
Leprosy Control
The leprosy elimination target of less than 1 new case per 10,000 population has been maintained since 1994. However, seven districts still have a prevalence rate above the elimination target as shown in the Table 3.8 below. During FY 2003/04, the leprosy prevalence rate was 0.27 per 10,000 of the population. However, the fact that 11% of the new cases are seen in children, against a target of 0%, indicates active spread of the
39
disease. It is also important to note that the Multiple Drug Therapy completion rate for Paucibacillary is on target at 90% while for Multibacillary it is only at 74% against a similar target. It has again been noted that among the new cases, there is a 15% disability Grade 2 rate against a target of 5%.
Table 3.8: District leprosy prevalence Rate
District Leprosy Prevalence Rate
1 Pader 2.1 2 Kitgum 1.4 3 Kalangala 1.3 4 Adjumani 1.2 5 Yumbe 1.1 6 Gulu 1.1 7 Mayuge 1.1
All these indicators point to delayed case detection and poor case holding especially for the Multi-bacillary cases which are the potential sources of infection and also run high risks of developing impairments and disability.
Challenges
The control of TB has been greatly affected by the HIV epidemic. It is important to integrate the management of HIV/AIDS with TB control. The specific programme challenges include the low case detection rate of 49%. This clearly indicates that more than 50% of the openly infectious cases of Pulmonary TB go undetected. Even if we attained 100% cure rates, at this low level of case detection, the overall TB disease burden will remain high. The community health departments of the HSDs need to make a deliberate effort to improve on this index. Other challenges are;
• Gaps in the reporting system which excludes cases handled by the private sector • A weak support supervision mechanism for DOTS. This should be addressed by
focal persons at the HSD level • Utilisation of the available human resource from partner programmes, such as
AIM and UPHOLD to boost the technical supervision for TB and Leprosy control
• Inadequate laboratory services for diagnosis
(4) Interventions against Diseases targeted for Eradication/Elimination
The Government of Uganda is a signatory to international resolutions committed to the elimination and eradication of selected diseases including poliomyelitis, guinea worm, Onchocerciasis, measles, and leprosy. Accordingly this programme will ensure that the country plays its role along with other nations in line with the international resolutions. One of the major strategies of this programme is to strengthen cross border disease surveillance and control through regional and bilateral collaboration. The main programme objective is to achieve the national and global targets for eradication/elimination. This is being implemented through strengthening the existing programmes for eradication/elimination control of poliomyelitis, onchocerciasis, Guinea
40
worm, leprosy, Vitamin A deficiency disorders, Iodine deficiency disorders, Neonatal tetanus, Human African Trypanosomiasis, Lymphatic Filariasis. Poliomyelitis, Leprosy, Maternal and neonatal tetanus and nutritional deficiencies are discussed elsewhere in this report under the relevant programmes. The achievements from efforts against the remaining diseases and others for which control is targeted can be summarized as follows: Onchocerciasis: - the programme achieved 100% therapeutic coverage as compared to 70 % the previous year. An evaluation of the CDTI programme was conducted in 13 districts. Six main and sub-foci were declared Simulium neavi vector free following effective river treatment. The programme is likely to be negatively affected by the reduction in APOC funding, especially for the CDTI component. Guineaworm – There was no indigenous case and only one imported case from Sudan was registered during FY 2003/04. Water filters and sufficient quantities of Abate were supplied to the target districts and so were vehicles and motorcycles for ease of surveillance. The issues of insecurity and continuous movements of people across borders remain big constraints in the eradication of this disease. Schistosomiasis – The 5 year programme for the control of Schistosomiasis and soil transmitted helminths (2001–2005) was launched in March 2003 to cover the 21 most affected districts. The schistosomiasis programme target is to treat 75% of the school children and couple it with mass treatment for communities with a prevalence rate above 40%. These efforts will be supplemented by improvement in water and sanitation facilities and conducting selective vector (snail) control. During the period under review, the following progress was registered;
• Capacity development for the 21 districts in the implementation of mass chemotherapy
• National deworming of all school children up to 14 years of age in response to the presidential directive.
Trypanosomiasis - Trypanosomiasis control is implemented in the South East and North West regions of the country. The South East programme, covering 12 districts, is supported under the “Farming in Tsetse Controlled Areas (FITCA)” project with a coordination office in Jinja. The North Western districts, after the expiry of the EU funded project in 2002, only depend on seed money from WHO for their activities. The long-term goal of the programme is the elimination of sleeping sickness as a public health problem in Uganda by 2020 as an integral part of the Pan African Tsetse and Trypanosomiasis Eradication Campaign (PATTEC). As a contribution to the attainment of the long-term goal, the following strategies were implemented during FY 2003/04;
• Revitalisation and strengthening of national and district capacity for the control of the disease
• Improvement of the quality of diagnosis through prompt and effective case detection and treatment
• Promotion of community involvement and participation in sleeping sickness control
Overall, during FY 2003/04, the following progress was made;
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• A draft national policy on control and eventual elimination of tsetse and Trypanosomiasis was jointly developed with the Ministry of Agriculture, Animal Industry and Fisheries
• A new treatment centre was opened at Serere Health Centre to handle the new ‘epidemic district’ of Soroti
• All treatment centres were supplied with drugs, laboratory equipment and reagents
• Six capacity development workshops were conducted and IEC materials were produced and distributed to the endemic districts
• Twelve screening surveys were conducted in outbreak areas in Soroti, Iganga, Arua and Yumbe districts.
Lymphatic Filariasis: The national programme for the elimination of lymphatic filariasis is in place, initially targeting the districts of Katakwi, Lira, Nakapiripirit, Kotido, Kumi, Soroti, Kaberamaido, Kamuli, Apac and Gulu. The long-term goal of the programme is to eliminate lymphatic filariasis in Uganda by 2020. This is to be achieved, among others, through annual community directed mass drug administration. During FY 2003/04, the following progress was made;
• National mapping has been completed and confirms 12 districts as highly endemic, 7 districts as moderately endemic and 6 with low endemicity
• Mass drug administration was implemented with Lira and Katakwi doing the second round while Kotido, Moroto and Nakapiripirit had the first round.
• IEC materials were produced and distributed • A sentinel surveillsnce system was established in Lira and Katakwi districts.
Zoonotic Diseases – The Veterinary Public health Unit in the MoH continued to work towards the objective of reducing the burden of zoonotic diseases among the human population with emphasis on rabies and brucellosis. During the period under review, the following achievements were registered;
• A total of 13,000 doses of rabies vaccine were procured by the MoH and supplied to districts and hospitals for treatment of suspected rabies cases upon request. An additional 800 doses of the vaccine worth Ugshs 11.2 million were procured by the SHSSP Project and supplied to 11 districts in Northern Uganda. A total of Ugshs 186.7 million was spent on the procurement of human rabies vaccine for post-exposure treatment.
• The introduction of the intra-dermal (id) regimen for rabies post-exposure
treatment (PET) was strengthened through training and provision of technical guidelines to treatment centres in five districts where this regimen has been recommended.
• The Rabies Immunization Days (RIDs) initiative has been conceptualised by the
MoH and is being discussed with the Ministry of Agriculture, Animal Industries and Fisheries (MAAIF) as a long-term strategy to reduce the rabies burden in both animals and humans. The main challenge however is funding of the programme.
42
• The VPH Unit in collaboration with research institutions initiated a brucellosis sero-prevalence survey in Nakasongola district to assess the zoonotic importance and risk factors for the disease in humans and animals.
3.1.2 Maternal and Child Health The Maternal and Child Health indicators for Uganda are still poor. Interventions that have been proven to be cost effective are being implemented. The focus is on Integrated Management of Childhood health illnesses, adolescent pregnancy, emergency obstetric care and overall maternal and newborn health. There is also need to proactively target the most vulnerable, the poorest of the poor, because they continue to disproportionately bear the brunt of maternal and child ill-health.
(1) Sexual and Reproductive Health and Rights
Sexual and reproductive health and rights (SRH) is an important programme in the HSSP in view of the high maternal and child mortality rates. It has been a priority programme since the start of the HSSP. The overall objective of the programme is to contribute to the reduction of neonatal, infant and maternal morbidity and mortality and the targets for the HSSP are shared in the Table 3.9. Three focal areas have been identified to address the poor reproductive health outcomes in the country. These include:
• Increasing access to institutional deliveries and Emergency obstetric services (EmOC);
• Strengthening Family Planning services; • Strengthening Goal Oriented ANC including PMTCT.
Table 3.9: Performance against HSSP SRH Indicators
Indicator Baseline Value
Achieved 2002/03
Target 2003/04
Achieved 2003/04
Target 2005
1 Reduction of Maternal Mortality Ratio
506 (1995)
505 (2000)
NA NA 354
2 Increased Contraceptive Prevalence Rate
15% (1995)
23% (2000)
NA NA 30%
3 Increased Couple Years of Protection (CYP)
228,675 223,686
4a Deliveries supervised by skilled health workers
38% (1995)
38% (2000)
NA NA 50%
4b Deliveries in GoU and PNFP health facilities
20.3% 30% 24.4% 35%
5 Increased TT2 coverage for pregnant women
42% 50% 70% 50% 80%
The implementation strategy of SRH programme is to revitalise health centres and the efficient operation of the health sub strict and the community health departments of the hospitals. Most HSSP indicators on RH are impact and output indicators relying on the UDHS survey results as shown in the above table. Using HMIS data, in FY 2003/04, there has been an increase, among other things, in the number of deliveries in health
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units – as discussed under Chapter 2 and Adolescent friendly RH services availed at more service delivery points
Safe Motherhood
The HSSP aimed at achieving a significant reduction in the unnecessary deaths associated with pregnancy. During FY 2003/04, a number of activities were undertaken to improve safe motherhood such as the development and distribution of RH IEC materials, purchase and distribution of equipment and supplies including 27 delivery beds, 46 delivery sets, 11 theatre beds and 400 mattresses, 6,500 Mama Kits to Luwero district and IDP camps and 1,150 Home Care Kits to the IDP camps. The referral system and support to districts was strengthened by procurement of 20 ambulances and communication equipment for the Rescuer System in 5 districts; The proportion of mothers delivering in government and PNFP health units has made a slight improvement in the FY 2003/04 to a value of 24.4%, compared to 20.3% in FY 2002/03 and 19% in FY 2001/02. The performance of the individual districts is illustrated in Chapter 2.
Emergency Obstetric Care
During FY 2002/03, a needs assessment for Emergency Obstetric Care (EmOC) was conducted in 19 districts. The results clearly indicated that the ability of the health care system to handle the life threatening complications of pregnancy were very low. While emergency measures were being put in place to address this situation, it was resolved at the 9th JRM that the needs assessment be conducted for the remaining 37 districts. The results of this exercise are summarised in Table 3.10. The results agree with earlier studies and indicate the need to prepare our health facilities to handle pregnancy and its complications better. Table 3.10: Results on a Needs Assessment for EmOC in 37 districts of Uganda
Level of Facility No. Sampled Availability of CEmOC
Availability of BEmOC
EmOC Not available
Hospital 59 29 (49.2%) - 30 (50.8%)
HC IV 95 2 (2.1%) 7 (7.4%) 86 (90.5%) HC III 242 NA 7 (2.9%) 235 (97.1%) Total 396 31 14 351 (88.6%)
The Rescuer System: During FY 2003/04, the Rescuer System was established in the districts of Arua, Bushenyi, Kiboga and Yumbe. During the same period, a baseline assessment for the extention of the Rescuer System was conducted in the districts of Adjumani, Busia, Kayunga, Nebbi and Moyo. When this exercise is completed, a total of 19 districts (34%) will be implementing the Rescuer System. This should go a long way to improve the EmOC and the Reproductive Health outcomes. Family Planning: Over the period of the HSSP, there has been a considerable gain in the level of FP services uptake. However, the general unmet need still remains high (35 %) and the unmet need for Long Term Permanent Methods (LTPM) is even more, especially in the rural areas where the capacity to provide these services is still low.
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During FY 2003/04, the Couple Years of Protection (CYP) was adopted as the proxy indicator for FP. This indicator represents the total number of years of contraceptive protection provided to a country’s reproductive population. The CYP factors for each FP method are indicated in Table 3.11. This indicator is not only more user friendly but also very useful in assessing trends in the provision of effective FP methods. Table 3.11: CYP Factors for each Family Planning Method.
Family Planning Method Couple Years of Protection Foam Tablets 1 / 750 ( 0.001 yrs ) Condoms 1 / 500 ( 0.002 yrs ) Pills 1 / 70 ( 0.0143 yrs ) Depo Provera 1 / 4 ( 0.25 yrs ) Norplant 3.5 yrs IUD 5 yrs Tubal Ligation 12.5 yrs Vasectomy 12.5 yrs
Guidelines for the calculation of this indicator were distributed to all districts. Being a new indicator, figures are only available for FY 2002/03 (228,675 CYP) and for FY 2003/04 (223,686 CYP). Individual district performance analysis indicates significant fluctuations between the two years. This was largely attributed to the poor availability of Family Planning supplies and mainly the long-term methods. Adolescent Reproductive Health: Adolescents continue to bear the brunt of poor accessibility to reproductive health services. They contribute almost 50% of the maternal mortalities, largely due to unsafe abortions. During FY 2003/04, the adolescent health policy was finalised, a guide to peer education was accomplished and a TOT was conducted for 101 health workers in 27 districts.
(2) Integrated Child Survival
According to 2001 UDHS under-five mortality rate stands at 152 per 1,000 live births. Cost-effective interventions, addressing a number of Child Survival Interventions and delivery strategies have been put in place. These include IMCI as broad strategy, Child days, Vitamin A supplementation, improving infant and young child feeding, revitalization of EPI and Home Based Management of Fever among other interventions. The overall effectiveness of these interventions is limited by; limited coverage, piecemeal implementation and sometimes a lack of logical synchronization. The multiplicity of child mortality risk factors within the health system and beyond is also a challenge. This is why integration and complementarity of the components of the NMHCP is of great importance. In this report, emphasis is placed on IMCI, Immunization and Nutrition.
Integrated Management of Childhood Illnesses (IMCI)
IMCI is a key strategy whose aim is to contribute to the reduction in under-five mortality through improvement in health workers skills in regard to assessment and management of common childhood illness and preventive measures like immunization all provided in an integrated manner. The strategy also focus on improving health system issues that affect care for children in health facilities as well as working to improve key family care practices that have the highest potential for improving child survival growth and development. The strategy focuses mainly on improving the health workers skills in the
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management of malaria, acute respiratory infections, diarrhoea and malnutrition, which contribute to over 70% of the overall child mortality in the country. Recently HIV/AIDS among children has become an important concern and the IMCI guidelines have been adapted to specifically address it. The HSSP targets for IMCI are indicated in the Table 3.12 below.
Table 3.12: Performance against HSSP IMCI Indicators
Indicator Baseline Value
Achieved 2002/03
Target 2003/04
Achieved 2003/04
Target 2005
1 Health Worker skills development
15% 65% 75% 65% 100%
2 Provision of Health Systems Support
15% 40% 50% 100%
3 Community Based IMCI coverage
10% 25% 50% 30% 50%
4 Reduction in incidence of diarrhoeal diseases of epidemic potential
Improving Health workers skills is critical to improving quality of care provided in the health facilities. Since the introduction of the strategy all districts have implemented IMCI and more than 8,000 health workers have been trained in IMCI. This includes about 4000 Nurse Assistants who received their IMCI training as apart of their 3 months training course. The Uganda IMCI Impact study clearly shows that IMCI trained health workers manage children better than the non-trained ones. Health worker refresher training to disseminate the new malaria policy for treatment of non-complicated malaria in children under-five was began in 11 districts. During FY 2003/04, fewer training sessions were conducted due to limited resources. In districts with IDPs, the home-based care treatment of childhood illness strategy was introduced where community volunteers were trained to treat malaria, pneumonia, diarrhoea and give First Aid. 3,000 community volunteers in 8 districts of North and Eastern Uganda have been trained and equipped with drug kits. Integrating HIV/AIDS into IMCI guidelines were developed in FY 2003/04 based on a validation study conducted by Makerere University and WHO. These guidelines have now been introduced in 12 districts. Additional guidelines for ARV use in children at referral hospitals are under pilot Improvement of Health Systems Support: The Uganda IMCI impact study clearly shows that training alone is not enough to improve the performance of health workers. During this year integrated child health supervision was revitalized and two rounds of supervision carried out in February and September in all the districts. Findings from this supervision indicate that about 25 districts have made provisions within their workplans to train health workers in IMCI. On the other hand most districts showed a general shortage of availability of ORS.
Community Based Child health
Child Days: The Ministry of Health dedicated the months of May and November each year for implementation of Child Days. During the child days the following services are
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offered: catch up and routine immunization, vitamin A supplementation, de-worming, tetanus toxoid for mothers and provision of health education messages. The May 2004 child days were implemented in all districts with an average district coverage of 50% for the different child health interventions. Child days are now institutionalized in the health care system as a routine activity using regular resources as opposed to campaigns. However for districts with IDPs, child days were done in a campaign mode and included vaccination of mothers with TT and ITNs distribution in addition to the above package of services. Coverage of 90% was achieved in this case. Family care practices survey: A survey to assess family care practices that have greatest potential of child survival growth and development was conducted in 8 districts. Results were disseminated at different levels in districts and districts plans for activities to improve family care practices were made.
Challenges
The major challenge in this area has been limited human resources, funds to ensure appropriate and timely technical support to districts. The area of monitoring also requires strengthening.
Immunisation
The Government of Uganda puts great emphasis on immunisation as a cost effective intervention contributing to the improvement of health indices within a relatively short time by preventing morbidity and mortality from a number of vaccine preventable childhood killer diseases. The overall objective of the HSSP is to attain the highest level of coverage such that EPI target diseases are no longer of public health significance in the country. The specific programme objectives for FY 2003/04 were:
• To increase accessibility, demand and utilisation of immunisation services • To provide potent and safe vaccines • To strengthen efforts towards polio eradication, elimination of maternal and
neonatal tetanus (MNT) and measles control. The immunisation coverage for FY 2003/04 is 83% compared to 84% in FY 2002/03. The coverage by district is discussed in Chapter 2. Table 3.13: Performance against HSSP Immunisation Indicators
Indicator Baseline Value
Achieved 2002/03
Target 2003/04
Achieved 2003/04
Target 2005
1 Levels of Fully Immunised 12 – 23 months old Children
44% 80% 71% 70%
2 Increased DPT – HepB + Hib 3 coverage
55% 84% 85% 83% 85%
3 Increased TT2 coverage for pregnant women
42% 50% 66% 50% 80%
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Utilisation of Immunisation Services: The GoU is contributing 100% towards purchase of all the routine immunization vaccines except DPT-HepB +Hib vaccine, which is being provided in kind by GAVI. Monthly distribution of vaccines and injection safety materials to the districts was done as scheduled irrespective of the security situation in some parts of the country ensuring availability of vaccines at all times at the service delivery points. Immunization services are provided both at static units and through outreach services. Districts have been supported to implement integrated outreaches through the use of Primary Health Care funds. The districts of Kisoro, Nakasongola, Kibaale, Kapchorwa and Kalangala were facilitated by WHO and UNICEF to consolidate the on going Sustainable Outreach Services activities. To create and sustain community demand and utilization of immunisation services, IEC messages and materials were developed, produced and disseminated to the communities namely; 15,000 pieces of immunisation schedule, 25,000 pieces of leaflets on immunisation and airing of radio messages. Footage for production of a documentary on routine was collected and the TV crew filmed members of Senior and Top Management of MoH. Community films were conducted in the districts. Improvement in the quality of vaccines: Cold chain corrective maintenance was done in all the 56 districts and throughout the year. A total of 11,892 gas cylinders were refilled for distribution and use with the cold chain fridges. Installation of 46 solar fridges and 3 radio-calls was done in selected districts Following the recommendations of the vaccine potency testing done by the EPI laboratory in 2002, the districts of Kabale, Luwero, Iganga, Ntungamo, Apac, Masindi, Nebbi, Hoima, Kamwenge, Bundibugyo, Soroti, and Kapchorwa were visited. During these visits, vaccine management and use of Vaccine and Injection Material Control Books was thoroughly discussed with DHTs and service providers. Districts were encouraged to use the vaccine wastage monitoring forms and have regular monthly distribution to avoid overstocking/under stocking of vaccines at the health facility level Polio eradication: Ministry of Health is fully committed to the World Health Assembly resolution to eradicate poliomyelitis globally by 2005 by adopting the following strategies: • Attainment of high infant immunization coverage with four doses of oral polio
vaccine (OPV) in the first year of life • Provision of supplementary doses of OPV to all children under five years of age
during National Immunization Days (NIDs) • Laboratory-backed Acute Flaccid Paralysis (AFP) surveillance in search of the wild
poliovirus • Mop-up campaigns, when the wild poliovirus transmission is limited to a specific
focal area. During FY 2003/04, routine immunization was emphasized (OPV3 coverage of 82% was attained) and so was continuation of laboratory backed AFP surveillance. The progress made specifically for AFP surveillance is summarized in Table 3.14 and clearly indicates that over the years there has been a tremendous improvement in the AFP surveillance indicators.
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Table 3.14: Selected AFP surveillance performance indicators
Performance indicator Target Achievement 2002/03
Achievement 2003/04
1 Non-polio AFP rate per 100,000 population < 15 years
1/100,000
2.26 1.50
2 Percent AFP cases with 2 stool specimens collected within 14 days of onset of paralysis
80% 84% 92%
3 Percent of specimens from AFP cases arriving at the lab in good condition
90% 99% 100%
4 Percent of specimens from AFP cases where non-polio enterovirus was isolated
20% 26% 18%
5 Percent of specimens from AFP cases polio virus was isolated
0 0 0
Maternal and Neonatal Tetanus Elimination: The third round of the Tetanus Toxoid mass immunization were successfully implemented in the 5 districts of Busoga i.e. Bugiri, Jinja, Iganga, Kamuli and Mayuge targeting women of aged 13 –49 year, achieving coverage of 91%. Elimination of Maternal and Neonatal tetanus in the Busoga region has almost been achieved since no NNT case has been detected in the region for the past 12 months, as shown in Figure 3.7. Figure 3.7: Progress of Maternal and Neonatal Tetanus in Busoga Region
Measles control:
At the beginning of the FY 2003/4, measles was still ranked fourth among the top 10 causes of childhood morbidity and mortality in Uganda. To reverse the situation, the Ministry of Health through UNEPI developed a plan of action with a focus on achieving measles control. Among the strategies was provision of a second dose of measles vaccine
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2001 56 53 3 64 9
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Bugiri Iganga Jinja Kamuli Mayuge
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to all children 6 months to 14 years irrespective of their immunization status using mass immunization. In October 2003 a nation wide mass measles campaign targeting children 6 months to 15 years was carried out building on previous experiences, competencies and skills. The mass measles vaccination campaign was able to reach 13,458,675 (105%) of the targeted 12,861,020 children aged 6 months to 14 years. In addition, with 95% of the districts achieved the desired 90% coverage. Picture on the measles campaign There has been a dramatic decline in the reported and confirmed measles cases and deaths through all the surveillance systems (see Figure 3.8). a) Weekly reporting - From January to June 2004, 1,498 cases of measles have been
reported nation-wide compared to 11,880 for the same period in 2003. This gives 87% decline in the number of reported measles cases through this system.
b) Monthly HMIS - From January to June 2004, 2,306 cases of measles have been reported nation-wide compared to 13,292 for the same period in 2003. This gives 83% decline in the number of reported measles cases through this system.
c) Case based measles surveillance- From January to June 2004, 675 suspected cases of measles have been investigated for laboratory confirmation from all districts except Bundibugyo, Kibaale, Kitgum, Kotido, Moyo and Sironko districts. Out of 675 suspected measles cases investigated 22 (3%) were laboratory confirmed measles IgM cases while 177(26%) were positive for rubella IgM, which shows more rubella cases than measles.
d) Measles mortality - Only 4 deaths from measles have been reported since the beginning of the year.
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Figure 3.8: Measles morbidity and mortality trends FY 2003/04
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Challenges
Despite the improvement in the national DPT3 coverage, more than 50% of the districts have problems with high DPT 1 –3 drop out rate and poor access to immunization services as evidenced by DPT 1 coverage of < 80%. There are still scores of children that are left un-immunized even in the districts that are reporting immunization coverage of above 80% especially those with big populations. Inadequate vaccine management skills at district and lower levels remains a challenge to the programme. During the year 2003, vaccine potency testing by the EPI laboratory revealed that, 19.8% of units visited had non-potent measles vaccine. This was attributed to inadequate cold chain maintenance, lack of support supervision of the next lower levels by the centre, DHT and HSDs, and lack of district ownership of the immunization programme. Poor data management at the district and lower levels still exists as shown by the Quality Assurance visits to districts and the National data quality audit. (3) Nutrition Nutrition is an important underlying cause of child mortality from associated infections or concurrent illnesses. In order to control diseases due to nutritional anaemia, protein energy malnutrition, iodine deficiency disorders and vitamin A deficiency, a combination of strategies including awareness creation, case management, rehabilitation, supplementation, food fortification and diet diversification are being employed. The MoH is pursuing a multi-sectoral approach with other sectors in implementation of strategies to improve the nutritional status of the population. The focus the Programme
Measles Campaign
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is to contribute to the improvement of the nutritional status of the population with special emphasis to mothers and children (see Table 3.15). In the FY 2003/04, Community Growth Monitoring Promotion was initiated in 6 Districts to provide nutrition counselling support to caretakers with children below 3 years of age. UPHOLD supports some districts in strengthening Community Growth Monitoring. The regulations on the marketing of breast milk substitutes have been reviewed to expand the membership as well as address the HIV/Infant Feeding and Emergencies’ components. The Ministry of Health identified consultants to develop modified cow’s milk to be fed to Infants born to HIV positive mothers with the aim of reducing mother to child transmission of HIV to the infants. Table 3.15: Performance against HSSP Nutrition Indicators
Indicator Baseline Value
Achieved 2002/03
Target 2003/04
Achieved 2003/04
Target 2005
1 Reduce rate of stunting in under fives*
38.5% 28%
2 Reduce proportion of under fives who are under weight*
26% 20%
3 Increase exclusive breast feeding at 6 months*
68% 75% 75%
4 Increase and sustain Vitamin. A supplementation coverage for children 6 – 59 months
80% 60% 90% 76%** 95%
5 Increase the proportion of households consuming Iodised salt
69% 95% 98% 95% 100%
6 Increase public awareness on appropriate nutrition practices
90% 95% 95%
*The first three indicators will be assessed through the UDHS in 2005/06. **This figure is an aggregate of the November 2003 and the May 2004 Vitamin A supplementation during the respective Child Health Days. In addition to the above achievements, nutrition assessments were conducted among the IDPs in the five northern Districts of Gulu, Kitgum, Pader, Soroti and Katakwi and the Karamoja region indicated that the levels of malnutrition were of public health concern (Average of Global Acute Malnutrition Rates of 14%) and called for intensified interventions to address them. A multi-sectoral task force for coordination of Nutrition interventions in emergencies has contributed significantly to the harmonization of management protocols as well as nutrition assessment methodologies and assessment tools. This has improved the management of malnutrition and assessments on nutrition and health among the target populations. The death rates among children in Therapeutic Feeding Centres (TFCs) in northern districts have consequently reduced from the previous 24% (2003) to 2% (2004) in Lira TFCs. Health Workers from 50 PMTCT sites have undergone training in integrated infant and young child feeding counselling. The infant feeding practices among mothers being supported by the health workers trained have greatly improved as a result. Bi-annual Vitamin A Supplementation has been carried out in all districts alongside measles
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campaign and achieved 76% coverage in children 6months to 5 years. The Child Days Strategy introduced in May this year now incorporates VACS, de-worming, and catch up on routine immunization.
The Food Fortification Initiative.
Food fortification is one of the strategies in the campaign against Micronutrient Deficiencies in Uganda. The others are Iron and Vitamin A capsule Supplementation and promotion of consumption of micronutrient rich foods. The strategy is efficient and effective as a medium term measure in addressing the problem of micronutrient deficiencies. For purposes of sustainability, it is implemented as a partnership between the Government and the private sector. During the period under review, a number of activities were undertaken and several achievements registered;
• The National Food Fortification Working Group commissioned a food consumption survey by the Department of Food Science and Technology to determine the consumption patterns for maize flour, cooking oil, cassava flour, sugar and milk
• In collaboration with Uganda National Bureau of Standards (UNBS) and other stakeholders, standards for fortified foods were developed and regulations for their marketing were also developed under the Foods and Drugs Act
• Equipment and fortificants were provided to the partner industries to start the fortification trials
• Mukwano and Mbarara based Unga 2000 passed the quality assurance tests and were allowed to start the fortification process
• Well labelled Vitamin A fortified Cooking oil and maize flour fortified with mineral multimix are currently on the market, with no price differential.
Challenges
Given the cross cutting nature of nutrition, coordination of interventions across programs and sectors requires adequate financial and human resource capacity that at the moment are limited at all levels.
3.1.3 Prevention and Control of Non-Communicable Diseases and conditions
(1) Prevention of Non – Communicable Diseases
Non-Communicable Diseases (NCD) contributes considerably to morbidity, disability and mortality rates in Uganda. Documentation of the extent of the problem of non-communicable diseases in Uganda is still poor. The lack of data is often taken for non-existence of the problem and limited attention has thus far been given to the problem of NCDs. Anecdotal reports indicate that the prevalence of NCDs in on the increase. The most prevalent non-communicable diseases in Uganda include: Hypertension, Diabetes, Cancer, Chronic Obstructive Pulmonary Disease, Sickle Cell Disease and Obesity. Some of these conditions are preventable but not much has been done for the following reasons:-
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• Lack of policies on the prevention of some NCDs. • Limited practical methods of preventing NCDs because of poor socio-economic
status of the country. • Limited information to the public and policy makers.
During the period under report, the new Insulin 100 IU was introduced to replace the 40 IU variety as part of the response to international standards.
(2) Essential Clinical Care
The programme for essential clinical care services includes care for injuries and common illnesses including non-communicable diseases, palliative care, oral health, ear/eye care, disability and rehabilitation. Accidents and other injuries form a significant proportion of the burden of disease at all levels. The general objective of the Programme is to provide basic care for common illnesses including non-communicable diseases and injuries. During FY 2003 04, significant progress was made in this area ;
• The draft Hospital Policy for Uganda is at the final stages and is ready for Top Management. The specific role played by each hospital level except by the national hospitals is yet to be clarified. The national Hospital Policy is expected to define the type, roles and functions of each hospital level. It is also expected to streamline the organisation, management and institutional framework of the units in the national health care system.
• Health workers in 4 districts were trained in Injection Safety • The annual workshop for Senior Hospital Managers was held to look into issues
affecting the delivery of clinical care. Common Illnesses and Injuries Essential clinical services aim at alleviating human pain and suffering inflicted by common illnesses and injuries. In Uganda, the ten commonest causes of morbidity in order of frequency are: Malaria, Acute Respiratory Infections (ARI) – Not Pneumonia, Intestinal Worms, Diarrhoea, Trauma (injuries and wounds), ARI – Pneumonia, Skin Diseases, Eye Diseases, Anaemia, Ear Diseases and Others. The above morbid conditions constitute the major causes for attendance at the various levels of the health care services delivery system. One of the major objectives of the HSSP is to increase accessibility of the population to essential clinical care. During the period under review, this has been achieved through improved equity of service delivery points. Laboratory Services The quality of clinical care has a lot to do with the availability of quality laboratory services. The HSSP service standards provide for laboratory services up to HCIII level. The equipment that was provided at these levels still remains largely under utilized due to lack of personnel. The existing laboratory services, especially below the hospital, are constrained by quantity and quality issues mainly caused by;
• Poor staffing, both in quality and quantity • A poor Support Supervisory system
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The appointment of District Laboratory Focal Persons and the “ regionalisation ” of laboratory services around Arua, Mbarara, Mbale and now Hoima Regional Referral Hospitals will go a long way to improve on the quality of laboratory services. During FY 2003/04, a number of initiatives have been taken to address the issues of laboratory services. The details appear later in the Chapter under in the Section on Laboratory Support Services. (3) Oral/Dental Health Care
Oral/Dental health care is an important component of PHC. The nature of the commonly required oral health care in the community setting is the relief of dental pain. The main objectives of the HSSP are;
• To ensure equitable availability of oral health services. • To conduct In-service training of health workers on oral health • To create public awareness on early detection, appropriate treatment and referral.
In line with the above objectives, a number of achievements were registered during the period under review;
• 32 oral health staff were sensitised on the common oral lesions associated with HIV infection
• Technical support supervision was provided to 18 General Hospitals Human resource and equipment constraints continue to plague the delivery of oral/dental services. (4) Mental Health
The Government of Uganda attaches much importance to improvement of mental health services because of the significant burden of disease attributable to mental illness in the country. The main objective of the Programme is to provide improved access to primary mental health services to the entire population and to ensure ready access to quality mental health referral services at district, regional and national levels. During the HSSP period the Programme is expected to:
• Develop policy and guidelines for implementation of mental health services • Provide, coordinate and educate population on mental health promotion and
disease prevention; Reactivate the mental health coordinating committee at national level and create inter-sectoral committees at district levels
• Integrate mental health into all the general health services from HC I up to the district
• Establish a system of integrating mental health patients into their families and communities ; Establish a system to address psychosocial needs arising as a result of disaster and conflict situations
• Identify and address effects of violence including violence against women • Introduce a gender responsive mental health component in the paramedical,
nursing, midwifery and medical school curricula During FY 2003/04, several achievements were made; Policy: - The principles for the Mental Health Act were completed, guidelines for the healing of wounds of mass violence adapted and a cabinet memo for the ratification of
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the Framework Convention for Tobacco Control (FCTC) was submitted to Top Management Capacity Development: - Trained 80 health workers in the SHSSP supported districts of Northern Uganda and IEC materials developed on emotional and behaviour disorders among children and adolescents Monitoring: - Conducted a baseline survey on mental health services in 11 districts of Northern Uganda and incorporated some Mental Health conditions in the revised HMIS tools.
Challenges
The funds for all Mental Health activities remain grossly inadequate and so are the appropriately trained service providers. The information gaps in the mapping of specific health problems like epilepsy in order to determine its magnitude as well as the geographical distribution. There are still low levels of community appreciation of the existing and potential magnitude of the mental health burden.
(5) Disability, Prevention and Rehabilitative Services
During the FY 2002/03, efforts were consolidated on new central and district rehabilitation programmes as well as assessing the disability situation in the remaining districts. The six draft policies on prevention of blindness, prevention of deafness, health care of older persons, assistive devices for persons with disabilities, prevention and management of non-communicable diseases and prevention and control of injuries are at various stages of scrutiny and vetting. The other notable achievements during FY 2003/04 include the training of 98 health workers in primary ear care in a 2 week course and a refresher course held for 80 health workers in ear care. Three Regional Referral Hospitals were equipped with ENT and Eye equipment and Ugshs 89 million released to the orthopaedic workshops for making assistive devices. Prevention of deafness outreaches conducted in 15 districts and sensitisation of political and civic leaders done in 17 districts. Picture on Disability celebrations held at MoH
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(6) Palliative Care
Palliative Care has largely focussed on providing care to the terminally ill persons, especially those with cancer and HIV/AIDS. The objectives of Palliative Care (PC) under the HSSP are to:
• Increase the number of health workers trained to provide PC. • Increase accessibility of ill persons to PC
The consolidation and expansion of PC services to all the districts was the mainstay of implementation for the period under report. The statutory instrument that allows Nurses and Clinical Officer trained in PC to prescribe is already in place. This will allow them to prescribe a limited range of Class A drugs for PC. Oral morphine constituted centrally at Joint Medical Stores is provided for pain relief and is available at all hospitals. Implementation of PC continues to be jointly carried out with Hospice Uganda, Mildmay, TASO and other stakeholders.
(7) Hospital Services
The National Health Policy and Health Sector Strategic Plan 2000/01 to 2004/05 have the provision of the UNMHCP as the priority of the sector, including preferential allocation of financial resources. In particular, the NHP categorically stated that funding to the central level, national and regional referral hospitals would be held constant in real terms4. This led to minimal focus at the hospital level with most attention being paid to the Primary Health Care level. More recently it has been recognised that hospitals play a key role the delivery of the UNMHCP and also consume substantial resources. For example for the FY 2003/04 a total of Ugshs 48 billion was transferred to public Regional Referral, public General hospitals and PNFP hospitals for wage, non-wage and drugs (credit lines) equivalent to 39% of all transfers to the districts5. There are 2 national, 11 Regional Referral and 43 public General hospitals in the country. There are 45 PNFP hospitals and 7 recognised private hospitals. Hospitals have continued to play a vital role in providing a continuum of care to patients referred by self or from lower Health Centres. Also, hospitals, through provision of preventive and promotive services have complemented PHC services in their catchment areas. There is need to assess their performance and appreciate constraints of delivering services at this level and options for improvement given current sector resources. In the AHSPR FY 2002/03, the first attempt was made to include information specific to performance of hospitals. This report of FY 2003/04 builds on this and further develops a framework with which to objectively assess the performance of hospitals, initially the Referral hospitals, including some of the PNFP hospitals and in future reports carrying this assessment to cover the general hospitals. During FY 2003/04, the sector took a keen interest in hospital services as shown by the progress made in the formulation of the Hospital Policy, increasing resources to hospitals and focusing on hospitals during the first Area Team monitoring and mentoring visits.
4 National Health Policy Page 15 5 this does not include the wages for public general hospitals which are included in district wage grants
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Resources for Hospital Service Delivery
Resources for delivery of health services at the hospital level increased between the FY 2002/03 and 2003/04 through the following:
• Increase of the budget at the different levels: National Referral, Regional Referral and General Hospitals including PNFPs6;
• Introduction of the Credit lines at the Regional Referral, General Hospital and PNFP Hospitals7;
• Recruitment of health workers;
The Area Teams Report on Hospitals
The first Area Teams visits of March and April 2004 looked at: the overall management of the facilities; patient management/quality of care; and assessed facility outputs given facility inputs8. The findings indicated that there was wide variation in utilisation rates at the different hospitals, but also variations in resources including human and financial resources. The lack of an assessment framework for this level of health service delivery made it difficult to distinguish the good performing from the poor performing hospitals. The findings further indicated that infection control measures needed to be improved and that the safety of health workers is sometimes compromised. In addition the visits noted that the many of the hospitals were in dire need of repair, and that in many cases laboratory and Blood Banks were not at the appropriate standards for these institutions given the specialist level of service delivery and the wide catchment areas including the need for higher level services compared to those at the Health Centre IVs. Another pertinent finding was that the hospitals were no longer able to carry out support supervision and mentoring visits to the lower levels of service delivery (National Referral to Regional Referral, Regional Referral to General Hospitals and Health Centre IVs). This was mostly due to financial constraints. The Report recommended reviving of the Consultants Outreach Programme and plans have already been made to have this active in the FY 2004/05. Assessment of hospital functions for the Financial Year 2003/04 For purposes of this report, the general hospital functions are largely covered under district performance hence only the National and Regional Referral hospitals are considered here in detail.
National Referral Hospitals
Mulago Hospital serves both as the National Referral Hospital and the Teaching Hospital for Makerere University Medical School. The hospital also provides referral
6 See Budget Framework Paper and Financial Resource Allocation Documents 2003/04 for more information on this 7 as in previous Footnote 8 More about this in the March-April 2004 Area Team Report
58
services for the Central Region as well as the Minimum Health Package for a significant proportion of the population of Kampala and the neighbouring districts. Mulago operates as one Complex, comprising New and Old Mulago Hospital. This makes it difficult to disaggregate the national referral functions from other functions, including the management of minor ailments. The complexity of assessment of a hospital in terms of its proficiency is proportional to the complexity of its functions. For purposes of this report, comparison will be made between Mulago Hospital Complex and the Regional Referral Hospitals. Table 3.16 summarises the service outputs for Mulago Hospital Complex. Table 3.16: Mulago Hospital Service Outputs FY 2003/04
Outpatient Outputs
Med
ical
Pae
dia
tric
s
*Su
rgic
al G
en
Gyn
aeco
logy
AN
C
Eye
EN
T
Neu
rolo
gy
Car
dio
logy
Ora
l
Oth
er
Tot
al
OPD New
13,860 38,046 13,734 1,764 35,124 15,636 9,084 1,539 273 1,935 91,987 222,982
OPD Re-Attend
33,405 18,093 17,165 1,935 37,902 5,343 4,587 1,683 264 3,783 128,995 253,115
Referral In
In patient Outputs
Med
P
aed
*Su
rg
Gyn
Ob
s.
Eye
EN
T
Neu
ro
Car
dio
Ora
l
Oth
er
Tot
al
Admissions
16,257
19,770 4,011 26,337 28,530Deliv.
909 1,098 681 53,421 151,014
ALOS 8
8 7 14 16 14
Major Surgical Operations
NA
NA
5,565 5,142C/Sect.
569 89 - - 497
In relative terms, the wage and recurrent non-wage inputs for Mulago Hospital (Ugshs 20.71 billion) are greater than the allocation to all the 11 Regional Referral Hospitals (Ugshs 17 billion). On the other hand, Mulago Hospital’s bed capacity is equivalent to 29% of all Referral Hospital beds in the country (excluding Butabika Hospital). Furthermore, the human resource capacity (trained health workers) at Mulago stands at 1,636 against 1,600 for all the Regional Referral Hospitals put together (excluding Mbarara University Teaching Hospital). Though the data is incomplete (especially for the super-specialties such as cardiothorathic surgery), analysis of the outputs shows that 9.4% of all deliveries in public and PNFP facilities in Uganda actually take place in Mulago Hospital. The facility also admits as many patients as the Regional Referral Hospitals put together. A closer look at the outpatient workload reveals that 46% of the Outpatient consultations could
59
have been managed at a lower level facility. It is difficult to make comparisons beyond this level. To take this process further, Mulago hospital will need to develop a method of comparing the performance of the various departments using Standard Units of Output as demonstrated for the Regional Referral Hospitals and their PNFP equivalents in this report. Butabika Hospital: is the National Referral Mental Health Institution in Uganda, was established in 1955. In line with the HSSP mental health strategy, the hospital provides quality referral mental health services for the whole country. During FY 2003/04, the hospital has been undergoing infrastructural rehabilitation. This is part of a broader mental health development programme, covering six Regional Referral Hospitals as well. As part of this restructuring programme, and in view of the low levels of human resource availability, the hospital has already started utilising technical support teams to cover the districts of Masaka, Fort Portal, Soroti, Arua, Jinja, Mbale, Kabale, Gulu, Moyo and Adjumani. The hospital also continued to conduct training for all the cadres specialising in mental health services delivery.
Regional Referral Hospitals
The health sector is in the process of developing an appropriate framework to assess performance of hospitals and in particular Regional Referral Hospitals, given the level of investment and expected outputs from these hospitals. As an initial step, this report has puts forward an analysis of the pattern of inputs and outputs at the Regional Referral Hospital level. The framework shall be refined to allow for performance assessment for hospital service delivery in the future. The HSSP II (2005/06-2009/10) will include a more explicit performance assessment framework for hospitals. The RRHs deliver a mixture of referral and general hospital services, which presently cannot be de-linked. These hospitals are usually the sole hospitals in the districts. The catchment areas are often diffuse such that the target populations cannot be ascertained. As the referral system gets streamlined it is anticipated that the referral roles and functions of these units will become clearer. Regional Referral Hospitals provide specialist services depending on the availability of the specialists and other inputs like equipment, drugs and supplies. In addition these hospitals/specialists are expected to provide technical support and capacity building in areas such as IMCI, reproductive health, malaria and CME to the staff in the lower health centres. All the Regional Referral Hospitals reported an increase in OPD attendance in FY 2003/04 compared to FY 2002/03 which trend is also seen in ANC attendance and In-patient admissions. However this is not observed in the case of deliveries and worse still, a number of hospitals show a decline in the number of deliveries in FY 2003/04 compared to FY 2002/03. The Standard Unit of Output as a measure of performance at the RRH Given the difficulty already indicated in objectively analysing the performance of a Referral hospital, a tool, the Standard Unit of Output (SUO) has been used in this Report9. The Outpatient visits (new and re-attendances), Antenatal Care visits, In-Patient 9 The Standard Unit of Output has been used previously by the UCMB to assess performance of the affiliated hospitals, more information on this can be attained from their published articles
60
stays and deliveries have been weighted and a composite index, the SUO derived. Immunisation and family planning services although initially targeted for inclusion have been excluded because of gaps in data. See Annex IV for details of RRH inputs and outputs that have been included in this analysis. The analysis includes 10 RRHs, Mbarara University Teaching Hospital plus 3 PNFP hospitals with specialist services namely Lacor, Nsambya and Rubaga Hospitals. Mbale and Lacor Hospitals had the highest number of SUOs in the FY 2003/04, well above 600,000 SUOs each (see Figure 3.9). While the performance may be related to the size of the hospital (Mbale has a bed capacity of 384, whereas Lacor has 474), Jinja Hospital with a bed capacity of 500 and Arua with 356 beds have much less SUOs. Kabale and Fort Portal Hospitals had SUOs well below the national average at less than 200,000 SUOs each. Figure 3.9: Standard Unit of Output (SUO) by the Regional Referral Hospitals
-
100,000
200,000
300,000
400,000
500,000
600,000
700,000
800,000
Kabale
RH
F/Port
al RH
Hoima R
H
Rubag
a
Gulu R
H
Mbarar
a
Arua R
H
Nsamby
a
Masak
a RH
Nation
al Ave
rage
Jinja
RH
Soroti R
H
Lira R
HLa
cor
Mbale
RH
Stan
dard
Uni
t of O
utpu
t
Analysis of RRH Outputs against Inputs The SUO provides an opportunity for assessing the RRHs outputs against inputs rather than just using official bed capacity – which is often misleading, as actual situation on the ground may differ markedly from the officially recognised position. The financial resources available to different hospitals were computed and analysis made at how efficiently the hospitals were in converting their financial resources into SUOs. Mbale emerged as the most efficient followed by Soroti, Lira and Gulu hospitals, which utilise less than Ugshs 5,000 to produce one SUO (see Figure 3.10) On the other hand Rubaga and Nsambya Hospitals emerged as the least efficient using more than Ugshs 8,000 to produce one SUO. The national average was about Ugshs 6,000 to produce one SUO.
61
Figure 3.10: Comparison of Efficiency at the Regional Referral Hospitals
-
2,000
4,000
6,000
8,000
10,000
12,000
14,000
Mbale
RH
Soroti R
H
Lira R
H
Gulu R
H
Hoima R
H
Masak
a RH
Arua R
H
Nation
al Ave
rage
Mbarar
a UTH
Jinja
RH
Kabale
RH
Laco
r
F/Port
al RH
Rubag
a
Nsamby
a
Cos
t of p
rodu
cing
a S
UO
A different way of analysing the efficiency of the RRHs is by using the human resources (health workers) available to the hospital as an input. Lira Hospital was using its health workers most efficiently producing 2,500 SUOs per health worker, whereas Nsambya, Arua and Jinja RRHs were the least efficient with a health worker producing less than 1,500 SUOs (see Figure 3.11). On average one health worker in the Regional Referral Hospitals produced 2,000 SUOs in FY 2003/04. Figure 3.11: Comparison of Health Workers' Outputs at the Regional Referral
Hospitals
0
500
1000
1500
2000
2500
3000
Nsamby
a
Arua R
H
Jinja
RH
F/Port
al RH
Rubag
a
Mbarar
a UTH
Kabale
RH
Hoima R
H
Masak
a RH
Nation
al Ave
rage
Laco
r
Gulu R
H
Lira R
H
SUO
per
Hea
lth W
orke
r
62
Challenges with the SUO methodology
While this methodology has been applied before in the PNFP sector in Uganda, this is the first time that it is being applied to public hospitals. The findings of the above analysis need to be considered with the understanding that there are a number of issues which need to be resolved even as ways and means are sought to further develop a performance assessment framework for hospitals in general and regional and national referral hospitals specifically. These include: Quality of services - the SUO methodology does not take into account quality of services. It is therefore difficult to know whether some of the differences in the observed “efficiency” are due to quality differences. For example the variation in Average Length of Stay (ALOS) varies markedly in the different hospitals as seen in the table in Annex IV from 3 days in Mbale RH to 15 days in Arua RH and the Maternal Death Rate varied from 3.6% in Kabale to 0.2% in Nsambya and the Total Death Rate from 7% in Mbarara UTH to 0.9% in Soroti RH. Case mix and other complexities – there are likely to be variations in case mix even though facilities at the same level (in this case the 3 PNFP hospitals were taken to be equivalent to RRHs) have been considered. The differences in case mix have not really been taken into consideration in this analysis. For example major surgical operations were not used as one of the variables in computing the SUO. This was because the data was considered unreliable. If current data on major surgical operations was used, Arua’s performance would markedly improve since it registered more than 5,000 operations. Data quality, classifications and definitions – the quality of the data, and the definitions/classifications employed still need to be improved. For example is the category major surgical operation understood uniformly throughout the country? Is it possible that Kabale Hospital registered only 275 operations while Arua Hospital carried out 5,142 operations? What would be the implication of this? Another example is the number of referrals, which in effect should be a key indicator for a Referral Hospital. Again data on this was found to be scanty possibly due to lack of appreciation as to the purpose for collecting this data at facility level. As this is the first time this analysis has been done, individual hospitals are encouraged to examine their performance in absolute terms and also in relation to other facilities of similar status in order to judge their performance. Areas of under-performance should be identified and efforts made to improve. Constraints should be identified and plans made to overcome them. Resource allocation in the future should be clearly related to both the capacity of the facility to convert inputs into outputs, and also targeted at gaps as have been noted in some hospitals in terms of infrastructure, equipment and human resources and not just related to official bed capacity.
PNFP Hospitals
The performance of three of the PNFP hospitals has already been analysed together with the public RRH. Further note is made here of some of the observations that have been made in the PNFP hospitals over the FY 2003/04 and also to provide a trend analysis. GoU has provided subsidies to the PNFP health sub sector with the following objectives:
• Increasing the accessibility to the sub sector.
63
• Improving the quality of services in the PNFPs. • Encouraging the sub sector to recommit themselves to the provision of PHC
services around them. Observations from a sample of 65% of PNFP Hospitals have shown positive trends of the main output indicators (cumulative values – across all the hospitals; there are variations form one to the other). Outpatient and Inpatient attendances have registered an increment by 7.7% and 7.1% respectively. Deliveries in the Hospitals have also registered an increment of more than 5%, as well as the utilisation of pre and post-natal services, which shows an increment in utilisation of 15%. These are illustrated in Figures 3.12 and 3.13. Figure 3.12: Cumulative admissions in a sample of 65% of PNFP Hospitals
Figure 3.13: Cumulative Number of Deliveries is a sample of 65% of PNFP
Hospitals
154,705 159,706 149,872
172,318
199,464
238,621 255,635
0
50,000
100,000
150,000
200,000
250,000
300,000
97 98 98 99 99 00 00 01 01 02 02 03 03 04
23,709 22,618
26,91828,403 28,949
32,377 34,064
0
5,000
10,000
15,000
20,000
25,000
30,000
35,000
40,000
97 98 98 99 99 00 00 01 01 02 02 03 03 04
64
Information about improving financial access is included in the Financing section of this report. The contribution of the PNFP Hospitals and LLUs is captured in the district outputs reports.
3.1.4 Health Promotion and Disease Prevention
(1) Health Education and Promotion
Knowledge and attitudes of the population are key determinants of the health seeking behaviour of the communities. A comprehensive health education and promotion Programme is implemented as an essential cross-cutting component of all the health programmes. The main objective of the programme is to promote individual and community responsibility for better health and to advocate for the HSSP. In the HSSP period the programme is expected to:
• Promote adoption of health promotive and disease preventive behaviours at individual and community levels;
• Support the development and adoption of strategies for dissemination of specific Programme messages through various mechanisms
• Create demand for and effective utilization of health services • Collaborate with other sector institutions in promotion of community
participation and advocacy for health Although targets were set for the different interventions under this Programme, the performance has not been regularly measured since the HSSP began (see Table 3.17). This kind of information can only be derived from surveys a number of which have not been carried out yet. A survey, covering 14 districts but biased towards Mid–North and North West, has provided an insight with respect to a number of health promotion indicators. Table 3.17: Performance against the HSSP Health Education and Promotion
Indicators
Indicator Baseline Value
Achieved 2002/03
Target 2003/04
Achieved 2003/04
Target 2005
1 Increased public awareness of personal and community responsibility for better health
2 Provide IEC materials to Village Health Teams
75%
3 Implementing an effective advocacy plan for the HSSP (Stakeholders familiar with the NHP and HSSP)
0%
4 Recruit positive media participation in health education and promotion
0% 50% 75% 70% 85%
Promotion of Health Literacy: Health literacy is the ability of individuals to recognise the common conditions that pose a threat to health and know what action to take to
65
address those conditions. That is the ultimate goal of the HSSP. In FY 2003/04, the survey noted above, indicated that though the radio was the commonest source of health information in 82% of the households, the existing community mobilisation modalities are not well appreciated and utilised. This information base should guide the development of an appropriate communication strategy for the promotion of health literacy. Media Participation in Health Education and Promotion: The availability of FM radio stations in virtually all parts of the country and the 50% discount extended to the Ministry of Health, have enabled the sector to exploit this communication channel to reach the households. During the period under review, 18,000 messages were disseminated using 33 FM stations. This is the basis for the registered achievement of 70% in this indicator. What may need to be clarified further is the equity in access to the radio sets within the households. Training of Village Health Teams (VHTs): This activity has been conducted with total district coverage in 11 districts in Northern Uganda. In 33 other districts, the activity was introduced in one sub-county so that the district can take off from there to replicate the activity. This is an important activity in promoting advocacy for health education and promotion.
Challenges
Successful health promotion can only be achieved after attainment of satisfactory levels of health literacy. At the district level this requires a strong political will as well as a multi-sectoral approach that combines the health and community development components with strategic guidance from the central level. Some of the difficulties facing the central programme are:
• Shortage of manpower to meet the IEC needs of all the sector programmes. • Lack of equipment to aid in the production of educational materials. • Limited resources and logistics, especially for community mobilisation.
(2) Environmental Health
Environmental factors are major determinants of health outcomes. In the HSSP period, the Environmental Health Programme focuses on raising awareness of the population on the relationships between their health and their surroundings. This addresses issues of access to safe water, sanitation both at the household and institutional levels, personal hygiene and environmental/occupational hazards. It should be borne in mind that unsafe water and poor environmental sanitation are significant risk factors for child mortality. The main objective of the programme therefore is to contribute to the attainment of a significant reduction in morbidity and mortality due to environmental health related conditions. The environmental health programme through the national environmental health action plan and the Kampala Declaration on Sanitation (KDS) is expected to achieve the following:
66
• Implement the minimum environmental health services package with special emphasis on the safe water chain and sanitation as spelt out in the National Health Policy and the Kampala Declaration on Sanitation;
• Strengthen collaborative mechanisms at all levels and with relevant agencies for promotion of safe water, sanitation and occupational health;
• Promote proper food hygiene and safety, management of wastes (solids and liquids), pollution control and occupational health and safety in work places;
• Promote gender responsive sanitation and hygiene promotional materials to support community mobilisation on environmental health matters;
• Promote clean and hygienic living conditions at household level; • Integrate sanitation and hygiene in school health and educational programmes;
The HSSP targets for the period under review are shown in Table 3.18 Table 3.18: Performance against HSSP Environmental Health Indicators
Indicator Baseline Value
Achieved 2002/03
Target 2003/04
Achieved 2003/04
Target 2005
1 Increased access to safe water 43.9% 54% 70% 54% 75% 2 Proportion of districts conducting
water surveillance activities 2% 18% 50% 18% 100%
3 Safe waste disposal (Latrine coverage as proxy)
47.2% 47% 60% 57% 60%
4 An Environmental Health Act and subsidiary legislation in place and enforced
Draft stage
Cabinet approval
Still pending
Safe Water: Provision of safe water sources is a responsibility of Directorate of Water Development (DWD). The health sector staff work closely with DWD staff and lobby very hard for improvement in the availability of safe water. The data available indicates no improvement in household accessibility to safe water between FY 2002/03 and FY 2003/04. The health sector on the other hand is specifically charged with the responsibility of monitoring the water quality and advising on the steps to be taken to maintain the safe water chain. Performance against this indicator remains very poor. There was no procurement of water quality testing equipment for the districts during FY 2003/04.The main activity undertaken during the FY 2003/04 in respect to safe water was the development of a “Safe Water Chain” handbook. Waste Disposal: Safe disposal of human and other wastes is important for disease control. In Uganda, the practices associated with the disposal of human waste poses a huge threat to health. The latrine coverage, which is the proxy indicator, is 57% for FY 2003/04. This is an improvement of 10% from FY 2002/03 levels but still below the target for FY 2003/04, which was 60%. The performance for the districts is illustrated in Figure 3.14. The performance range for the indicator is from 94% for Rukungiri to 2% for Kotido district. The best performers are Rukungiri, Kanungu, Kabale, Kabarole and Masaka while the least performers are Kotido, Nakapiripirit, Pader, Moroto and Kitgum. Further analysis indicates that only 21% of the districts registered an improvement in coverage since FY2002/03. It is also noted that the districts of Kotido, Kitgum, Moroto and Nakapiripirit have continued to register a coverage less than 20%. On the whole, therefore, the improvement in the national latrine coverage has been contributed by a few districts.
67
Figure 3.14: Pit latrine coverage by district
0
10
20
30
40
50
60
70
80
90
100
Kotid
o
Nak
apiri
pirit
Pade
r
Mor
oto
Kitg
um
Kata
kwi
Kabe
ram
aido
Mas
indi
Gul
u
Sem
babu
le
Bugi
ri
Bund
ibug
yo Lira
Kapc
horw
a
Soro
ti
Kala
ngal
a
Igan
ga
Arua
Wak
iso
Yum
be
Neb
bi
Kam
uli
Mub
ende
Kum
i
Siro
nko
Kibo
ga
Apac
Adju
man
i
Nat
iona
l
Mba
le
Toro
ro
Kam
wen
ge
Kiso
ro
Hoi
ma
Pallis
a
Mpi
gi
Nak
ason
gola
Rak
ai
Luw
ero
Moy
o
Muk
ono
Kiba
ale
Kam
pala
Jinj
a
Mba
rara
Kayu
nga
Kase
se
Kyen
jojo
May
uge
Busi
a
Ntu
ngam
o
Bush
enyi
Mas
aka
Kaba
role
Kaba
le
Kanu
ngu
Ruk
ungi
ri
57%
During FY 2003/04, a number of sanitation promotion activities were undertaken;
• Advocacy for the implementation of the Kampala Declaration on Sanitation (KDS) was intensified
• Staff from 35 districts were trained in the use of the Health Mapper as well as the collection of household data
• Sanitation promotion materials were disseminated • Sub-county sanitation implementation plans were launched in the 9 model
districts of Moroto, Katakwi, Soroti, Kumi, Mbale, Sironko, Pallisa, Tororo and Busia.
• Demonstration latrines were constructed in the districts of Nebbi, Apac, Lira, Nakasongola, Pallisa and Sironko.
At the National Sanitation Conference, Busia district shared its success story of improved sanitation coverage (see Box 3.2)
Environmental Health Legislation
a) The draft Environmental Health Bill: is awaiting the submission of the Community Mobilisation Bill to Cabinet by the Ministry of Labour, Gender and Social Development.
b) The Draft Food Safety Bill: is ready for submission to Cabinet
c) The National Food Safety Strategic Plan: Finalised and ready for submission
to the Cabinet for consideration.
68
Box 3.2: Improved Sanitation Coverage – The Success Story of Busia District
Challenges
Resources for Environmental Health Activities • The available water testing kits are not sufficient for the districts with trained
staff. Districts were expected to procure the equipment and reagents but they are currently not able to do so. The sector should plan for central procurement of the water testing kits.
• Inadequate Human Capacity and Logistical support such as transport for monitoring and training activities in districts;
Institutional Framework for Environmental Health
• The differentiation of roles for the water and health departments at the district level, though less marked, still poses a challenge to smooth implementation of water and sanitation activities;
• Shortfalls in data management at all levels thus hindering verification of key indicators;
• Weak enforcement mechanisms especially at the community level e.g. community by-laws;
Social Mobilisation
• The attitude and practices of some communities towards human waste disposal require fresh approaches for effective and sustainable behaviour change;
• District Political and Civic leadership need to get more involved in community mobilisation for water and sanitation activities in accordance with the KDS;
• Population instability that makes it difficult to implement household sanitation in areas affected by conflict
Busia district, in a bid to uplift its sanitation coverage, has employed a model sub-county strategy and managed to improve latrine coverage in Dabani Sub-county from below 40% to well over 90% during the year under report. As a result, the district latrine coverage has improved from 50.9% in FY 2002/03 to 76% in FY 2003/04. The thrust of the strategy was home improvement campaigns, with the active involvement of the District Water and Sanitation Coordination Committee (DWSCC), the district health, administrative and political leadership. The associated remarkable achievement is that the district and the sub-county did not require any extra resources but rather utilized the existing resources in an integrated manner. The other sub-counties in Busia district are now emulating the Dabani Sub-county success and the district success has become a model for the other districts in Uganda. The Environmental Health Division (MoH) and the World Bank’s Water and Sanitation Programme (WSP), are promoting holistic sanitation and hygiene approaches, including hand washing promotion. If all the districts can proactively emulate the Busia success story, then this country would be able to move towards achieving a faecal-free environment and breaking the faecal-oral disease transmission chain.
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(3) School Health
The school going population in primary and secondary schools constitutes about 42% of the total population. The UPE population alone is about 30% of the national population. This underscores the importance of school health in health promotion and disease prevention in this country. The main objectives of the School Health Programme are to improve the health status of the school children, their families and teachers and to inculcate health seeking behaviour among this population group. The specific objectives of the Programme are to:
• Improve personal hygiene and promote healthy lifestyles among school children; • Ensure delivery of health education in schools; • Strengthen medical and dental care services for school children; • Promote construction and use of pit latrines in all schools; • Promote provision of safe water supplies in all schools; • Improve physical and psychosocial school environment; • Improve nutritional status of school children; • Strengthen physical education and recreation; and • Improve health-seeking behaviour among school children, their households and
their teachers. Implementation of the School Health Policy: For over a year, the school health policy has been awaiting endorsement by the Top Management of both the Ministries of Education and Sports and that of Health. However, on the ground, the policy is already being implemented. During FY 2003/04, guidelines on mass screening of school children, malaria control in schools and oral health were developed and disseminated and as part of the May 2004 Child Health Days, there was mass de-worming of school children up to 14 years of age. In addition, tools for monitoring the health status in schools were developed and disseminated, School Health supervision was conducted in 24 districts and 50 Boarding Schools, a proposal for feeding school children developed and implemented in parts of Northern Uganda and a costing of the School Health Policy is being undertaken with support from WHO.
Challenges
The multi-sectoral nature of school health implementation remains a dominant challenge. The success of the strategy will largely depend on its prioritisation both at the strategic and operational levels by the partner implementers.
(4) Integrated Disease Surveillance and Response (IDSR)
In 1998, Uganda together with other member countries within the World Health Organization (WHO) regional bloc for Africa, adopted integrated disease surveillance (IDSR) as the strategy for multi-disease surveillance. The disease priority list for Uganda is categorized into:
• Diseases with epidemic potential; • Diseases for elimination/eradication; and
70
• Other diseases of significant public health importance. Formal sensitization of the political, health workers and surveillance stakeholders was then done resulting into strong political support and increased demand for surveillance data as well as greater commitment by the Government of Uganda and development partners to support IDSR. An assessment of the existing surveillance systems was conducted in 2000 and a five-year strategic plan which serves as the basis for resource mobilization was formulated. The annual work plan for FY 2003/04 was based on the five year strategic plan.
Coordination of IDSR implementation
In order to streamline IDSR implementation at National level, a coordination body (the IDSR/HMIS committee) was established and has representation from the technical departments in the MoH, the Institute of Public Health (IPH), the Medical Bureaus, the laboratory technical committee, Development Partners and other stakeholders. The committee meets monthly and has the mandate to determine priorities, assess data requirements and agree on the tools for data collection. At district level, surveillance focal persons have been established in all districts and in 44 of 56 of districts laboratory coordinators have been appointed. During FY 2003/04, the following activities were implemented in an effort to strengthen the core and support functions of IDSR. Strengthening case detection and registration: Standard case definitions and action thresholds for the priority diseases (predominantly communicable diseases) were printed and disseminated to all public health facilities and the World Health Organization (WHO/AFRO) generic IDSR guidelines were adopted, printed and disseminated to all the districts. However, the continuous utilization of these guidelines/tools at the health unit level still remains a challenge. Strengthening reporting: The revised weekly, monthly, quarterly and annual surveillance and HMIS tools were distributed to districts. In order to ensure sustainability the tools are currently distributed by the National Medical Stores (NMS) and distribution for one year has been assured through assistance from partners. The Government however needs to take on this role so that forms and other surveillance tools do not run out and affect the reporting and feedback chain. Strengthening data management, analysis and interpretation: At the National level, data are analyzed on a weekly and monthly basis to track epidemics and for early detection and timely response to the outbreaks and an EPI-INFO database has been created at the center for data storage. Data analysis at district, health sub-district and health facility level still remains a big challenge. In order to stimulate data analysis for action a generic data analysis guide/book was developed. Strengthening feedback: During FY 2003/04, the epidemiological surveillance division continued to publish the weekly epidemiological newsletter and a quarterly surveillance bulletin. The weekly epidemiological newsletter was disseminated to all districts and published in the main print media. Feedback from district to health sub-district and from HSD to health facility level still remains a big challenge. A new initiative to try to improve feedback at these levels was the development of a generic feedback guide in the last financial in an effort to encourage routine written feedback in addition to oral feedback.
71
Strengthening Laboratory Capacity and Networks: A national laboratory technical committee was established with membership from public, private, NGOs and partners to coordinate laboratory activities. Standard operating procedures (SOPs) for the laboratory were developed and will be used in the FY 2004/05 to train laboratory staff. Furthermore, district laboratory coordinators were appointed in 44 of 56 districts to coordinate the strengthening of laboratory surveillance at district level. A network of 3 regional laboratories (Mbale, Mbarara and Arua) was set up and another 7 are to be up in a phased manner. Strengthening support functions for IDSR: A good surveillance system needs good support functions such as training, supervision, communication logistics etc. In the FY 2003/04, a training plan was finalized and the WHO generic training modules were adopted. All the eight planned IDSR in-service training workshops were conducted. The participants included 40 Health Centre III staff, 20 Trainers of Trainers in data analysis, 35 rapid response teams (RRTs), 20 pre-service students, 33 Masters of Public Health students and 30 trainers of trainers in IDSR). Inclusion of IDSR in the pre-service training curriculum of health training institution was initiated. ESD maintained weekly radio contact with all districts and extension of radio communication to all HSDs in phased manner will be done in the next plan period. At 6 monthly intervals, surveillance focal persons meet to review and discuss surveillance issues and provide feedback. Monitoring IDSR implementation: To ensure that IDSR implementation is monitored in Uganda, core indicators were adapted and are being used to monitor implementation of IDSR. The estimates for these core indicators are presented in the Table 3.19. Table 3.19: Performance against HSSP IDSR indicators
Indicator Achieved 2002/03
Target 2003/04
Achieved 2003/04
Target 2005
1 Proportion of epidemics with laboratory confirmed diagnosis
81% 100% 97% 100%
2 Percentage of epidemics with Case Based reports
50% 100% 61% 100%
3 Percentage of epidemics reported to higher levels within 48 hours
29% 100% 32% 100%
4 Proportion of district weekly reports that are timely
92% 100% 97% 100%
5 Proportion of weekly newsletters submitted to districts
100% 100% 100% 100%
6 Proportion of IDSR bulletins produced and disseminated
50% 100% 75% 100%
7 Proportion of districts with action thresholds
100% 100% 100% 100%
8 Case Fatality Ratio (CFR) for Cholera
6 < 1 2.9% < 1
9 CFR for Measles 2 < 5 2.1% < 5
10 CFR for Meningococcal Meningitis
16 <10 13.5% < 10
11 CFR for Plague 7 <1 8.5% < 1
72
Monitoring the impact of successful health interventions on morbidity – the case of measles mass campaigns
In order to monitor the impact of health interventions, it is important to rule out surveillance bias due to incomplete reporting. The completeness data demonstrates that there were no remarkable fluctuations in completeness of reporting throughout the year (Figure 3.15). However, there was a remarkable drop in the weekly and monthly measles cases reported following the mass campaigns (Figure 3.16a and b). This data confirms that the Uganda surveillance system is robust enough for tracking successful health interventions such as mass campaigns for measles. Figure 3.15: Completeness of weekly district and health unit reporting, Uganda
2003
Figure 3.16a Impact of mass campaigns for measles cases, Uganda 2003
Panel a): Weekly measles cases
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73
Figure 3.16b Impact of mass campaigns for measles cases, Uganda 2003
Panel b): Monthly measles cases
Challenges
Despite some of these successes, the division has had some challenges. The most important constraint has been inadequate staffing and the loss of critical staff. Lack of office space is another constraint; and in addition the lack of laboratory space limits the functions of the National Public Health Laboratory. Furthermore, harnessing the data and information management benefits of IDSR and applying them to the whole HMIS to cover both communicable and non-communicable diseases remains a major challenge.
Finally, although many challenges exist, IDSR has made considerable progress. The necessary policy and regulatory framework for implementation of IDSR is available and the WHO country office, WHO/AFRO, the Centres for Disease Control (CDC), USAID, Rockefeller foundation have been critical in technically and financially supporting IDSR implementation. Continued support from the GoU and the development partners will be important to sustain the gains made and to continue investing in building capacity for IDSR at national, district, and HSD and facility level. Capacity needs to be created to respond to new and re-emerging infectious diseases. Uganda is in an epidemiological transition that has been termed the double disease burden as non-communicable diseases increase. The current HMIS In-patient reporting format should address the disease data for non-communicable disease (NCD) surveillance. Strategies have to be put in place for risk factor surveillance and sentinel sites should be established for this purpose.
measles trends 2002-2004
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74
3.2 Integrated Health Sector Support Systems
3.2.1 Health Care Financing The HSSP objectives for Health Care Financing are to eliminate financial barriers to access, ensure effectiveness, efficiency, equity in allocation and utilisation of resources, transparency and accountability in the sue of resources; and mobilise additional funding for the sector. Every Financial Year an appropriate budget that is consistent with the HSSP and the PEAP is developed and efforts are made to streamline the different financing mechanisms in the health sector. The financing target for the HSSP The Health Financing Strategy (HFS) estimated that the total annual cost of the HSSP, in the medium term, would be US$ 28 per capita. In order to maximise efficiency, the bulk of this financing would be channelled through the GoU budget as this has been shown to enable the sector to target funding against set priorities. As part of the process to produce the second HSSP the MoH is currently revising its financing target to take into account revisions in service coverage and quality. For example since the start of HSSP I changes have been agreed in staffing norms and in the provision of anti-retroviral drugs for HIV as part of the UNMHCP. As there are no obvious areas where HSSP I services will be scaled back, it is certain that the HSSP II financing target will be higher than that for the first plan, probably in the range US$ 30-40 per capita. This level is consistent with that presented in WHO’s Commission for Macroeconomics and Health. The HSSP Resource Envelope The health sector financing levels have continued to fall a long way short of the HSSP requirements. Based on recent information from MoFPED and estimates of other financing sources Figure 3.17 below shows that the resource envelope for the sector has remained fairly constant over recent years. Furthermore, resource levels in real terms are not projected to rise in the immediate future. Figure 3.17: Resource Projections for the Ugandan Health Sector
Resource Projections for the Ugandan Health Sector (2003/04 prices)Using MoFPED's MTEF Projections
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75
Two rounds National Health Accounts studies have been done in Uganda covering FY 1997/98 to FY 2000/01. The estimates from the National Health Accounts differ from those presented here because the National Health Accounts includes expenditure in the private-for profit sub-sector, which is not necessarily targeted at the HSSP. The overall resource envelope10 increased by Ugshs 72.6 billion in FY 2003/04 (see Figure 3.18). This is an increase of 21% taking the overall funding of the HSSP up to a level equivalent to US$ 9 per capita. The majority of this increase was accounted for by a recalculation of the donor project portfolio by MoFPED. Given the unpredictability associated with donor project funding, the sector recognizes that these figures are unlikely to reflect the real financing contributions made by projects in the financial year based on the Donor Expenditure Survey carried out for the FY 2003/04 reported on later in Chapter 3. This is of particular importance given the current policy by MoFPED to include donor project funds within sector ceilings. Trends of Government Budget Funding for Health in the recent past The GoU budget (including donor budget support) in the health sector saw marked growth - over 100% in the last 4 years of the HSSP. This growth spurt however seems to have ended, with minimal growth noted between FY 2002/03 and FY 2003/04 and in the medium term. In a bid to improve efficiency and equity, the health sector has maintained its commitment to allocate the budget to priority HSSP services. In particular there has been effort to target the funds at the Primary Health Care levels. For example the expenditure at the MoH HQs reduced from 30% of GoU health sector expenditure in FY 1999/00 to 26% in FY 2001/02 and to 23% in the approved budget for FY 2004/05; while expenditure at the district level increased from 32% in FY 1999/00 to 48% in FY 2001/02 and 59% in FY 2004/05 (see Table 3.20). Table 3.20: Trends of GoU Budget Funding for the Health Sector FY 1999/00 to
FY 2000/03 (Billion Ugshs.)
Service delivery level
1999/00 2000/01 2001/02 2002/03 2003/04 2004/05
Bn shs. % Bn Shs. % Bn Shs. % Bn Shs. % Bn Shs. % Bn Shs. %
MoH Hqs. 24.01 30% 34.8 30% 43.6 26% 55.8 28% 58.36 28% 49.66 23% Central Hosp. 17.9 22% 15.2 13% 23.2 14% 23.9 12% 27.77 13% 33.67 16% Agencies 1.37 2% 1.8 2% 3.3 2% 3.66 2% 3.87 2% 3.25 2% District health services
25.3 32% 50.6 44% 81.3 48% 96.4 49% 103.36 50%
125.32 59% District PHC 15.5 19% 37.6 33% 60.9 36% 71.1 36% 75.88 36% 97.24 46% PNFP 3.3 4% 6.7 6% 11.6 7% 16.6 8% 17.04 8% 17.72 8% District hospital 6.5 8% 6.3 6% 8.9 5% 8.7 4% 10.44 5% 10.36 5%Regional Ref. Hospitals
11.2 14% 11.8 10% 18.6 11% 16.2 8% 14.63 7%
Total 79.8 100% 114.2 100% 170 100% 195.96 100% 208.09 100% 211.9 100%
10 The sum of contributions from the three main financing sources: MTEF Envelope is composed of GOU budget and donor Projects; other sources refer to User Fees in private wings of public units and PNFP units and small contributions from insurance and prepayment schemes
76
Donor projects Donor Project funding for the health sector dipped in the first half of the HSSP but was projected to increase again during the latter half of the HSSP. The dip in donor project funds in the first half of the HSSP was due to the switching of most of the donors from largely project funding to budget support. This is the explicitly preferred mode of funding for the HSSP. The rise in the latter half of the HSSP was based on expectations from Global Initiatives like Global Fund for AIDS TB and Malaria and the President (Bush) Emergency Plan for AIDS Relief (PEPFAR). It is not possible to get information about trends of donor project funding in similar detail as for the GoU budget. The National Health Accounts covering the FY 1997/98 to FY 2000/01 attempted to capture some of the detailed information about donor projects but even then data had a lot of gaps and could not be used for meaningful analysis below the aggregate level. Budget Performance FY 2003/04 GoU Budget Performance for FY 2003/04 During the FY 2003/04, the GoU expenditure on health was Ugshs 207.99 billion representing 95.04% of the total budgeted figure of Ugshs 218.84 billions.11 This translates into a per capita expenditure of US$ 4.51 per capita. The GoU budget expenditure on health increased by 5% in real terms in the last financial year and represented 9.6% of total budget expenditure (up from 9.0% last year). Health’s approved allocation represented 10.2% of the budget. This variance reflects the under-spend (5%) of the health sector budget and overspend in other sectors. With the population growing at 3.4%, the real per capita increase in the health budget over FY 2002/03 was only 1.2%. This rate of increase is not adequate compared to the requirements of the Health Financing Strategy. The Health Financing Strategy had advocated for a health budget of Ugshs 246 billion in FY 2003/04, if the sector is to be on track to close its financing gap by FY 2019/20. The actual budget in FY 2003/04 fell Ugshs 27 billion short of this target. The GoU budget expenditure by level and item (wage, non-wage and domestic development) is provided in detail as Annex II. Some highlights are discussed here. During the FY 2003/04, the non-wage component was allocated the largest proportion of 47% compared to wage and domestic development12 as is shown in the Figure 3.18. The percentage expenditure on wage remains low for efficient delivery of health services. A further disaggregation of the sector budget by level and category is presented in Figure 3.19. The National Referral Hospital Mulago achieved 112% budget performance. This was contributed to by more than budgeted expenditure both against wages and non-wage. The Health Service Commission and Uganda AIDS Commission both achieved 100% budget performance. 11 It is important to note that this proportion of GoU funding includes both the government funding through revenue collection and donor contributions channelled through the budget support. 12 Domestic development includes the counter-part funding to donor development projects and government infrastructure developments such as construction of theatres and purchase of equipment.
77
Figure 3.18: Allocation of health sector budget FY 2003/04
Domestic Development
21%
Wage32%
Non-wage 47%
The District Primary Health Care Grant, the District Hospital and the NGO Hospital and LLU Grants all achieved budget performance of more than 95%. These are PAF grants protected by government to ensure high budget performance and thus enable service delivery at the Primary Care levels. Figure 3.19: FY 2003/04 Approved Budget Estimates and Releases (Bn Shs)
Budget Against releases - 2003/04
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MoH HQ Butabika Mulago HSC UAC PNFPs District PHC District Hosps Ref. hosps
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The Regional Referral Hospitals experienced the lowest budget performance that is wholly attributed to the low performance of the wage budget at 70%. This is important to note for future budget allocation because as was the case in FY 2002/03 the Regional Referral Hospitals under-spent their wage budget.
District budget performance
The PHC-CG is spent at the DDHS level (management functions), HSD (management and service delivery functions) and NGO units (mainly service delivery). An analysis of actual disbursement against budgets was performed on submitted data from 22 districts. The expenditure against budgeted for non-wage recurrent grants, which are spent at the DDHS office and HSDs was 94 and 95% respectively. This is comparable with the national figure of 96% for the aggregate District Primary Health Care Conditional Grant.
78
The performance of the NGO grant at 89% performance is much less than the national figure of 96% indicating under-performance in the set of districts included in this analysis. The low performance on the PHC Development grants at 72% is lower than expected and is attributed to poor release of funds by MoFPED. Only 88% of the budgeted funds for PHC wage in the analysed districts were disbursed and this could mainly be attributed to the fact that some districts have not been able to recruit against their budgets for the last 4 years. The national figure for PHC wage performance is 106%. The LGDP is constituted of mainly contributions from the central government’s consolidated fund and as is shown, disbursements against budgets remain very low.
Donor Expenditure in the FY 2003/04
This report has made an effort to collect information from Development Partners on the Donor Funding currently available to the sector. Efforts to understand Development Partner spending in the sector have previously relied on budget estimates based on information within the Project Implementation Plan and Development Partner-Government agreements in MoFPED. In conducting the survey, information was requested from all Development Partners on spending in the health sector for the FY 2003/04 but responses were received from only 50% of partners namely: DfID, DANIDA, EU, Department for Cooperation Ireland (DCI – former Ireland AID), SIDA, World Bank – the Uganda AIDS Control Project and WHO. Some information on the Global Fund is also included in the analysis and is discussed in more detail later in Chapter 3. The Development Partners/Donor Projects who failed to provide FY 2003/04 expenditure information include: the ADB Project; German Technical Cooperation; IDA/World Bank Project – Early Childhood and Nutrition; The Kamuli/Kisoro Spanish Project; UNFPA, UNICEF, JICA and USAID. The following discussion focuses on Donor Project Support becuase all funds within budget support are already included in the GoU budget13. According to the MTEF as of July 1, 2003 the Donor project budget for the FY 2003/04 was estimated at Ugshs 166 billion. The updated figures from MoFPED dated October 14, 2004 estimate donor project funding for FY 2003/04 at US$ 100.2 million or Ugshs 180 billion. Table 3.21 illustrates the discrepancy in information held by different GoU entities regarding funds available under Donor Projects. The results of a Donor Survey carried out by the Health Planning Department, MoH at the beginning of FY 2003/04 (see AHSPR 2002/03) are shown in Table 3.21 in the column Budget MoH. These estimates approximate with actual expenditure at the end of the FY 2003/04. However, when the MoFPED database is used to determine budget figures they widely differ with the expenditure, with most donor projects except the Global Fund having budget performance well above 100%. The MoFPED database is applied in the analysis since it is used to determine funding levels for the MTEF. Data from the 8 donor respondents show a budget of US$ 61.5 million for FY 2003/04 of which US$ 52.26 million was spent. This represents budget performance of 85%. If this performance is taken as representative, then it can be projected that total donor projects spending for FY 2003/04 is approximately US$ 85.14 million or Ugshs 153 billion. 13 For example funds indicated under budget support for DfID and EU reflect all the funds to GoU budget support, whereas for SIDA and DANIDA this is ‘earmarked’ for the health sector
79
Table 3.21: Donor Expenditure FY 2003/04 (US Dollars)
The GoU budget (including donor budget support) at Ugshs 208 billion is therefore greater than the funding from donor projects in the sector. The project funding therefore contributes US$ 3.32 per capita to health expenditure. The public per capita expenditure in health (government and public) of US$ 7.83 still falls below the estimated requirement of US$ 28.15 Information received from four partners enabled further analysis of donor project spending in the public and private sector, and also to determine what proportion of the funding was spending on HSSP and non-HSSP inputs. Figure 3.20 dmonstrates that most of the funds are spent in the public sector. DfID funding to the private sector is mostly to the Non-Facility Based PNFPs involved in HIV/AIDS Care for example TASO. Figure 3.20: Percentage expenditure in the public and private sector
0%
20%
40%
60%
80%
100%
DCI DFID Danida WHO
Public Private
14 Reflects funds released into the country, and not necessarily spent on service delivery yet 15 Health Financing Strategy; MoH
Donor Expenditureon Donor Donor Project Support Total Donor
Budget Performance
Budget Support
Budget MoH
Budget MoFPED Expenditure Expenditure
excl. Budget Support
DCI 925,508 925,508 DCI Malaria Consortium 36,650 36,650
DFID 52,500,000 3,020,150 1,400,000 3,128,388 55,628,388 223%
DANIDA 2,705,500 7,843,878 6,800,000 8,192,167 10,897,667 120%
WHO 6,200,000 2,900,000 4,163,077 4,163,077 144%
EU 29,400,000 900,000 1,629,423 31,029,423
Global Fund14 36,000,000 18,325,000 18,325,000 51%
SIDA 8,583,603 500,000 1,509,740 10,093,343 168%World Bank – AIDS Control Project 13,000,000 14,347,791 14,347,791 110%Total - Data Available 93,189,103 17,064,028 61,500,000 52,257,744 145,446,847 85% Total as with MOFPED US $ 100,200,000 85,141,885 Total as with MOFPED Ug. Shs 180,360,000,000 153,255,392,198
80
Given the recent approach by the MoFPED to consider donor project funding as a component of the sector funding ceiling it has become crucial to ensure that donor project funding is targeted just like GoU budget funds at priorities as indicated by the HSSP. Analysis was therefore done of donor project expenditure against the priority inputs identified by the HSSP. Figure 3.21 shows that 70% of DCI project expenditure was on non-HSSP inputs. Malaria Consortium and AMREF implement the DCI projects and the non-HSSP inputs are mainly project overheads by these entities. Figure 3.21: Percentage expenditure on HSSP and Non HSSP inputs:
0%
20%
40%
60%
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100%
DCI DFID Danida WHO
HSSP Non HSSP
Global Fund The Global Fund for AIDS, TB and Malaria (GFATM) was put in place to bridge funding gaps in existing plans for prevention and control of HIV/AIDS, TB and Malaria. As of the end of FY 2003/04 a total of US$ 18 million had been released by the GFATM HQs in Geneva to Uganda. This was much less than had been expected for the FY – the MoFPED had reflected US$ 36 million in the budget for the FY 2003/04 (see Table 3.22). Table 3.22: Global Funds approved against disbursed
HIV/AIDS TB Malaria Total
Approved for 1st 2 years US $ million 36.3 4.69 23.2 64.19
Additional for Year 3 US $ million 15.6 15.6
Approved for Round 3 US $ million 70.4 70.4
Disbursed into the country US $ million 13.29 1.177 3.858 18.325
Disbursed to districts Ug. Shs billion 1.457 .254 .612 2.323
Disbursed to line Ministries including MoH Ug. shs billion
.975 .040 .772 1.787
Disbursed to CSOs, special interest groups Ug. shs.billion
.057 .057
Disbursements are as of June 30th 2004
The main reason for the low budget performance of 51% is the difficulty experienced in starting up a project of such magnitude. However the figure of 51% just represents funds
81
sent into the country. When funds actually spent are considered, only a total of Ugshs 4.68 billion has been released for activities. This is equivalent to 7% of the budget of the GFATM for the FY 2003/04. It is expected that performance of this funding entity will be much better in FY 2004/05 especially following the implementation of the GFATM procurement plan. This again highlights the unpredictability of project spending and the challenges involved in including these resources in MTEF ceilings. Funding in the Private not-for Profit Sub-sector The Health Policy recognizes that the private sector is a major partner in health care and the HSSP Costing includes the cost of provision of services in the PNFP facilities. The total income for the PNFP Sector is estimated at Ugshs 26 billion in FY 1998/99; Ugshs 35 billion in FY 1999/00; Ugshs 35 billion in FY 2000/01; Ugshs 33 billion in FY 2001/02, Ugshs 48 billion in FY 2002/03 and Ugshs 59 billion in FY 2003/04. The breakdown is highlighted in Figure 3.22 and shows the increasing proportionate contribution of the government subsidies from about 15% in FY 1998/99 to close to 25% in FY 2003/04. Figure 3.22: PNFP Health Sector – Trends in income structure:
0%
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100%
1998-99 1999/00 2000/01 2001/02 2002/03 2003/04
Govt. Subsidies (money and drugs) User Fees Aid
This is clear testimony of the commitment in the sector to consider the PNFP’s contribution to the HSSP as major. In contrast the reliance of the PNFPs on user fees has declined from about 60% of the total budget to about 40%. The reliance on user fees is still inequitably distributed amongst the PNFPs with the hospitals relying less on the fees than the Lower Level Units, whereas the latter is at the primary level where less rationing to health care should take place. Over the years, user fees, as a mechanism of financing health care in has declined as a proportion of total funding for PNFP hospitals from 56% in FY 1998/99 to 34% in FY 2003/04 (Figure 3.23).
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Figure 3.23: Relative sources of income over time – PNFP Hospitals:
11% 15% 19% 27% 27% 23%
56% 49% 44%38% 36%
34%
17% 26% 19% 9% 20% 26%
16% 10% 18% 26% 17% 17%
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1998-99 1999/00 2000/01 2001/02 2002/03 2003-04
Delegated Funds Users' Fees
Other Financial Sources External Donation of Goods and Services
In the Lower Level Units on the other hand the contributions from the different funding sources has not shown a clear trend over the last five years. The percentage contributions from user fees have remained rather high – at 43% in the FY 2003/04 despite increasing contribution from delegated funds over the years. This seems to be partly because of the declining contribution of external donations and other financing sources, but is likely to be contributed to by the rising costs of health care delivery (Figure 3.24). Figure 3.24: Relative sources of income over time – PNFP LLUs
11% 13% 14% 22% 28% 35%36% 43% 26%
32% 31%43%22% 7%
8%9% 10%
31% 36% 51% 37% 32% 18%4%
0%20%40%60%80%
100%
1998-99 1999/00 2000/01 2001/02 2002/03 2003-04
Delegated Funds Users' Fees
Other Financial Sources External Donation of Goods and Services
Financial Management
The Ministry of Health has continued to make efforts targeted at improvements in financial management. In particular actions agreed as follow up to the Programme 9 Tracking Study, which had overarching implications for the entire MoH, were undertaken. These include:
83
• Delay in releases within MOH – the internal process within the MoH requires at least 5 working days. Delays well beyond this period should not take place except for requests with queries and officers for outstanding accountabilities.
• Arbitrary reallocation – reallocations have been cut back, and discussions are being held with concerned parties if reallocation has to happen.
• Accountabilities – the Accounting section has worked very hard to ensure that officers with activities do provide the accountabilities in time, and if not are not advanced more funds.
• Quarterly financial and output reports – these are to be made available every quarter at the MOH Quarterly Review Meetings.
Financial Management at the district level
Analysis of expenditure against releases for the different quarters was done based on data from 18 districts. Over FY 2003/04, 93% of the disbursed funds were spent. Given an average budget performance of 99% by the District PHC-CG, this means that actually 92% of the funds budgeted for the districts actually reached and were utilised within the FY. The low rate of utilisation in the 1st and 2nd quarters was compensated for in the 3rd and 4th quarters (see Figure 3.25). This can be attributed largely to late release of funds from the centre (MoFPED) to the districts. However this has implications for efficient use of resources since the districts scramble to spend all the funds in the last quarters in the FY leading to too many activities at the same time and poor value for funds spent in some instances. There were variations in performance across districts: among the districts with adequate data Moyo was the best performer utilising 100% of released funds in the 4 quarters. Majority of districts registered low utilisation of disbursed funds in the first 2 quarters but seemed to catch up in the last 2 quarters. Figure 3.25: Percentage of released funds that are spent in the different quarters.
59%
82%
103%111%
93%
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Q1 Q2 Q3 Q4 FY
Preliminary assessment of the effect of FDS on the pilot districts
The Government of Uganda started the process of implementing the Fiscal Decentralisation Strategy (FDS) with 15 Local Governments piloting the new financing arrangements in FY 2003/04. The strategy has been rolled out to all Local Governments
84
this FY 2004/05. Anecdotal evidence from the pilot phase reveals a sketchy knowledge of FDS by many LG officials and as such it is still too premature to make a meaningful assessment of the scheme.
Additional Sources of Funds for the HSSP
The Government of Uganda has appreciated the need to continue identifying and developing additional and/or alternative sources of funding for the health sector. In the FY 2003/04 efforts were made to initiate the formation of a Commission for Macroeconomics and Health in the country. Such a body is expected to continue articulating the health sector needs for resourcing if the country is to achieve the PEAP and MDG targets. Social Health Insurance: The process of developing Social Health Insurance (SHI) in the country continued in FY 2003/04. Advocacy and sensitisation meetings/workshops have been carried out, and a Cabinet Paper prepared. It is envisaged that SHI will be ready for roll out in about two years.
Tracking Health Sector Funding - The National Health Accounts FY 1998/99 to FY 2000/01
The 2nd round of Ugandan National Health Accounts covering the FY 1998/99 – FY 2000/01 was finalised in FY 2003/04. This was in updating information on health sector spending. The National Health Accounts particularly highlighted the high contribution from private sources, a large proportion of funds controlled by the Private not for profit entities, and the low spending on hospitals and human resource for health. The National Health Accounts show that spending in the health sector including both public and private has stagnated just below US$ 20 per capita (see Figure 3.26). Figure 3.26: Total Health Expenditure in Uganda FY 1998/99 to FY 2000/01
A large amount of spending is from private sources (see Table 3.23). It is important to note that the period studied coincided with the period when cost-sharing was common in public facilities. Table 3.23: Sources of Funds Spent in the Health Sector (US $ per capita)
Source of Funds
1998/99 1999/00 2000/01
Public 8.37 8.31 8.35 Private 10.31 10.12 9.96
423411
402269
181819
13
05 0
1 0 01 5 02 0 02 5 03 0 03 5 04 0 04 5 0
1 9 9 7 /9 8 1 9 9 8 /9 9 1 9 9 9 /0 0 2 0 0 0 /0 1
THE
mill
ion
US$
dol
lars
024681 01 21 41 61 82 0
per c
apita
hea
lth
expe
nditu
re U
S$
85
When compared with other countries, Uganda spends more on health than Ethiopia, Rwanda, Mozambique and Malawi, but much less than Kenya and Botswana (see Table 3.24). As a proportion of the Gross Domestic Product, Uganda is spending more on health than any of the countries. This high spending as a proportion of the GDP, coupled with high contributions by private sources, indicate that the high private sector spending could be a strain on the population, and there are questions as to how efficiently this spending in the private sector is being converted into outputs. Table 3.24: Comparison of Health Expenditure in Other African Countries
Country Total health expenditure per capita US$
Govt expenditure on health as a % of total Govt expenditure
Total health expenditure as a % of GDP
Uganda 18 7.4 8.1 Kenya 29 6.2 7.8 Ethiopia 3 4.9 3.6 Malawi 13 12.3 7.8 Rwanda 11 14.2 5.5 Botswana 190 7.6 6.6 Mozambique 11 18.9 5.9
When analysis is made on the entities that manage health sector resources (referred to as Financing Agents) it is noted that most of the funds are still managed directly by households, followed by Private-not for Profit agencies (both facility- based and non-facility-based) with government Ministries (including MoH), district health services all together taking last position. Hardly any funds are channelled through insurance (see Figure 3.27). This has very serious implication for the health sector. The MoH and other government stakeholders who are responsible for policy formulation and monitoring have access to only a limited portion of sector resources. There is the challenge for sector stakeholders to ensure that as much of these resources as possible are spent on articulated country priorities and strategies. Figure 3.27: Management of Health Sector Resources by Financing Agents
0%
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1998/99 1999/00 2000/01
Private firms
Private not-for ProfitAgenciesHouseholds
Private InsuranceEnterprises Parastatals
District Health Services
Other Ministries andNational Health ServicesMinistry of Health
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This is very crucial as the sector develops the HSSP II. The high spending of donor project resources through PNFPs especially non-facility based PNFPs needs to be studied further for their concurrence with sector priorities. This is particularly important given inclusion of these projects under sector ceilings and therefore their ability to displace government funding in the sector. The proliferation of Global Initiatives with high spending in the private sector is also noted. The health sector is to carry out the NHA for the FY 2001/02 to 2003/04 in the FY 2004/05 to enable the sector make policies and allocate resources based on updated total health spending information.
3.2.2 Human Resources for Health The HRH Division initiated compilation of staff data from all GoU and PNFP health units in the districts around May-June 2003. Data collection was conducted through DDHS following a simple data format for each district, including number of staff per staff category, per facility (HC II-IV, hospital, and DDHS), and per owner (GoU, PNFP). Data formats and structures were arranged to enable direct comparison and analysis between staffing norms and actual staff numbers. For each district facility data was validated against the MoH Health Facility Inventory (October 2002), discrepancies and inconsistencies identified and returned to the districts for adjustments or confirmation, and extensive follow-up visits to districts by staff from HRH Division assisted by the PHC monitoring (Area Teams) teams carried out. Data from all districts has now been collected, compiled and is represented in this report. The analysis is limited to the existing minimum staffing norms in so far as they appear in the HSSP document and related working papers. The HSSP document indicates minimum norms for HC II-IV, whereas norms for District (General) Hospitals appear in related working papers only. Data was also collected from the National and the Regional Referral Hospitals. The overall total staff in the health sector (GoU and PNFP) is presented in Table 3.25). Table 3.25: Current number of staff in the Health Sector – GoU/PNFP
Total TotalDistricts DDHS Districts RH Mulago Butab. MoH hq GoU PNFP Total
Clinical 1,319 53 1,372 168 91 7 1,638 436 2,074Medical 308 50 358 164 111 15 648 305 953Midwifes 1,635 18 1,653 312 147 35 2,147 914 3,061Nursing 2,542 34 2,576 758 1,114 86 4,534 1,915 6,449Total Medical/clinical 5,804 155 5,959 1,402 1,463 143 8,967 3,570 12,537Nursing Assistants 4,165 21 4,186 175 123 0 4,484 2,005 6,489Diagnostic 356 4 360 79 75 3 517 358 875Pharmacy 76 22 98 29 25 6 158 43 201Other Medical related 988 161 1,149 63 144 5 1,361 126 1,487Other staff 1,627 245 1,872 462 433 79 2,846 3,052 5,898
Total 13,016 608 13,624 2,210 2,263 236 18,333 9,154 27,487
Payroll Nov03 16,070 2,284 2,092 283 525 21,254 9,154 30,408Difference/adjustment 2,446 74 -171 47 525 2,921
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It is estimated that about 900 of the staff difference between the District Inventory data and the District Payroll can be explained by under-reporting from the districts. Up to 1,500 of the remaining staff differences may, however, be explained by other factors. A number of visits by HRD and Area Team staff to individual districts showed a significant number of staff from other departments in the districts – notably Agriculture – appearing on the Health Department Payrolls. There are also indications that double counting of staff, retired or deceased staff still on the Payrolls etc. may contribute to the differences between the HR Inventory and the Payroll. There is clearly a need for a comprehensive cleaning-up of the Payroll district by district. Except for Records Assistants, staffing norms do not cover non-medical staff. The analysis below is concentrated on Government units in the districts, excluding non-medical staff (see Table 3.26). Table 3.26: Analysis of Actual Number of Staff (excluding Non-medical staff)
and Minimum Staffing Norms – All Districts, GoU only.
Categories/services Level No. Level No. Level No. Level No.Excl. non-medical HC II 870 HC III 714 HC IV 152 Hospital (GH) 38 TotalStaff Act Norm Gap Act Norm Gap Act Norm Gap Act Norm Gap Act Norm GapClinical 110 110 552 714 -162 356 456 -100 301 304 -3 1,319 1,474 -155Medical 5 5 22 22 142 152 -10 139 152 -13 308 304 4Midwifes 236 236 659 659 313 152 161 427 646 -219 1,635 798 837Nursing 472 870 -398 677 2,142 -1,465 451 608 -157 942 1,634 -692 2,542 5,254 -2,712Total Medic/clinic 823 870 -47 1,910 2,856 -946 1,262 1,368 -106 1,809 2,736 -927 5,804 7,830 -2,026Nursing Assistants 1,406 1,740 -334 1,444 714 730 520 152 368 795 795 4,165 2,606 1,559Diagnostic 9 9 113 714 -601 127 304 -177 107 190 -83 356 1,208 -852Pharmacy 1 1 3 3 20 152 -132 52 114 -62 76 266 -190Other Medic related 116 116 439 714 -275 297 456 -159 136 152 -16 988 1,322 -334
Total 2,355 2,610 -255 3,909 4,998 -1,089 2,226 2,432 -206 2,899 3,192 -293 11,389 13,232 -1,84390% 78% 92% 91% 86%
The overall proportion of actual health staff compared with the minimum staffing norms is 86%. Although the percentage reported in the previous report (FY 2002/03) was 84%, data had been compiled from only 51 districts and validation was not yet completed. In particular, data from Kampala was not available last year. There are significant coverage variations between districts ranging from 40% to 265%16 (refer to District League table). In addition, there is substantial variation in coverage between facilities within the districts. The staff gap analysis in the above table does not take into consideration that surplus staff from one district cannot be re-distributed to another district with staff deficiencies. By adjusting for that, and therefore recognizing that possible surplus of specific staff categories will remain in the individual districts, the overall deficit of health staff is 3,953 instead of the above 1,843. The summary staff category Medical (Medical Officers i.e. General and Specialists) shows hardly any overall deficit gap. Although the norm indicates one Medical Officer (MO) per HC IV, there are 47 out of the 151 HC IVs – or 31% - without any MO and 21 HC IVs have 2 MOs or more.
16 Upper end - Kampala: 264.8%; Adjumani: 157.9%Kalangala: 146.9%. Lower end – Kamwenge: 40.0%; Pader: 43.6%; Kanungu: 49.1%.
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The most conspicuous deficit gap is found in the largest staff category – Nursing which shows an overall deficit gap of 52% (2,712) in GoU facilities. On the other hand Midwives show a surplus of 837. Nursing Assistants show a surplus of 1,559 and Clinical Officers only a deficit gap of 11% (155). The staffing norms do not include provision for midwifery staff at HC IIIs. The staffing norms assumed that maternity services at HC III should be delivered by Comprehensive Nurses. Since the output of comprehensive nurses is still low, there is a tendency to post midwives to HC III to cover maternity services. For the lower level facilities (HC IIs and IIIs), Clinical Officers, Nurses, Midwives and Nursing Assistants are combined in order to analyse availability of overall clinical staff in the facilities rather than compare the staff categories separately (Table 3.27). Table 3.27: Analysis of Actual Number of Clinical Staff and Minimum Staffing
Norms – All Districts, GoU only.
Level No. Level No. Level No. Level No.Categories/services HC II 870 HC III 714 HC IV 152 Hospital (GH) 38 TotalClinical staff Act Norm Gap Act Norm Gap Act Norm Gap Act Norm Gap Act Norm GapClinical 110 110 552 714 -162 356 456 -100 301 304 -3 1,319 1,474 -155Medical 5 5 22 22 142 152 -10 139 152 -13 308 304 4Midwifery 236 236 659 659 313 152 161 427 646 -219 1,635 798 837Nursing 472 870 -398 677 2,142 -1,465 451 608 -157 942 1,634 -692 2,542 5,254 -2,712Nursing Assistant 1,406 1,740 -334 1,444 714 730 520 152 368 795 795 4,165 2,606 1,559
Total 2,229 2,610 -381 3,354 3,570 -216 1,782 1,520 262 2,604 2,736 -132 9,969 10,436 -46785% 94% 117% 95% 96%
The HC IIIs register 94% available clinical staff compared with minimum staffing norms. The large deficit of Nurses is partly compensated for by Midwives and a surplus of Nursing Assistant. Again, as indicated above, midwives to a certain extent are posted to HC IIIs to compensate for the lack of comprehensive nurses. The HC IIIs have a deficit gap of 23% for Clinical Officers. Similarly, a surplus of Nursing Assistants partly compensates for a similar deficit of Nurses in General Hospitals. Overall, HC IIs have 85% available clinical staff compared with minimum staffing norms. There is a deficit of 46% of Nurses. This is to a significant extent compensated for by Midwives and Clinical Officers (Midwives and Clinical Officers are not included in the staffing norms for HC IIs). As indicated in Table 3.28, the available clinical staff at HC II level are unevenly distributed between districts as well as between facilities within the district. Table 3.28: Distribution of Clinical Staff in HC IIs (GoU)
Number Clinical Number ofStaff per HCII HC IIs
0 651 173 113 (1 Nursing Assistant)2 231 94 (2 Nursing Assistants)3 207 39 (3 Nursing Assistants)4 109 4 (4 Nursing Assistants)5 41 1
6 and above 44 4Total 870 255
HC IIs with Nursing Assistants only
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65 GoU HC IIs have no staff at all17. Of the remaining 805 HC IIs 255, or 30%, are staffed by Nursing Assistants only. 203 HC IIs are staffed by more Clinical Staff than the minimum staffing norms. Five HC IIs are currently staffed by between 9 and 12 Clinical Staff. This might indicate some misperception regarding the distinction between HC IIs and HC IIIs. It has been contended that the Nursing Assistants cannot be considered trained health staff, and therefore should not be included in the HSSP indicator – proportion of approved posts that are filled by trained health personnel. Excluding the Nursing Assistants from the indicator reduces the overall indicator (as indicated in the Table 3.26 above, excluding non-medical staff) from 86% to 69%. For technical support (Diagnostic and Pharmacy) staff there is an overall shortfall of more than 70%. This is most significant at HC III level with an average coverage of only 16% of Laboratory staff (See Table 3.29) Table 3.29: Analysis of Actual Number of Technical Support Staff and Minimum
Staffing Norms – All Districts, GoU only.
Level No. Level No. Level No. Level No.HC II 870 HC III 714 HC IV 152 Hospital (GH) 38 Total
Act Norm Gap Act Norm Gap Act Norm Gap Act Norm Gap Act Norm GapLaboratory 9 9 113 714 -601 126 304 -178 87 152 -65 335 1,170 -835Radiographer 1 1 20 38 -18 21 38 -17Total Diagnostic 9 9 113 714 -601 127 304 -177 107 190 -83 356 1,208 -852Dispenser 1 1 3 3 18 152 -134 46 76 -30 68 228 -160Pharmacist 2 2 6 38 -32 8 38 -30Total Pharmacy 1 1 3 3 20 152 -132 52 114 -62 76 266 -190
Total 10 10 116 714 -598 147 456 -309 159 304 -145 432 1,474 -1,04216% 32% 52% 29%
Technical Support staff
In – Service Training: The implementation of the In-Service Training Strategy (IST) has experienced considerable difficulties right from its inception. The slow uptake can be attributed to lack of systemic and effective coordination. This has resulted into fragmented and overlapping training activities without any monitoring mechanism compounded by inadequate funding. A number of achievements, however have been registered in the implementation of the Distance Education Programme, which is now integrated and managed within the framework of the national and district IST strategy with support from partners. The Distance Education Programme (DEP). • The decentralisation of the DEP has registered a remarkable improvement with 93%
of the districts having functional Distance Education Units (DEUs) as compared to 59% in the previous tear
• In the 52 districts with established DEUs, the transformation of these units into CME/In-Service Training Centres has been initiated and needs to be followed up and strengthened
• The number of courses offered has been expanded to take care of the changing needs of the new spectrum of health workers and all courses have been modularised
17 This includes 11 HCIIs in Apac district.
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• There has been further decentralisation of the DEP from the district to the HSD level. Tutors and mentors have been trained at HSD level and this has already translated into improved enrolment of learners, script marking and course completion
• Innovative approaches to sustainability have been tried through the newly introduced course on Pharmacy Practice for Dispensers and Pharmacy Technicians. The Learners have paid a registration fee of Ugshs 20,000 and are expected to pay an extra Ugshs 50,000 as examination fees
• A drive has been initiated to affiliate some of the courses to institutions of higher learning so as to raise their profile and give them some added value.
Enrolled Comprehensive Nurse Training
The Enrolled Comprehensive Nurse (ECN) is the cadre expected to play a major role in the delivery of the MHCP, especially at the HC II level. It was therefore envisaged that the training of Enrolled Nurses and Midwives would be scaled down as the training schools convert to ECN training. The HSSP I expected outputs for the respective cadres are shown in Table 3.30. Table 3.30: The projected and actual output of ECN and Enrolled Nurses and
Midwives
YEAR
Projected Output Actual Output
Enrolled Nurses
Enrolled Comprehensive Nurses
Enrolled Nurses
Enrolled Comprehensive Nurses
2000/01 686 - 445 2001/02 686 - 4652002/03 686 200 274 - 2003/04 430 630 266 242004/05 - 630
Only about 2% of the expected HSSP I ECN output has been achieved to date. The training schools, of which 70% belong to the PNFP sub-sector, have encountered difficulties in converting to ECN training. The start up and maintenance costs of running this training are enormous. While for the schools that train ECN, the high entry requirements for the course have left the schools running at half their capacity. After a series of consultations between the MoH, MoES and other stakeholders, a consensus was finally reached to lower the Minimum Entry Qualifications for the ECN from 5 Credit passes to 5 Ordinary passes, two of which must be in English and Biology as core subjects. The other three passes can be obtained in the non-core subjects of Chemistry, Mathematics and Physics or their substitutes which include Food Science, Food and Nutrition, Home Economics, Health Science, Geography and Agriculture. This development will facilitate the scaling up of ECN output through the support from DCI/AMREF and the EU supported project on “Developing Human Resources for Health”.
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3.2.3 Health Infrastructure Development and Management The Health Infrastructure that comprise of physical capital inputs into the HSSP comprise of the following productive assets:
• Buildings (both medical and non medical) • Medical and Hospital Equipment • Communication facilities (Radio Calls, ICTs) • Ambulance Services and other transport requirements.
Health facilities act as an interface between the health service delivery and the community. They house equipment and technologies, and act as a springboard from which outreach services are provided to facilitate accessibility to both curative and preventive health services. Effective health care delivery requires a network of functional health facilities. The NHP and the HSSP aimed at improving accessibility of health facilities within 5 km from 49% (pre-HSSP) to 80% by 2005. Presently, the coverage is estimated at 72% and this will be reviewed with the completion of the mapping exercise in the 11 remaining districts.
Infrastructure Inventory
After the national population census and creation of new districts in 2002, the existing health facility maps needed to be updated. Plans were made to undertake the exercise showing the distribution of population as well as the geographical and administrative structural adjustments. During FY 2003/04, maps for 45 of the 56 districts were completed and, contractual arrangements for the remaining 11 districts were made and the undertaking is already in progress. An updated (2004) health facility inventory is indicated in Table 3.31. Table 3.31: Summary of Health Facilities by level and ownership
OWNERSHIPLEVEL OF FACILITY
GOVT NGO PRIVATE TOTAL
HOSPITAL 56 45 7 108HC IV 148 9 3 160HC III 706 157 10 873HC II 945 391 257 1593TOTAL 1855 600 274 2731Source: Health Facilities Inventory (May, 2004) Health Unit Standard Designs and Specifications: Standard designs and specifications for levels Health Centre II to General Hospital were developed. During the period under review, all districts received the latest sets of Designs, Specifications and Bills of Quantities for the various health facility levels. Assessment of condition of Health Facilities: A condition survey was undertaken for HC III to HC IV to ascertain the condition, the physical infrastructure gap and determine required capital input to achieve the standard for delivery of the Minimum Health Care Package. The results of the survey are as in the Table 3.32 (a) and (b).
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Table 3.32(a): Status of Medical Buildings at HC IIIs for the 39 Districts Surveyed
BUILDING CONDITION
A B C D N
No. % No. % No. % No. % No. % TOTAL
OPD 266 63.33 75 17.86 66 15.71 1 0.24 12 2.86 420
MATERNITY 210 50.00 43 10.24 37 8.81 0 0.00 130 30.95 420
GEN. WARD 101 24.05 30 7.14 23 5.48 0 0.00 266 63.33 420
Table 3.32(b): Status of Medical Buildings at HC IV's for the 39 District Surveyed
BUILDING CONDITION
A B C D N
No. % No. % No. % No. % No. % TOTAL
OPD 65 63.11 18 17.48 19 18.45 1 0.97 0 0.00 103
MATERNITY 59 57.28 19 18.45 17 16.50 0 0.00 8 7.77 103
GEN. WARD 49 47.57 18 17.48 14 13.59 1 0.97 21 20.39 103
OP THEATRE 87 84.47 6 5.83 3 2.91 0 0.00 7 6.80 103
MORTUARY 17 16.50 7 6.80 6 5.83 0 0.00 73 70.87 103
Key: A: Good condition only need routine maintenance D: Recommended for demolition B: Minor renovation N: Building not available C: Major rehabilitation or under construction Source: Condition survey of Health Facilities (September, 2003) Upgrading of Health Centre IVs: 150 Health Centres were proposed for upgrading to HC IV status. In the FY 2003/04, 110 operating theatre buildings were completed, 68 theatres equipped and all the 150 HC IVs provided with a multi purpose vehicle. In addition, 128 doctors’ houses were completed. Opening theatre picture
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Construction and Rehabilitation of Health Facilities: There was minimum support for rehabilitation of hospitals. The major interventions were in 3 hospitals (Kisoro, Kamuli and Butabika), 15 Health Centre IVs and 50 HC IIIs. Construction of HC IIs was mainly by Local Governments on the LGDP funding. Health Care Waste Management: The Health Care Waste Management (sorting, collection, transportation and disposal) system was identified to be lacking. In FY 2003/04, a consultant was procured to develop appropriate Health Care Waste Management System with guidelines, standards and specifications of health care waste handling facilities. 56 mini incinerators were constructed at selected Health Sub-districts country-wide. Medical and Hospital Equipment: An Equipment database, compiled against a standard equipment list for hospitals and health centres, revealed gross deficiencies especially at the HC IIs level. During FY 2003/04, the following equipment were procured: 58 sets of theatre equipment for HC IV, 3 sets of hospital theatre equipment; 840 patient beds including beddings; 3 sets of ENT, 4 sets of Ophthalmology and 3 sets of Orthopaedic specialised equipment. In addition the following health facilities were fully equipped: 2 hospitals, 14 HC IVs, and 21 HC IIIs. Ambulance Services and other transport facilities: The focus in the FY 2003/04 was to provide multipurpose vehicles to Health Sub-Districts (HSDs) for referral of patients, collections and delivery of supplies, and facilitating supervision of lower level units and outreach services. During the FY 2003/04, 88 vehicles were procured. In addition 38 Suzuki modified ambulances were distributed to support obstetric referral.
3.2.4 Management of Medicines and Health Supplies Availability of medicines and health supplies at health facilities is widely perceived as a major indicator of quality health services, and this has led to inclusion of this HSSP indicator in the monitoring framework of PEAP II and the FDS. The HSSP continues to focus on improving this important component of the health system through the Working Group on Medicines Procurement and Management, and support to the Pharmaceutical Section including continuing technical assistance from the Danish HSPS, and WHO. The MoH proposal to upgrade the section to a Department of Pharmaceutical Services and Health Supplies (DPSHS) is still under consideration at the Ministry for Public Service, and another year has passed without any clear indication of the time-line for establishment. The cost of these delays is lost opportunity for capacity building within MoH to sustain the necessary stewardship and institutional framework for successful implementation of the National Drug Policy (NDP) and the National Pharmaceutical Sector Strategic Plan (NPSSP) during HSSP II.
Achievements
During the FY 2003/04, the Pharmaceutical Section has ably provided - through the District Medicines Management Programme - the requisite support to consolidate the gains from improved drug financing using credit lines, and the new demand-based ordering system (‘pull’ system). The key achievements include:
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• Districts utilized the credit line funding in full, and the new system was extended to hospitals up to the Regional Referral level.
• Malaria and AIDS Control Programmes integrated products procured using project or donor funds into the credit line system (antimalarials from DfID/DCI and STI/OI medicines from World Bank-funded UACP), giving districts and users more control of these resources and improving efficiency.
• MoH continuously monitored performance of both NMS and JMS with reference to the MoU, and districts in relation to procurement and expenditure guidelines.
• MoH and HDPs conducted a comprehensive technical review of the National Medical Stores following the NHA/JRM undertaking, resulting in planned additional investments in working capital, warehousing, vehicles, and technical support, to enable improved performance in 2005.
• DMMP introduced a new multi-purpose tool to assess medicines management and utilization at the facility level (in 7 districts), showing that the gap between demand and supply has closed for essential items overall, but HSD needs to better support poor performing facilities.
Medicines Financing and Budget Allocations
The public funding of medicines and health supplies for the NMHCP increased from about US$1.20 per capita in FY 2002/03 to about US$ 1.60 per capita in FY 2003/04, excluding funding for ARVs and pentavalent vaccine. Additional funding of US$ 0.05 per capita for ARVs (US$ 1.3 million) was received from the World Bank/MAP, and GAVI funding for the pentavalent vaccine and related injection supplies was costed at US$ 0.61 per capita (US$ 15.6 million). There continues to be a large gap compared with the projected requirement of US$ 3.50 per capita (Health Financing Strategy) excluding ARVs and pentavalent vaccine. The FY 2004/05 budget and MTEF projections shows zero growth in the coming years. The apparent trend is for new medicines funding to flow through projects, tied to expanded coverage of ARVs and more expensive interventions such artemisinin-based combination therapy (ACT) for malaria. Therefore a high burden of out-of-pocket household spending on basic medicines, estimated to be more than US$ 4.00 per capita in FY 2002/03, is likely to continue. Table 3.33 shows the FY 2003/04 budget allocations for EMHS with breakdowns by hospital/PHC level and GoU/PNFP in Ugshs. Table 3.33: Medicines budget allocation FY 2003-04 (UGX billions)
Credit Lines
Decentralised Funding
Total Assumption (Decentralised)
Government PHC 7.2 9.5 16.7 50% NW District Hospital
3.6 4.1 7.7 40% NW
Regional Hospital
1.8 2.4 4.2 40% NW
NGO PHC 1.4 2.5 3.9 50% Grant Hospital 1.8 2.8 4.6 25% Grant
Total 15.8 21.3 37.1
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After several years of stagnation, the hospital medicines budgets were increased substantially through new credit line allocations for general and Regional Referral Hospitals. In real terms, the government medicines budget allocation was US$ 0.21 per capita for hospitals and US$ 0.33 per capita for health sub-districts (PHC). Assuming that 25-50%18 of PNFP grants were utilized for medicines, public funding added US$ 0.17 per capita to PNFP medicines spending. These budgets19 amounting to US$ 0.71 per capita are indicated in the annual district transfers and are directly controlled by the health providers for the purchase of essential medicines and health supplies (EHMS). The expectation is that providers can now be more effectively match individual requirements, and there will be less duplication, wastage and thus more efficient use of resources. Centralized, vertical programming continues for categories such as vaccines for immunization, TB/leprosy medicines, contraceptives, condoms, HIV tests and other diagnostics, blood products, infection control supplies, and a few individual items (e.g. Homapak, rabies vaccine) for new or specialized disease control programmes, and epidemics and emergency preparedness. These have separate budgets that are held and allocated centrally. Health providers do not generally know their entitlements at the time of annual planning. Distribution of these ‘programme supplies’ may be tracked as far as the district level. Information on programme expenditure, allocation and actual utilization at service delivery level is not easy to capture and rarely analysed. Similarly, direct support to selected districts, IDP camps, NGOs, and CBOs as medicines funding or in-kind donations is not captured.
Medicines Expenditure by Source
Expenditure on medicines has been given high priority, and ring-fenced even within the FDS guidelines. Procurement of medicines and health supplies is a specialized area that requires technical specifications be met in addition to value for money considerations. For these reasons, MoH guidelines require that government institutions first source their requirements from NMS, use JMS as a second option if NMS cannot supply, and buy from the private sector only as a last resort. Overall performance on the decentralized medicines budget has greatly improved in FY 2003-04 compared with the previous FY, mainly due to the new credit line system. Figure 3.28 shows expenditure at NMS and JMS by districts, general hospitals and regional referral hospitals against the indicative medicines budget (cash and credit lines). Utilization of FY 2003/04 credit lines was consistently high among districts and regional hospitals (>75% in all cases with the exception of one hospital). There is room for improvement at many general hospitals, but it may be because the system was introduced there later and is not fully established. There is marked under-spending of cash budgets for medicines, with less than 50% of indicative budget spent at NMS and/or JMS. Only a small part of the shortfall can be accounted for by non-release of funds (see section on Financing). Details of actual expenditures, including breakdown of purchases by source are tabulated. These are NMS and JMS sales data supplemented by data on purchases from the private for-profit (PFP) sector if provided by the district. 18 25% at the level of hospitals and 50% at lower level health units 19 The budget for national level referral hospitals (Mulago and Butabika) and Mbarara University Hospital are not included.
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Figure 3.28: Performance against indicative budget FY 2003/04
After including for reported PFP purchases, district expenditure increases from 48% to 54% of indicative budget. Only 17/56 districts and 9/50 hospitals provided expenditure reports from their own records. It is therefore not clear whether the unaccounted funds were spent in the private sector, or spent on items other than medicines, or simply not spent. Districts were scored on their performance on the cash medicines budgets and the score incorporated into the league table as a proxy indicator of district management.
The ‘Pull System’ and Medicines Supply
In the new Pull System, the credit lines were linked to a logistics system that included scheduled ordering, and agreed dates for delivery (NMS) or collection (JMS) on a 2-monthly ordering and delivery cycle instead of the traditional quarterly one. The use of pre-printed order forms facilitated ordering and packaging by and for individual health units, and prioritisation of “core supplies” for the minimum package. A Memorandum of Understanding (MoU) between MoH and NMS/JMS provided for periodic cash-based commitment of MoH funds to NMS/JMS, fixed prices, and agreed performance levels on the supply of specified medicines and health supplies for the NMHCP to end-users, and timeliness of order processing by the supply agencies. MoH put in place monitoring mechanisms and arrange additional human resources to manage the timely processing and payment of NMS invoices. MoH has continued to support the central supply agencies in upgrading their computerized financial systems (both NMS and JMS) and warehousing (NMS only). This includes for computerised invoicing and account statements from NMS and JMS to feed back available credit line balance and medicines budget utilization by individual health units in the HSD.
Performance against indicative drug budget for FY 03-04
60%65%
47% 44%
106%
75%
92%
73%
48%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
110%
DISTRICT LLHU GENERAL HOSPITAL REGIONAL HOSPITAL
OVERALL
CASH
CREDIT LINE
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The fast-increasing budgets and high uptake of the new systems by the HSDs has placed a greater than anticipated challenge to NMS financing, procurement, and distribution logistics. Table 3.34 shows the dramatic increase in value of orders and value of supplies to government facilities through NMS. The average monthly value supplied by NMS continues to increase, at Ugshs 1.25 billion in the first half of the FY, and Ugshs 1.8 billion in the second half of this FY, compared with less than Ugshs 0.8 billion per month in the previous FY. Table 3.34: Analysis of Performance of National Medical Stores
This includes ‘Third Party’ items such as antimalarials and medicines for STI/OI integrated into the pull system since October 2004. However, NMS has been unable to meet the agreed level of service (80-100% of order value supplied depending on item priority) with service level remaining below 70% overall. This places the burden on the HSD to seek alternate suppliers, adding significant delays and costs with the added difficulty that available funds may be tied up at NMS. NMS may mitigate this problem by collaborating with JMS or the local private sector to arrange bridging supplies, but these mechanisms cannot make up a shortfall of Ugshs 0.8 billion per month. Delays in order processing and delivery are ongoing, with districts receiving supplies 2-4 weeks after published deadlines. Nonetheless, all six cycles for the year have been completed. MoH recognized the challenges facing NMS early in the FY, and the issues were the subject of discussions at the National Health Assembly and 9th Joint Review Mission (Oct.-Nov. 2003) resulting in the ‘undertaking’ to conduct a technical review of NMS. MoH and Health Development Partners assembled an international team of consultants who conducted a comprehensive review in April 2004. The review team identified the need for additional investments in working capital, warehousing, vehicles, and technical support. The team also identified problems with uncoordinated Third Party (parallel) procurements, often in excess to demand, tying up limited NMS warehousing and causing a financial drain on NMS due to an inappropriately fee structure. The DANIDA HSPS planned additional funding to support these investments during FY 2004/05, including technical assistance by an Operations Management Consultant and Financial Management Consultant beginning January 2005.
FY 2003-04 FY 2003-04Jul-Dec Jan-Jun
MONTHLY VALUE ORDERED (cash & credit) 1,765 2,606MONTHLY VALUE SUPPLIED (cash & credit) 1,251 1,811OVERALL SERVICE LEVEL (%) 71% 69%
MONTHLY CREDIT LINE VALUE ORDERED 1,026 1,725MONTHLY CREDIT LINE VALUE SUPPLIED 754 1,254CREDIT LINE SERVICE LEVEL 73% 73%
MONTHLY CASH VALUE ORDERED 739 881MONTHLY CASH VALUE SUPPLIED 497 557CASH SERVICE LEVEL 67% 63%
Monthly value ordered and supplied (UGX bil) and service level in FY 2003-04
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Medicines Availability at Service Delivery Levels
The increased levels of drug expenditure and the improvements from the pull system are expected to translate into improved availability of medicines at health unit level, or in a context of unmet demand, increased utilization of health facilities. The HMIS does not reliably report on medicines availability at service delivery levels. HMIS monthly reports on stock-outs for the 6 HSSP indicator drugs were found to be erroneous at the health unit, HSD, and district levels due to incomplete reporting by health units, denominator problems and aggregation errors. Reporting format in the HMIS 105 form was proposed to enable valid reporting on the HSSP indicator “Percentage of health units having no stock-out of any HSSP indicator medicine”. The MoH District Medicines Management Programme (DMMP) again conducted a survey in 6 districts, reviewing stock cards20 at the same sample of 36 health units as last year. Table 3.35 shows some improvement in the HSSP ‘zero tolerance’ availability indicator: 60% of health units have a monthly stock-out of any of 6 indicator drugs (we assume that 40% having no stock-out21) compared with 67% last year, on average. The change is more notable if individual indicator drugs are compared: stock-outs of S-P and cotrimoxazole tablets were much lower. Table 3.35: Medicine availability by indicator drug FY 2002/03 and 2003/04
20 Stock cards may overestimate stock-outs because there may be a zero balance in the store-room while the drug continues to be available in the outpatient or dispensing area for some time. A stock-out will only be reported on HMIS Form 105 if there is no drug available for dispensing at the health unit during the reporting month. 21 Incomplete data could result in underestimates of stock-outs. As shown in Table 3, only 161/216 stock cards were available for review, i.e data was 75% complete.
Percentage of health units with a monthly stockout of HSSP indicator drugBased on stock card review at 36 health units, average of 6 months, Q2 and Q4.
Stock card months* % HU
Stock card months* % HU
Any HSSP indicator drug** 201 60% 67% Chloroquine tab 198 16% 198 13% Sulfadoxine Pyrimethamine tab 201 13% 193 28% Cotrimoxazole 480mg tab 201 35% 196 50% Oral Rehydration Salts (sachet) 134 20% 130 18% Medroxyprogesterone inj ("Depo") 106 17% 117 13% Measles vaccine 127 8% 167 5%Average of 6 HSSP indicator drugs 161 18% 167 21%
FY 03-04
Medicines availability by indicator drugComparing FY 2003-04 and FY 2002-03
FY 02-03
*Number of S/C months reviewed out of a maximum of 216 (36 health units X 6 months = 216). Data was about 75% complete overall (161/216). Less than 216 stock card months reported because health unit stock card often not available for review, or not updated; or < 3 S/C out of possible 6 for analysis 'any HSSP indicator drug'. ** 'Zero tolerance' indicator: the health unit was considered to have a stock-out if any one of the 6 HSSP drugs was out of stock in the month reviewed.
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As noted last year, however, stock-outs were more likely to occur at HC II and HC III compared with HC IV level (Table 3.36). Outpatient cases increased only marginally (3-4%) in this sample of 36 health units compared with last year, reaching about 1,000 cases per month in FY 2003/04. Table 3.36: Medicines availability by level of care, FY 2002/03 and 2003/04
Additional analyses of survey data using intermediate indicators such as ‘percentage stock-out time’ and ‘quantities consumed per 1,000 cases’ provide evidence of improved flow of medicines, particularly those prescribed most frequently in outpatient care. However, data also highlight great variation between individual health units suggesting the need for improved support for drug management from the HSD level and district.
Challenges
Routine monitoring, surveys and Area Team visits highlighted the following continuing challenges: • Irregular drug procurement and below target expenditure on drugs compared to the
indicative cash budget. Contrary to the PHC Conditional Grant Guidelines, medicines expenditure falls far below 50%. Under spending may be related to re-allocation of funds, irregular ordering, and/or sub-optimal service level at NMS.
• Some districts and hospitals were found to be purchasing predominantly from the private sector. This brings into question the issues of value for money and also quality of the products
Area Teams will explore this further during monitoring visits (Q1 FY 2004/05) and take up this issue during the annual FDS negotiations and the next district planning exercise. MoH will work with NMS in the coming year to expand inventory and capacity to supply the range of hospital items, including a review of items authorized under the credit line system. UNMHCP requirements continue to be met by direct procurement of commodities from donor project funds, and global initiatives such as GAVI and presently, also from GFATM and PEPFAR. The health system is increasingly faced with new and expensive
Percentage of health units with a monthly stockout of any HSSP indicator drugBased on stock card review at 36 health units, average of 6 months, Q2 and Q4.
Num of HU % HU Num of HU % HUAll levels 36 60% 36 67%
HC II 10 67% 10 70%HC III 17 70% 17 75%HC IV 9 35% 9 46%
FY 03-04 FY 02-03
Medicines availability by level of careComparing FY 2003-04 and FY 2002-03
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medicines and health products for basic interventions, including artemisinin-based combination therapy (ACT) for malaria case management, antiretroviral (ARV) medicines for HIV-AIDS, the pentavalent vaccine for universal immunization, and auto-disposable syringes. The observed trend is a return to vertical programming of these interventions using parallel funding, and direct procurement from single-source suppliers at fixed high prices. Within the medium term expenditure framework (MTEF), the public sector medicines budget under GAVI and GFATM alone could represent as much as US$ 2.00 per capita at these prices. Lower prices and other efficiency gains are possible if:
• New funding is incorporated into existing channels and structures to allow procurement from multiple sources based on generic substitutes where available.
• Medicines supply for the new interventions is integrated within the recently established ‘pull system’ of medicines logistics to improve sustainability.
Direction and guidance by an upgraded and strengthened pharmaceutical unit (DPSHS) at MoH will be required to promote effective coordination and efficient management of resources in this more complex environment. There is need to address the issue of drug availability at the health unit level. This can only be achieved if: • We exercise zero tolerance for stock-outs of the HSSP indicator drugs, and improve
the reporting system to provide meaningful information on this HSSP indicator, now included in PEAP and FDS monitoring frameworks.
• NMS improves on performance to ensure 100% availability of the core items through more effective procurement plans, local private sector purchases and instituting collaboration with JMS as necessary. There is sufficient integration of financing, procurement planning and logistics management at national level for all health commodities. This will contribute to improved NMS performance in procurement and distribution. Additional capitalization of NMS may be needed to meet the expected increased turnover.
• Capacity of the pharmaceutical unit at the central MoH level is strengthened through upgrading the unit and improving on the numbers of technical staff available for coordinated planning, monitoring, and improved technical support supervision through support to MoH area teams and direct support to districts.
3.2.5 Monitoring and Mentoring of District Health Systems. The implementation of the HSSP is a shared responsibility between the central partners and the district Local governments. Within the districts, the DHT is mandated to support the HSDs and these in turn should support the lower level health units. The central partners on the other hand have the cardinal responsibility of providing guidance and technical support to the district health systems. The HSSP Mid-Term Review identified multiple weaknesses in the monitoring and mentoring function and made explicit recommendations. This issue was again taken up at the 9th JRM and a recommendation to adopt the Area Teams Strategy was made.
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The Area Teams
An Area Team Secretariat, headed by the Director of Health Services in charge of Planning and Development, was constituted to implement the strategy. For purposes of providing effective geographical coverage, the country was divided into 10 Areas to be taken care of by an equal number of Area Teams. Each of the teams, headed by a Commissioner or an Assistant Commissioner, is composed of officers from the technical and supporting departments of the MoH with the following Terms of Reference;
• Facilitation of the designated districts for purposes of planning, budgeting, delivery of the MHCP and monitoring performance against agreed targets
• Provision of on-job training for the various cadres of health workers • Continuous assessment of district and HSD needs and ensuring equity within
and across districts • Facilitating information sharing within MoH regarding the districts under
their jurisdiction • To ensure effective communication with appropriate feedback to the districts • Ensure a results oriented approach by following up the actions to be taken to
address the bottlenecks identified during the Monitoring and Mentoring process.
For every quarter, the teams have specific areas of focus and utilise uniform tools for the purpose. The first monitoring and mentoring visits were conducted in March 2004 and since then the teams have grown from strength to strength. A start up phase assessment was conducted with a purpose of identifying constraints and capacity development needs, facilitating information sharing and developing a common sense of direction. The identified strengths and weaknesses are indicated in Box 3.3. As a result of the identified constraints, a two-day capacity building workshop was conducted to update members on the most recent sector developments and to upgrade their skills in monitoring and mentoring. This continuous development process has become institutionalised in the Area Team implementation mechanisms. Box 3.3: The strengths and weaknesses of the Area Team Strategy identified
during the start up phase.
On the whole, it is fairly evident that although it is not a magic bullet, the Area Team strategy should be able to register significant successes in strengthening district health systems. The district health system managers and political leadership have identified positively with the strategy. Implementation started on the right footing and the focus is now on turning the identified weaknesses into strengths while taking full advantage of the opportunities available. The success of this strategy will also be enhanced by;
STRENGTHS WEAKNESSES Appropriate skill mix Insufficient coordination High levels of commitment Late releases of funds Team work Uncertainty of roles Demonstrated integration Sub-optimal commitment levels Cost effectiveness Insufficient operational logistics Internal capacity building Multiple demands on members
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• High level commitment by Top Management • Active involvement of the district political and administrative leadership • Taking appropriate and timely action
The effectiveness of this strategy will be assessed by the gains made in improvement of the quality of services, utilisation of health facilities and services and Client satisfaction levels. While the Area Teams provide the bulk of the monitoring and mentoring functions, individual Technical Programmes were still in a position to provide focussed support, at the recommendation of the relevant Area Teams.
Quality Assurance
The central mandate of ensuring the delivery of quality health service is superintended by the Quality Assurance Department (QAD). The overall purpose of the department is to ensure that the required standards and guidelines are developed, disseminated and used. This cross cutting function is a collective responsibility of all directorates, departments and programmes. During the FY 2003/04, the Quality Assurance Department achieved the following;
• Dissemination of the Uganda Clinical Guidelines to all the 56 districts. • Introduction of the Yellow Star Programme in 8 more districts. This effort has
been supplemented by UPHOLD in another 10 districts. This makes a total of 35 districts that have been introduced to the QA tool
• Dissemination of guidelines on hospital management boards for the Referral hospitals
• Sensitisation of DHMTs of 15 districts with respect to the National Supervision Guidelines and the revision of the Infection Control Guidelines
National and Regional Referral Hospital Support – The Consultants’ Outreach Programme
National and Regional Referral Hospitals are an important resource to the health sector, especially in the provision of technical monitoring and mentoring at the general hospital and the HC IV levels. In turn the MOH and other organs of central government should support these institutions to appropriately carry out their mandated responsibility. During FY 2003/04, definitive steps were taken to revive the Consultants’ Outreach Programme, which had stalled for a number of years. The programme will operate under the Area Team strategy, with an almost perfect match between the 10 Area Team and the 11 Regional Referral Hospital catchment areas. The programme should become fully operational during FY 2004/05.
Challenges
The monitoring and mentoring function of the health sector has registered marked improvement during the period under report. However, the process faces a number of challenges;
• The recipients of the support need to take it more seriously • The high level commitment needs to be practically demonstrated
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3.5.6 Laboratory Support Services Many elements of the HSSP require appropriate laboratory support in order to achieve the required levels of efficiency and effectiveness. The HSSP objectives in this respect were:
• To develop a comprehensive National Medical Laboratory Service Policy • To strengthen central capacity for assuming effective national laboratory services
quality assurance • Upgrade the staffing and competence of the medial laboratory personnel • To ensure adequate supplies and equipment for medical laboratories at all levels
During the FY 2003/04, a National Technical Laboratory Committee was put in place and comprises experts from the MoH, CPHL, Makerere Medical School, TB Central laboratory, Mulago hospital, UVRI, UBTS and JCRC. This committee has been able to register the following achievements;
• Strengthening the laboratory services at 10 Regional Referral hospitals through supply of equipment for monitoring Anti-retroviral therapy, coupled with user training. The equipment included a Flucytometer, haematology and blood chemistry analysers.
• The Standard Operating Procedures that had been piloted in FY 2002/03, were now produced with assistance from WHO and distributed to all the districts
• A list of standard laboratory reagents was provided to guide NMS and JMS in their procurement for the essential supplies for laboratory services
• Provision of In-service training for 51 laboratory technicians and technologists in the Mbale and Mbarara regions. The staff in the Arua and Hoima regions will be covered during FY 2004/05.
• A laboratory reporting database format was developed and is under discussion with the MoH Resource Centre.
Activities at the district level are coordinated through the Laboratory Focal Persons. At the time of compiling this report, the districts of Yumbe, Kamwenge, Kalangala and Nakapiripirit had not yet appointed these focal officers.
3.2.7 Blood Transfusion Services The Uganda Blood Transfusion Services (UBTS) is mandated to meet the national needs for blood products while at the same time protecting patients from transfusion transmitted infections, including HIV, hepatitis B and syphilis. This is achieved through the network of Regional Blood Banks at Mbarara, Mbale, Fort Portal, Arua and Gulu. The UBTS headquarters at Nakasero in Kampala provides overall management and supervision while at the same time acting as the regional bank for the central region. Summary of achievements for the FY 2003/04 • The draft National Blood Transfusion Policy was produced and is under scrutiny by
the various stakeholders
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• The regular supply of consumables and reagents was successfully done. Voluntary donors were recruited and counselled. 100,000 units of blood were collected.
Challenges
Meeting Increasing Demand: The extra demand for blood is felt most at the HC IV level. As part of the preparation process, solar powered refrigerators were supplied to all the HC IV facilities without access to the Grid. The few facilities that started blood transfusion services were supplied adequately. The availability of timely funding is very crucial for the success of blood transfusion services. This is largely due to the nature of the required consumables. There should be zero tolerance for stock outs of safe blood at hospitals and HC IVs. If this is to be achieved, then a financial sustainability plan needs to be put in place.
3.2.8 Health Information and Research
Health Information Management
Health information is both an input and an output of a health system. The importance of this management tool in directing the critical interventions in the health system cannot be overemphasised, especially in the monitoring of the HSSP The bulk of the health information continues to come through the HMIS, incorporating both the weekly epidemiological reports and the monthly district summary statistics. A number of achievements have been registered in the improvement of information management:
• There has been significant improvement in the timeliness and completeness of reporting. There were proactive attempts to capture data from the national and regional referral hospitals and even the big PNFP hospitals around Kampala.
• Quarterly HMIS supervision, coupled with Area Teams support, enhanced prompt feedback to the districts
• The development of the Geographical Information System (GIS) was completed country wide
• The Ministry of Health Website was updated, internet services improved and automation of the Resource Centre library initiated
During the FY 2003/04, Gulu district displayed good practices with respect to Health Information Management as indicated in Box 3.4.
Box 3.4: Successful HMIS Management: The case of Gulu District
Gulu District has demonstrated that Health Information Data can be well harnessed and presented for the primary users and all other interested parties. The district Health Management Information System Focal Person has compiled and summarised the Monthly, Quarterly and Annual health information requirements into a one stop centre document that is user friendly and provides all the databases required for the district. The Ministry of Health Resource Centre has availed specimens of this exemplary work for other districts to learn and emulate.
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The challenges for effective information management include staff shortages, insufficient HMIS tools at the district and HSD levels and the establishment of a linkage between community based health initiatives (IMCI, HBMF etc) and the facility based HMIS.
Health Research
Health research is a fundamental aspect of health sector development. The Uganda National Health Research Organisation (UNHRO) is the umbrella organisation for the coordination of research efforts in the health sector. The steering committee guides the activities of the secretariat and coordination of research in health. During the period under review, the UNHRO Bill was approved by Cabinet and is now ready to go to Parliament. Other important activities during the period included;
• The draft health research policy and health research strategic plan have been completed and are under discussion by the relevant stakeholders
• The guidelines for health research were shared with the District Directors of Health Services in order to get their inputs.
Uganda Virus Research Institute (UVRI)
The Uganda Virus Research Institute is a multi-disciplinary research organisation, established in 1936 as the Yellow Fever Institute and serving the purpose of providing a solid evidence base for health interventions in the country. Its undertakings are largely done with international bodies like MRC and the International AIDS Vaccine Initiative. The main research activities undertaken in the period are;
• Quality Assurance for HIV laboratory testing and proficiency assessment for laboratory facilities
• HIV related immunological research focusing on the use of Tat in vaccine development and the effects of HIV / hepatitis co-infection
• Provision of laboratory support to EPI, particularly in studies related to poliomyelitis elimination and accelerated measles campaign
• Dog ecology and rabies in Kampala and now planned for Wakiso district • Continuing surveys on malaria vectors, their breeding grounds and the effect of
phytollaca (endod) on mosquito larvae
Natural Chemotherapeutics Research Laboratory (NCRL)
The laboratory was initially set up to study the efficacy of medicinal plants and that is what it has continued to do in its departments of Botany, Chemistry and Pharmacology. In the UNHRO Bill, the NCRL will be named the Uganda National Institute of Traditional and Complementary Medicine (UNITCOM). This is in line with its overall mission “to harmonise the role of Traditional and Complementary Medicine in the Health Sector”. During the period under review, the institution undertook a number of research activities as indicated in the Table 3.37.
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Table 3.37: Research conducted by UNHRO
RESEARCH CONDUCTED PURPOSE 1. Laboratory and clinical evaluation of four antimalarial herbs
To assess the clinical value of Artemesia annua, A. affra; Calendura officinalis; Aristolochia elegans in the control of malaria
2. Analysis of the Moringa oleifera for possible immunoboosting properties
To explore possible application in the management of HIV complications
3. Evaluation of Aloe verra and Rosemarinus officinalis as internal cleansers in human health
For possible application in several disease entities
The institution has also been actively involved in the following activities;
• Consultations on the Traditional and Complementary Medicine Bill in the districts of Bushenyi, Kamuli, Masaka, Rakai, Mbale and Tororo.
• Evaluation of the economic potential of Shea nut butter and its development into a usable form tried out in the industrial laboratory
• Support to a group of healers in Luwero district to cultivate antimalarial herbs on a large scale
• Training of traditional healers, among other things, in preparation and preservation of herbal medicines, including the use of natural preservatives
3.2.9 The Stewardship of the Health Sector.
SWAp Partnership Implementation
The JRM/NHA of November 2003 was successfully held and laid the ground for the development of HSSP II. The Health Policy Advisory Committee (HPAC) as a forum for MOH and Development Partners to keep track of HSSP implementation and to take the necessary strategic decisions has functioned fairly smoothly. The committee was able to meet monthly with good representation from all the stakeholders. The 9 Health Sector Working Groups provided a lot of inputs on behalf of HPAC. The most notable activities of these working groups during the period under review were in the preparation for the second HSSP.
Public Private Partnership for Health (PPPH)
The HSSP emphasises the Public Private Partnership strategy for the improvement of health services delivery. The steadily increasing levels of funding for the PNFP facilities and the purposeful attempts to bring the other players on board are clear testimony to the importance attached to this strategy. During the period under review, a number of achievements were registered in the advancement of the partnership principle:
• Implementation guidelines for Private Health Providers (PHP) have been finalized and these covered the areas of HSSP monitoring and evaluation; Coordination and planning; Financial resource allocation and management; Human resource development; Service delivery; Capacity building and Community empowerment.
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• Training of HUMCs for lower level PNFP health units has continued through the period.
• The Ministry of Health has continued to provide stewardship via the coordination role of the PPPH desk office to address issues of funding and human resources for the PNFP health facilities.
• A Task Force was charged with a responsibility of assessing the PNFP human resource with the aim of harmonising personnel emoluments across the sector and the results are summarised below;
Harmonising Personnel Emoluments Across the Health Sector.
The recently proposed pay rises and ongoing recruitment of health workers in the public sector is likely to trigger off unease and instability within the PNFP sub-sector including low morale, massive exodus or even strikes by the PNFP health workers. In a nutshell: if the planned public sector emoluments take effect and these are not counterbalanced by corrective flows of resources to the PNFP sub-sector, their health units are likely to experience man power instability and this will no doubt affect overall sector outputs. Table 3.38 summarises the estimates of the additional costs needed to enhance PNFP health worker salaries in the medium term. Failure to harmonise the personnel emoluments across the board will have several consequences;
• The strategy for accelerated reduction of user fees may need to be halted and, almost certainly, will need to be reversed.
• The credibility and leverage that the Bureau has established with the affiliated units will partly be lost, and will not be restored easily. The Ministry will not be able to bank on the voice of the Bureaus that have so far been strong advocates of the HSSP with the second largest network of health providers.
• The halting (and perhaps reversal) of the positive trends/dynamics will certainly affect results in the immediate term. The Bureaus fear that the mid to long-term effects of the concurrent adverse trends (increased cost of service delivery and decreased government subsidies) could be the trigger to a new crisis for the PNFP sub-sector.
Table 3.38: Estimates of additional costs to enhance PNFP health worker
salaries in the medium term.
Level of Health Unit
No of HU
Total staff at all levels
Pay for all staff for one year ‘000
Pay for critical staff for one year ‘000
Hospitals 44 12,412 13,653,011 9,565,553
LLU 558
Preliminary Recommendations of the Task Force
i) Use of Project savings
It is anticipated that some projects that are winding up may not have used all their moneys and these could be channelled to alleviating the current problem of the PNFP salaries. Since these are already part of the MTEF, it would not present any
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difficulties with the macroeconomics settings and would be an immediate term option.
ii) New project for donor partners to consider funding to cover PNFP salaries.
MoH ought to draft a proposal, indicating the medium term funding gap for salaries for the PNFP health workers and the task force would scrutinize this. The reflected gap would be for critical staff. The observation is that doctors and other higher administrative staff were actually better paid than in the public sector and were not part of the critical staff. It was observed however that this was a medium term option.
iii) Administration of Government Subsidy to PNFP facilities
Ministry of Health should issue new guidelines on how to use the subsidy, especially for salary enhancement of PNFP health workers in the short term. It was also noted that money from donors could come in form of drugs or equipment to possibly circumvent the rigidities of sector ceilings and macroeconomics. The task force has recommended that a proposal be developed to be part of the budgeting process for FY 2005/06.
Health Sector Regulation
The health sector has rules, standards and a code of conduct that help to constrain the behaviour of individuals and institutional organisations. The focus during the period under review was on areas of the regulatory framework that facilitate the implementation of the National Health Policy and the HSSP.
The Nurses and Midwives Council
The Nurses and Midwives Council was established by an act of Parliament in 1996. The current Council was appointed in January 2002 for a period of 3 years. The Mission of the Council is to develop, improve and maintain the quality of nursing services delivered to individuals and communities in accordance with the national policies and priorities. The main achievements for the period under review include:
• Development of Guidelines and a handbook for nurses in private practice • Inspection and supervision of Nurse Training Schools with closure of five that
were found to be illegal • Verification of entry requirements for students in Nurse Training Schools with
discontinuation of those that failed to fulfil the standards • Registration/Enrolment of all nurses that qualified during the period under
review
The Medical and Dental Practitioners’ Council
The mission of the Council is to protect society from harmful effects of malpractice and to guide the professions so that the people of Uganda enjoy quality health care. In this regard, the Council has concentrated on two major functions;
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Supervision of Educational Standards. • The facilities and staffing of both Mbarara and Makerere University Medical
Schools were assessed for compliance with the required standards • The Council responded to requests from groups and organisations and provided
CME to 256 doctors in 37 districts Professional and Ethical Standards.
• Field Support supervision to assess these standards was conducted in 18 districts • Publication of the Annual Newsletter
The Pharmacy Council.
• The Pharmacy Practice and Pharmacy Professions draft bill 2003 was finalised and re-submitted to cabinet
• Technical support was provided to both Makerere and Mbarara schools of pharmacy
• Enforcement of the Pharmacy Practice, standards and Code of ethics in Kampala, Mbarara, Kabale, Masaka and Mbale
• Registration of 17 pharmacists, de-registration of 2 pharmacists and approval of 10 newly qualified pharmacists for internship training
• Kabale Hospital was accredited as an internship centre for pharmacists • One Continuing Pharmacy Education session held.
Allied Health Professionals
• Registration of Allied Health Professionals: 10 % remain un-registered • Inspection and approval of private Allied Health Professional Training schools • Investigating reported cases of malpractice
National Drug Authority (NDA)
The Mission of the NDA is to ensure that good quality, safe and efficacious human medicines are available and correctly handled, and to contribute towards accessibility, cost-effectiveness and appropriate use. During the period under report, the following achievements were registered; Drug Assessment / Registration.- A total of 536 new applications were processed bringing the number of pharmaceutical products on the current register to 2481 for human and 326 for veterinary use. The assessment also covered applications for herbal medicines and food / nutritional supplements. Drug Information – 17 districts benefited from a sensitisation drive targeting health workers, Local Councillors, Drug shop operators and the media on effective drug regulation. This was over and above the radio spots and TV programmes on appropriate use and regulation of drugs. A specific drive targeted 483 herbalists on NDA activities and the registration of herbal medicines. Drug Quality Control – Whereas antibiotics and other drugs are tested selectively, it is compulsory to test all batches of antimalarials, anti – TB drugs and anti-retrovirals. Out of the 822 batches of drugs tested, 63 were rejected for failure to meet the quality
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specifications. The 30 batches of anti-retrovirals so far tested have all complied with the standards. Drug Inspectorate - The audit for current good manufacturing practices was conducted for five large scale and 6 small-scale local manufacturers. A similar exercise was conducted for 72 foreign factories in Africa, Europe and Asia. The inspectorate was strengthened through recruitment but not to the levels required. Drug outlets (2,352 drug shops, 222 whole sale and 184 retail pharmacies) were inspected and licensed. A number of consignments of expired and substandard drugs were detected and removed from the market.
Health Sector Regulation Challenges
The Councils and other regulatory organs a common set of challenges;
• Gross human resource and other limitations, which make effective national coverage very difficult.
• Weak legislation that make enforcement rather difficult
Promotion of Health Sector Accountability/Consumer Satisfaction
The ultimate target and beneficiary of the health sector outputs is the individuals, the families and the broader community. As part of sector performance, the sector should keep checking the pulse of these important stakeholders. During FY 2003/04, this activity has been largely undertaken by the Uganda National Health Users/Consumers Organisation. The main areas of emphasis were intensification of advocacy and networking among the partners, strengthening the link between special interest groups and associations of health consumer NGOs and capacity building for district teams for purposes of decentralisation. IEC: - 4,000 Posters and 2,000 Leaflets on patients’ rights were produced in the English language and disseminated. They are in the process of being translated into three local languages. At the same time radio programmes and messages have been aired on patients’ rights and responsibilities. Advocacy: - A Memorandum of Understanding was signed between the MoH and UNHCO to further strengthen partnership in sensitisation of health consumers and providers on their roles and responsibilities in provision of quality care. VHTs should be the primary targets for capacity building in the promotion of patients’ rights and responsibilities. District Level Activities: - District working groups formed mainly in the pilot districts of Luwero, Bushenyi and Kampala. A survey carried out, with the support of the World Bank, in 10 districts in preparation for the introduction of the Citizen Report Card programme. This is meant to promote user feedback at health facilities.
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Chapter 4 The National Health Assembly and 9th Joint Review Mission
The National Health Assembly and the Government of Uganda/Development Partners Joint Review Mission, both held annually are of significance in the monitoring of the Health Sector Strategic Plan and identification of priorities for the sector.
4.1 The National Health Assembly The Memorandum of Understanding (MoU) between the Government of Uganda and Development Partners in health stipulates the participation of stakeholders through a National Health Assembly (NHA). The National Health Assembly, the first since the launching of the HSSP, was held from 10th – 11th November 2003. The NHA provided a wider forum to discuss the state of the health sector and to facilitate dialogue among the major stakeholders. The objectives of the assembly were:
• To review the national health sector performance • To share the results of individual district performance assessments • To lay strategies for improved community participation and health literacy • To agree on priority areas for health sector interventions
Summary proceedings and progress on resolutions
The National Health Assembly was officially opened by the Hon Minister of Health, Brig. Jim K. Muhwezi, who represented His Excellency the Vice President and was attended by over 400 delegates. The delegates included Members of Parliament (members of the Sessional Committee on Social Services and the Parliamentary Standing Committee on HIV/AIDS), Chairpersons District Local Council (LC) V, District Secretaries for Health, Chief Administrative Officers (CAOs) and District Directors of Health Services (DDHSs) from all 56 districts, Medical Superintendents from all Regional Referral Hospitals, selected General Hospitals and Health Centre IVs, Health Development Partners, Non Governmental Organisations (NGOs), other line Ministries and government organisations and private sector organisations. The delegates were treated to high quality presentations addressing the key issues in the health sector. These included a summary of the Annual Health Sector Performance Report FY2002/03 and district visit findings, both of them documenting continued progress with the majority of the HSSP indicators. Other presentations on HSSP implementation included progress on priority UNMHCP Programmes including Reproductive Health, Sanitation, Community Mobilisation; Drug Management; Health Financing; Human Resources for Health; Health Infrastructure Development and Management; Support for local governments; Fiscal Decentralisation Strategy and its implications; and the Global Fund for AIDS, TB and Malaria. The delegates, especially from the districts, provided valuable contributions to the debate. The NHA provided a series of resolutions. At the close of the NHA, a number of resolutions were made and the ten best performing districts in the District League Table were recognized and congratulated for
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their success while others were encouraged to improve and join the best performers at the next NHA. The progress on the NHA Resolutions is summarised in the Table 4.1.
4.2 The 9th Government of Uganda/Development Partner Joint Review Mission
The ninth Health Sector Joint Review Mission (JRM) on the implementation of the Health Sector Strategic Plan (HSSP), which was held 12th – 14th November 2003 in Kampala was preceded by visits to selected districts from 3rd to 7th November 2003 by representatives of the Ministry of Health and Development Partners, to assess progress in implementing the HSSP on the ground, to identify the major constraints being faced and to identify key issues from the districts to be raised during the NHA and JRM discussions. The main objective of the JRM was to review progress of implementation of the Health Sector Strategic plan and to agree on the priorities and Budget Framework for the upcoming financial year (FY 2004/05). Undertakings and actions were agreed upon at the conclusion of the JRM. The implementation of the undertakings and actions is monitored through out the year and progress reported on at the subsequent JRM. The achievements on the undertakings of the 9th GoU/DP JRM is summarised in Table 4.2. Pictures
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Table 4.1: Progress on the National Health Assembly Resolutions
Resolution Progress
The Health Status of the people of Uganda
NHA1: 1 The members of this Assembly firmly commit themselves to providing leadership and stewardship in ensuring that the unacceptable level of poor health status in Uganda is reversed. Key people to provide leadership and stewardship for the health sector will be determined.
Leadership at all levels of government participated in the advocacy and mobilisation for health. Health now a priority for government at all levels.
The Resource Envelope for the Health Sector
NHA1: 2 The GoU should increase the share of the budget allocated to health towards a medium target of 15% of the overall budget.
Health sector allocation in FY 2003/04 was 10.2% of the governmenty budget (excluding project funding)
NHA1: 3 The MoH should continue to explore alternative financing mechanisms which prove to be efficient and equitable, to supplement the budget funds.
Social Health Insurance Scheme being developed. Principles of Social Health Insurance already submitted to Cabinet. Community based Health Financing Schemes also being piloted in a number of districts
Human Resources for Health
NHA1: 4 The MoH should develop a Human Resource Plan, which should: • relate gaps in staff norms with wage budgets; • include specific strategies to improve management and outputs of the
training schools; • include specific strategies that will be put in place for recruitment and
retention especially in the hard-to-reach areas.
• Comprehensive HRH Inventory conducted which identified staffing levels and gaps
• Interministerial Committee on training of HRH strengthened • Support to Health Training Schools has improved with increase in
support by MoH, MoES, DCI, DANIDA and EU. Increase in the quality and output is expected as a result.
• Provisions were made in the budget for recruitment and the sector is currently undertaking pay reforms to enhance salaries of health workers
NHA1: 5 The local governments should improve management of human resources including:
• Distributing health workers efficiently and equitably across the health units in the districts;
• Bodies responsible for recruitment of health workers at both central and
• The Districts and the Centre have agreed to have central advertisement and conduct interviews concurrently to minimise double applications and movements across districts
• Funding for the recruitment bodies (Health Service Commissions and District Service Commissions) has been improved
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Resolution Progress district levels should improve their performance and ensure that budgets that are provided for recruitment are quickly utilised.
Drugs and supplies management
NHA1: 6 At the central level, all efforts will be made to:• secure more funding for drugs; • oversee the procurement mechanisms through credit lines and PHC
Conditional Grants; • monitor the main suppliers NMS and JMS for compliance against the
MoU; • handle non-availability and delays in delivery of drugs by NMS.
• Budget for Medicines and health supplies increased slightly in 2003/04.,
• Performance of NMS improved from about 60% to 75% service level • Delivery schedules improved to the two months requirements of the
MoU. • JMS performance is very good close to (100%) • Regular monthly monitoring meeting held between MoH and NMS.
NHA1: 7 At the Local Government Level, the leadership pledges to ensure that resources
available for drugs (PHC CG, Delegated Funds, Credit Lines, Donations) are appropriately used by adhering to the guidelines that are provided – 50% PHC CG; 40% at the district hospitals.
Performance on this resolution was poor. PHC CG drug expenditure for 2003/04 decreased compared to last FY
Health Infrastructure
NHA1: 8 Priority shall be given to improving the functionality of existing HC IIIs and HC IVs with special emphasis on maternal and child health services.
The allocation for capital development prioritised functionalising existing HC IIIs and HC IVs where maternal and child health services are delivered, in comparison to allocation to new construction. The purchase and distribution of multipurpose vehicles and health equipment to districts was carried out to functionalise HC IVs and improve referrals.
NHA1: 9 New construction of HC II will be:• Targeted at seriously under-served populations; • Agreed between MoH and Local Governments so as to take into account
equipment, human resources and other recurrent requirements. Health Units constructed without prior agreement at planning stage cannot be provided with the necessary support.
• The budget provided for construction of only19 HC IIs which were prioritised to grossly underserved areas
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Resolution Progress
NHA1: 10 Plans should be made for the rehabilitation and equipment of District and Regional Referral Hospitals, especially as we develop the HSSP II.
• Commenced the rehabilitation of Fort Portal and Butabika Mental Referral Hospital
• Conducted a consultancy for rehabilitation of Itojo, Kiryandongo and Kaabong Hospitals
• Started on the construction of Kamuli and Kisoro Hospitals • Started construction of 6 Mental Health Units at Regional Referral
Hospitals
Utilisation of Reproductive Health Services
NHA1: 11 At the central level the health sector will continue to highlight the importance of, and strongly advocate for maternal health, including: • providing resources, particularly for
o Infrastructure at HC III, HC IV including provision of staff accommodation and the necessary equipment;
o Strengthening the referral system through improved communication and appropriate transport facilities;
o Improving human resource availability, technical and interpersonal communication capacities.
• Greater attention will be paid to Adolescent Health Services, making them more available and accessible to the adolescents.
Progress on Infrastructure, drugs, human resources and budget allocation are highlighted under Resolution NHA1: 2, 4, 6 and 8. Reproductive Health and the identified core interventions are priorities for the sector in the medium term
NHA1: 12 At the Local Government level • Advocacy, Community mobilisation and sensitisation for maternal health • Ensuring a high profile for reproductive health services in district work-plans
– provision of the necessary services, drugs and supplies using the available resources maximally
• Prioritisation of Adolescent Friendly Health Services • Efficient management of Family Planning Supplies and services
The centre has assisted districts to prioritise Reproductive health during the planning and budgetary allocations Among the community leaders, the reproductive health issues are a concern and accorded priority
NHA1: 13 Consensus needs to be sought on the Government of Uganda Population Policy, so as to enable strong political support for Family Planning from the highest to the lowest levels
The Population Policy for Uganda is under review. The Government of Uganda, at the highest level, is committed to addressing the population issues which are key for sustaining economic development for Uganda.
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Resolution Progress
The Situation of Internally Displaced Persons (IDPs) in Uganda
NHA1: 14 At the central level, the MoH will bring together partners to encourage comprehensive health sector support to districts with insecurity, including health services for IDPs,
A comprehensive health sector planning meeting for IDPs bringing together all stakeholders was held on Monday August 9, 2004 at Grand Imperial Hotel, Kampala. This meeting reflected the importance the sector is putting on availing basic services to the disadvantaged, and in this case the IDPs in Northern and North-Eastern Uganda.
NHA1: 15 At the Local Government level there is need to comprehensively plan for health services, including IDP services and ensuring effective utilisation of basic resources like the PHC CG, credit lines for drugs etc together with other supplements.
The district at present produce Comprehensive health sector annual Workplans which reflect the needs of the population and captures all funding sources and contribution of partners at the district level.
Community Mobilisation for better health
NHA1: 16 At the central level provide strategic direction and advocacy for community mobilisation, including capacity building: • for managing health services at different levels, and • for community involvement in the management of their own health
The MoH prepared a strategy document for community mobilisation i.e. Village Health Team Strategy and it is being implemented in a phased manner. The MoH prepared and disseminated guidelines for the Health Unit Management Committees at all levels including Hospital Boards. Orientation of the HUMCs is in progress.
NHA1: 17 At the Local Government level
• Leaders should actively take responsibility for the health of their people • Work-plans at the various levels should clearly include community
mobilisation activities
The workplan for health (which includes community mobilisation activities) is an integral part of the District Development Plans approved by District Councils. The District Councils approve and allocates resources for its implementation. This illustrates the Local Government commitment to addressing the health of the population.
The Kampala Declaration on Sanitation
NHA1: 18 Implement (re-activate) the Kampala Declaration on Sanitation (KDS), and have Annual Progress Reports at the National Health Assembly
KDS activities are core activities within the sector’s Environmental Health Workplan. Environmental Health has been a priority for the sector within the HSSP and efforts to address sanitation-related issues has resulted in improved
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Resolution Progress latrine coverage from 47% in 2002/03 to 57% in 2003/04
Supervision, Monitoring and Mentoring
NHA1: 19 To implement the improved framework for Supervision and Monitoring to empower the different levels of government to appropriately carry out their functions
The MoH developed a strategy (The Area Team Strategy) designed to provide coordinated and comprehensive support to the Local Governments in the delivery and management of health services. The proposal was developed and operationalised. The Area Teams have supported the districts in monitoring performance of the district health services and finalizing the District Annual Workplans for 2004/05
Information Management
NHA1: 20 At the central level, increase utilisation of available information from the districts for national planning and to provide feedback to the districts
The information from the districts has been used to improve planning and budgeting and resource allocation for delivery of health services. The Centre provides feedback to districts through Area Team visits, quarterly HMIS Bulletin, Weekly Epidemiology Surveillance report in the Print Media, Programme reports and the Annual Health Sector Performance Report which is widely disseminated.
NHA1: 21 At the Local Government level Community Based Health Information should be linked to HMIS and used to monitor closely the implementation of the HSSP especially delivery of the UNMHCP
The centre is in the process of revising the HMIS to incorporate the community based health information. After the finalisation of the revision, the data collected in the HMIS will include community health data.
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Table 4.2: Progress on the Undertakings of the 9th Joint Review Mission
No Undertaking Means of verification Progress Comments 1 Sanitation
Establish a sub-sector working group for sanitation to coordinate and liaise with sanitation stakeholders and operationalise the MoU; outlining budget mechanisms for sanitation at all levels and testing models in selected districts and urban councils. (as was adopted by the Water Sector)
Terms of reference for and
composition of the sub-committee
Established sub-committee on sanitation
Minutes and reports of the sub-committee meetings
Action plan for the sub-committee
Sub-sector working group for sanitation set up in Dec. 03. EHD – MoH is the Secretariat. ToRs for working group developed.
Consultancy for finance/ resource flow for sanitation study undertaken and final report ready. Needs Assessment study for districts being proposed and ToRs already developed.
Held workshop for TSUs and DHIs and selected district officials and best practices identified. Visits made to several districts to see on-going practice. Held Annual Sanitation Conference for all DHIs and Best Practice concept initiated and each district set a target.
2 Finance Programme 9 Tracking Study:
• Hold stakeholders workshop to finalise Programme 9 Tracking study report'
• Implement recommendations
Report documenting the comments discussed at stakeholders meeting
Final report of Programme 9 Tracking Study
Draft final report discussed with stakeholders.
Comments raised were incorporated to produce final report.
Final report submitted to MoH
MoH and partners discussing the implementation of the recommendations of the Tracking Study
3 Drugs and Procurement Based on a technical review, examine the requirements for additional working capital/stock financing for NMS and related capacity to ensure zero tolerance for stock outs of essential drugs and health supplies and propose a mechanism to provide such funding and required to support to NMS
Final ToR technical review consultancy
Debriefing report (findings, indications of required support to NMS)
Final report (detailed plan for support for financing,
Consultancy secured. Technical review conducted within
the expected timeframe and stakeholders briefed accordingly,
The final report officially handed over to the MoH by the Royal Danish Embassy.
NMS needs additional cash injection to enable it stock sufficient supplies to meet the needs of the UMHCP,
Existing conflict within the management of NMS was impacting negatively on its performance,
Process of NMS privatization
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No Undertaking Means of verification Progress Comments procurement and institutional capacity building)
posses threat to possible investment by DPs,
MoH terminated the services of the NMS corporation secretary and the board with the view to reorganize NMS management
4.
Human Resources for Health Initiate the scaling up of training and improvement of the quality and outputs of health workers for the HSSP
Document detailing plan to scale up HRH production
Monitoring reports on outputs of various training schools.
Training to increase outputs of HTIs being scaled up through: Improving infrastructure, Increasing number of tutors and Financial backup for disadvantaged Students.
Quality of HRH produced from HTIs being improved through: Tutor development, Provision of training & health learning materials, Support for practical field work, Support to inspectorate activities of MoH and MoES, Reviews of the various curricula and Support to in-service training.
Several DPs with a comparative advantage in HRH have made significant inputs into scale up and improved quality of the HRH outputs. The DPs are DCI through AMREF, EU and DANIDA
5. Human Resources for health Minister of Health to appoint a technical committee to implement the recommendations of the Social Services Committee of Parliament on revisiting the minimum entry requirements for entry into Health Training Schools
Revised entry requirements
Consensus finally reached to low Minimum Entry Requirements for ECN from 5 Credits to 5 passes (2 passes in 2 core subjects (Eng and Biology) – a must and 3 passes in 3 non - core subjects (Chemistry, Maths, and Physics)).
Other science subjects can be substituted for any of the non – core subjects (e.g Foods and Nutrition, Food Science, General Science, H/Economics, Agric., Geog., H/Science. Takes effect from Nov. 04,
ECN now more accessible 6. Human Resources for health
Undertake a tracking study on Human Resource training output, recruitment, deployment and access to payroll, retention and promotion.
Terms of Reference for tracking study
Debriefing report Report of tracking study
Consultancy awarded AMREF. Data collection is complete and now
conducting data analysis Draft report will be ready by October
2004 JRM
Study divided into 3 parts: - Recruitment and management of health personnel, - Wages and issues associated with payroll management and
120
No Undertaking Means of verification Progress Comments - HRH production that includes capacity and management of this and quality of production.
7 Basic Package HIV/AIDS Scale up capacity for ART management and uptake to all hospitals and achieve accreditation to at least 50%.
Action plan for scaling up ART to all hospitals
Accreditation system or criteria
Action plan for scaling up finalized and being used for implementation,
58 health facilities in 20 districts accredited to provide ARVs,
26 health facilities (including all the 11 Regional Referral Hospitals) providing free ARVs (target 2,700 adults)
A number of hospitals are not yet accredited due to inadequate capacity. Training of health workers is going on at regional level. This will facilitate the accreditation process.
8 Basic Package Reproductive Health Initiate EmOC in the 17 districts where
needs assessment was done (only 5% of HC IV met the criteria for basic emergency obstetric care) to achieve at least 80% of all hospitals able to provide basic EmOC,
Complete the needs assessment of EmOC in the remaining 37 districts
Reports on percentage of
hospitals in the 17 districts able to provide basic EmOC
Report of needs assessment for
the remaining 37 districts
Constituted Regional Technical Support Teams to go the 10 hospitals where basic EmOC was found lacking,
Draft roll out EmOC plan for the rest of the country prepared
Needs Assessment for the remaining 37 districts and data analysis completed. Report writing in process but to be ready for Oct. 04 JRM
Secured funding for Regional Technical Support Teams from UNICEF
EmOC is area of priority under UN response on reduction of MMR and UNFPA has pledged to provide EmOC equipment
Secured funding from Programme 9 for procuring 1,000 MVA kits and emergency RH drugs.
9 Community Mobilisation Finalise and initiate implementation of guidelines for community dialogue, mobilisation and participation in health promotion and health services delivery
Final field implementation guidelines for community dialogue: Community dialogue implementation strategy, field manual for implementation, facilitation manual and brochure.
Documentation of implementation of community dialogue in 8 districts (reports, video, reports)
Field and facilitation manuals and brochure developed and pre-tested
Technical Assistance recruited for Strategy Development. Draft strategy in place
Documentation report and video for two districts (Mubende and Bugiri) available
Report on Community dialogue ready
Funds inadequate for implementing undertaking
Community Dialogue Strategy to be
launched on 20th October 2004
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Chapter 5 The 2nd Health Sector Strategic Plan (HSSP II)
Background
The implementation of the National Health Policy (2000–2010) is close to the mid-phase while the first Health Sector Strategic Plan (HSSP I) (2000/01-2004/05), as the first medium term policy implementation plan, is in its final year of implementation. This strategic plan was designed to contribute to the attainment of the national poverty eradication aspirations (PEAP 2000), the goal and objectives of the National Health Policy (1999), and to the requisites of the Ugandan Constitution (1995) and the Local Governments Act (1997 with Amendment 2001). The third National Poverty Eradication Plan (PEAP 2004), reaffirms the commitment of the Government of Uganda to achieving the Millennium Development Goals (MDGs) which are seen as being “fully consistent with Uganda’s national priorities”. Health therefore, continues to be an important element of the Human Development Pillar of the PEAP, ill-health having been identified by the poor themselves in successive Participatory Poverty Assessment reports as the leading cause of poverty in Uganda. The 2004 PEAP however, recognises that “the relative speed at which any particular target (of the MDGs) is approached will reflect the particular constraints and trade-offs that the country faces”. The second Health Sector Strategic Plan (HSSP II) has been developed to provide a common strategic framework for the remaining period of the NHP, covering the period from 1st July 2005 to 30th June 2010. This framework will guide ALL interventions by ALL parties at ALL levels of the national health system. The scope of the strategic plan is therefore national. As such, achievement of its targets is the collective responsibility of ALL stakeholders and service providers. HSSP II will guide the pattern of investment by Government, its development partners, the local governments, the private-not-for-profit service providers (PNFP), the private health providers (PHP), and the communities. The development of HSSP II derives a solid base from HSSP I. The successes and shortfalls of HSSP I provide a learning experience to shape the direction for HSSP II. While retaining the Development objective of HSSP I, to reduce morbidity and mortality from the major causes of ill-health and the disparities therein, the overriding priority of the plan is the fulfilment of the contribution of the health sector to the PEAP objectives of reducing maternal and child mortality. HSSP II will form the basis for: a) Developing the long (LTEF) and medium term expenditure frameworks (MTEF)
and the annual Budget Framework Paper (BFP) for the health sector b) Guiding investment by the health development partners, including project support c) Development of District Health Sector Strategic Plans d) Developing and implementing the respective operational plans of the departments,
divisions and units of the central Ministry of Health; the District and Health Sub-District Plans (including PNFP and PHP interventions), and Community health action.
122
5.1 Priority Areas for HSSP II Compared to HSSP I, the new strategic plan document is constructed to reflect more clearly, the maxim that the primary purpose of the National Health System (NHS) is to achieve improved health of the people. Individual programme outputs are seen as the means to achieving the desired health outcomes and not as an end in themselves. The programme overview has therefore been amended to show that implementing the Uganda National Minimum Health Care Package (UNMHCP) is the main approach for achieving the sector programme goal and development objective. This will be accompanied by a strong focus on health promotion and disease prevention. The elements of the UNMHCP and the programme outputs have been rearranged into clusters that are designed to foster improved operational coordination and integration. HSSP II will therefore refocus the sector’s priorities so as to achieve the maximum health outcomes that are possible within existing resource constraints. Based on the premise that over the medium term, perinatal and maternal conditions, malaria, acute respiratory tract infections, diarrhoeal diseases and AIDS will together continue to account for the overwhelming part of the causes of disease and premature death in Uganda, HSSP II represents a consolidation and extension of the achievements of HSSP I. Special effort will be applied to improving on areas that have not shown similar progress, particularly in mobilising communities for improved maternal and child survival and in the control of malaria, HIV/AIDS and tuberculosis.
5.2 Implementation Priorities The effective delivery of an Integrated National Minimum Health Care Package becomes the health service strategy. However, the components of the package are synthesised into a set of integrated interventions and will benefit from the accruing synergies. The attainment of equity, especially for the most vulnerable groups, remains the underlying priority. The other priorities revolve around the operationalisation of the Health Sub-districts and specifically the Health Centre IV facilities; increased spending on essential medicines and health supplies; the strengthening of the Public/Private partnership in health and intersectoral collaboration for health.
5.3 Priority Outcomes for HSSP II.
• Attainment of significant reduction in maternal and child mortality through support to a defined set of cost effective interventions
• Reduction in the burden of HIV / AIDS, Malaria and Tuberculosis • Intensification of preventive services especially health promotion and
environmental health • Monitoring progress within the context of PEAP and the health related
MDG and targets
123
Efforts have been made to better integrate services and programmes to enable efficiencies to be realised in both delivery and support. To this effect, four clusters have been defined;
1) Maternal and Child Health 2) Communicable Diseases 3) Non-Communicable Diseases and conditions 4) Health Promotion, Disease Prevention and Community Health as a cross
cutting cluster. The first two clusters respond directly to the PEAP and MDG targets for the sector and the country as a whole. To this end, HSSP II will: a) Further redirect available resources and activities towards achieving a defined set of
priority health outcomes: Reduce Infant Mortality Rate from 88 to 40 per 1,000 live births Reduce Neonatal Mortality Rate from 44 to 30 per1,000 live births Reduce Under-5 Child Mortality from 147 to 103 per 1,000 live births Reduce Maternal Mortality Ratio from 505 to 408 per 100,000 live births Reduce Total Fertility Rate from 6.9 to 5.4 Reduce HIV prevalence from 6.2% to 4.4% (at ANC sentinel sites) and 3%
(for the general population) Increase the Life Expectancy from 47 years to 55 years
b) Adopt strategies that would help overcome the key constraints identified in
implementing HSSP I.
5.4 Process for developing HSSP II HSSP II has been developed through an intensive and interactive process that involved all key stakeholders in health development in Uganda. The process commenced in the last quarter of 2003 and has continued throughout most of 2004. The process was coordinated by a specially constituted Secretariat based in the Health Planning Department of the Ministry of Health and under the direction of the Director General of Health Services. While a formal evaluation of HSSP I implementation was not undertaken, preparatory work for the successor HSSP II entailed an intensive process of SWOT (Strengths, Weaknesses, Opportunities and Threats) analysis of the past four years by each of the 7 Working Groups: Health Systems, Basic Package, Human Resources, Public-Private-Partnerships for Health (PPPH), Drugs, Infrastructure, and Finance. The reviews included examination of the Annual Health Sector Performance Reports, the report of the Midterm Review (2003) of HSSP I, data from the Health Management Information System, various monitoring and supervision reports, special studies undertaken during HSSP I, and detailed discussions within and between the Working Groups. This preparatory work culminated in joint retreat of all the Working Groups, representatives of health related sectors of Government, Local Authorities, Development Partners, the Private Health Sector, and the civil and other Non-governmental Organizations. Successive HSSP II draft documents went through review by the Annual Meeting of District Directors of Health Services (May 2004), the Annual Meeting of Hospital
124
Managers (June 2004), the Health Policy Advisory Committee (HPAC) in June 2004, Senior Management Committee (SMC) of the MOH, the Technical Review Committee of June 2004, back through SMC and Top Management Committee of the MoH. The October 2004 Joint Review Mission and National Health Assembly is expected to provide the final inputs. Thereafter, the final draft will be presented to cabinet for approval.
5.5 The costing and financing of HSSP II The costing of the proposed HSSP II key interventions, their scaling up, and the essential support needed to ensure access and effective delivery is based on the Health Financing Strategy as a starting point (i.e. US$ 28 per capita). However, it is acknowledged that the costs will inevitably rise with the addition of new and scaled up interventions. In malaria alone, there are substantial cost implications of scaling up the Home-Based Management of Fever (HBMF) and insecticide-treated nets, and the planned introduction of Artemesinin-based Combination Therapy (ACT). The process has also involved the identification and quantification of additional input requirements in terms of human resources, drugs and essential medical supplies and infrastructure. In terms of the financing for HSSP II, there is divergence of opinion regarding the extent to which the document should aim to be a fully costed and prioritised medium term plan, i.e. feasible within the available (known) resource envelope, or whether it should remain aspirational in the hope that additional resources would somehow become available to the sector. The decision was taken at the TRM that two scenarios would be presented in the document, reflecting each position, while endeavouring to ensure that the aspirational costing remained realistic. The main sources of finance for HSSP II are unlikely to differ very much from those of HSSP I, relying predominantly on the GOU budget (including projects). Community financing is unlikely to yield significant sums for the UNMHCP, particularly as this package is supposedly delivered free through GOU health units. Similarly, Social Health Insurance is unlikely to develop sufficiently during the implementation of HSSP II to be able to generate additional resources. The most likely funding scenario will therefore be based on the HSSP II period of the LTEF, i.e. rising from Ugshs 390 bn to Ugshs 649bn. This represents an increase of Ugshs 259bn or 66% in nominal terms. In real terms (constant FY 2003/04 prices), the increase is somewhat lower, rising from Ugshs 363bn to Ugshs 515bn, i.e. Ugshs 152bn or 42%. Even with rapid population growth, this still represents an increase in real per capita allocations to the sector.
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Annex I: The District League Table
Dis
tric
t
Pop
ula
tion
No.
of
HSD
s
No
of h
osp
ital
s
% P
HC
fu
nd
s d
isb
urs
ed
that
are
exp
end
ed
% H
/u
nit
s su
bm
itti
ng
com
ple
te H
MIS
ret
urn
s to
th
e D
istr
ict
% D
istr
ict
HM
IS r
etu
rns
sub
mit
ted
tim
ely
Pro
por
tion
of
app
rove
d
pos
ts t
hat
are
fill
ed b
y tr
ain
ed h
ealt
h p
erso
nn
el
Pro
por
tion
of
PH
C f
un
ds
spen
t on
dru
gs
% C
hild
ren
<1
rece
ived
3
dos
es o
f D
PT
acc
ord
ing
to
sch
edu
le
Tot
al G
ovt
and
NG
O O
PD
u
tiliz
atio
n p
er p
erso
n p
er
year
% D
eliv
erie
s in
Gov
t an
d
NG
O h
ealt
h f
acili
ties
Pro
por
tion
of
TB
cas
es
not
ifie
d c
omp
ared
to
exp
ecte
d
% P
reg
nan
t w
omen
re
ceiv
ed 2
nd
dos
e F
ansi
dar
fo
r IP
T
Pit
Lat
rin
e
Cov
erag
e
Tot
al S
core
Ran
kin
g
Max. Score 10 5 5 5 10 12.5 12.5 12.5 10 10 7.5 100
% Score % Score % Score % Score % Score % Score Utiliz Score % Score % Score % Score % Score %
Gulu 481,476 5 4 95 9.5 77 3.9 92 4.6 98 4.9 102 10.0 110 12.5 1.34 11.7 30 3.7 86 8.6 50 5.0 42 3.1 77.6 1
Jinja 426,645 4 3 92 9.2 94 4.7 100 5.0 111 5.0 76 7.6 86 10.8 1.12 9.7 52 6.5 65 6.5 27 2.7 71 5.3 72.9 2
Adjumani 214,248 1 1 100 10.0 99 5.0 100 5.0 158 5.0 102 10.0 79 9.9 1.43 12.5 19 2.3 49 4.9 38 3.8 57 4.2 72.5 3
Moyo 215,745 2 1 100 10.0 98 4.9 92 4.6 105 5.0 109 10.0 67 8.4 1.43 12.5 21 2.6 35 3.5 55 5.5 68 5.1 72.1 4
Tororo 576,594 5 4 100 10.0 92 4.6 100 5.0 87 4.4 96 9.6 80 9.9 1.00 8.7 23 2.9 48 4.8 33 3.3 59 4.4 67.6 5
Rukungiri 316,475 2 2 100 10.0 99 4.9 100 5.0 68 3.4 59 5.9 82 10.2 1.17 10.3 30 3.7 52 5.2 18 1.8 94 7.1 67.5 6
Mpigi 420,688 4 2 100 10.0 97 4.8 100 5.0 89 4.5 69 6.9 95 11.9 0.97 8.5 28 3.4 48 4.8 24 2.4 65 4.9 67.1 7
Bushenyi 737,244 7 3 100 10.0 95 4.7 67 3.4 79 4.0 74 7.4 102 12.8 0.94 8.2 20 2.5 52 5.2 27 2.7 79 6.0 66.7 8
Kampala 1,254,710 8 13 100 10.0 80 4.0 92 4.6 265 5.0 27 2.7 77 9.6 0.65 5.7 69 8.6 227 10.0 7 0.7 70 5.2 66.2 9
Busia 234,684 2 0 120 10.0 95 4.7 83 4.2 76 3.8 86 8.6 96 12.0 0.84 7.3 21 2.7 35 3.5 36 3.6 76 5.7 66.0 10
Kabarole 364,783 3 3 83 8.3 91 4.6 100 5.0 94 4.7 21 2.1 110 12.5 0.98 8.6 33 4.1 65 6.5 25 2.5 86 6.5 65.3 11
Mukono 829,899 7 4 100 10.0 94 4.7 100 5.0 81 4.1 69 6.9 92 11.5 0.69 6.1 32 4.0 35 3.5 37 3.7 69 5.2 64.6 12
Masaka 774,362 9 3 100 10.0 97 4.9 92 4.6 80 4.0 56 5.6 80 10.0 0.83 7.3 21 2.6 79 7.9 14 1.4 82 6.1 64.4 13
Mbale 743,706 6 2 107 10.0 98 4.9 100 5.0 57 2.9 67 6.7 139 12.5 0.84 7.3 26 3.2 54 5.4 20 2.0 57 4.3 64.1 14
Kabale 476,737 6 1 100 10.0 98 4.9 100 5.0 55 2.8 42 4.2 90 11.2 1.30 11.3 15 1.9 38 3.8 25 2.5 87 6.5 64.1 15
Kyenjojo 394,626 3 0 100 10.0 91 4.5 100 5.0 79 4.0 92 9.2 73 9.1 0.80 7.0 11 1.4 30 3.0 25 2.5 75 5.6 61.3 16
Nakasongola 127,665 1 1 73 7.3 91 4.6 67 3.4 92 4.6 93 9.3 87 10.9 1.09 9.5 22 2.8 20 2.0 19 1.9 66 4.9 61.1 17
Kisoro 222,477 3 2 100 10.0 85 4.3 58 2.9 61 3.1 79 7.9 77 9.6 1.24 10.8 33 4.2 21 2.1 16 1.6 60 4.5 61.0 18
Kamuli 735,506 5 1 99 9.9 94 4.7 100 5.0 75 3.8 72 7.2 91 11.4 0.65 5.7 30 3.8 22 2.2 28 2.8 53 4.0 60.3 19
Kumi 404,467 3 3 0.0 91 4.5 100 5.0 87 4.4 67 6.7 125 12.5 0.90 7.8 55 6.8 41 4.1 42 4.2 53 4.0 60.0 20
Kalangala 39,194 2 0 0.0 98 4.9 100 5.0 147 5.0 68 6.8 114 12.5 1.01 8.8 8 1.0 190 10.0 21 2.1 48 3.6 59.7 21
Rakai 480,204 4 2 72 7.2 73 3.6 100 5.0 82 4.1 42 4.2 81 10.1 1.06 9.3 19 2.4 60 6.0 26 2.6 66 5.0 59.5 22
126
Dis
tric
t
Pop
ula
tion
No.
of
HSD
s
No
of h
osp
ital
s
% P
HC
fu
nd
s d
isb
urs
ed
that
are
exp
end
ed
% H
/u
nit
s su
bm
itti
ng
com
ple
te H
MIS
ret
urn
s to
th
e D
istr
ict
% D
istr
ict
HM
IS r
etu
rns
sub
mit
ted
tim
ely
Pro
por
tion
of
app
rove
d
pos
ts t
hat
are
fill
ed b
y tr
ain
ed h
ealt
h p
erso
nn
el
Pro
por
tion
of
PH
C f
un
ds
spen
t on
dru
gs
% C
hild
ren
<1
rece
ived
3
dos
es o
f D
PT
acc
ord
ing
to
sch
edu
le
Tot
al G
ovt
and
NG
O O
PD
u
tiliz
atio
n p
er p
erso
n p
er
year
% D
eliv
erie
s in
Gov
t an
d
NG
O h
ealt
h f
acili
ties
Pro
por
tion
of
TB
cas
es
not
ifie
d c
omp
ared
to
exp
ecte
d
% P
reg
nan
t w
omen
re
ceiv
ed 2
nd
dos
e F
ansi
dar
fo
r IP
T
Pit
Lat
rin
e
Cov
erag
e
Tot
al S
core
Ran
kin
g
Kanungu 209,381 2 1 81 8.1 81 4.0 42 2.1 49 2.5 73 7.3 86 10.7 0.71 6.2 19 2.4 67 6.7 17 1.7 90 6.8 58.4 23
Soroti 391,106 4 1 0.0 93 4.6 92 4.6 57 2.9 83 8.3 103 12.5 0.74 6.4 40 5.0 57 5.7 47 4.7 48 3.6 58.3 24
Hoima 366,210 2 1 99 9.9 95 4.8 92 4.6 77 3.9 41 4.1 73 9.1 0.86 7.5 27 3.4 35 3.5 27 2.7 64 4.8 58.3 25
Apac 699,304 5 2 99 9.9 85 4.3 83 4.2 86 4.3 50 5.0 91 11.4 0.60 5.3 17 2.1 51 5.1 21 2.1 55 4.1 57.6 26
Kiboga 241,496 2 1 90 9.0 89 4.4 83 4.2 69 3.5 75 7.5 71 8.9 0.72 6.3 23 2.9 41 4.1 24 2.4 55 4.1 57.2 27
Nebbi 445,126 3 3 0.0 93 4.7 58 2.9 93 4.7 68 6.8 99 12.4 0.88 7.7 34 4.2 34 3.4 49 4.9 52 3.9 55.5 28
Kitgum 298,111 2 2 106 10.0 72 3.6 75 3.8 69 3.5 120 10.0 52 6.5 0.85 7.4 19 2.3 50 5.0 19 1.9 10 0.8 54.8 29
Sironko 299,875 3 0 0.0 99 4.9 100 5.0 53 2.7 85 8.5 118 12.5 0.77 6.8 17 2.2 37 3.7 29 2.9 53 4.0 53.1 30
Sembabule 188,064 2 0 90 9.0 99 4.9 100 5.0 70 3.5 56 5.6 68 8.5 0.64 5.6 11 1.4 38 3.8 16 1.6 42 3.2 52.0 31
Mbarara 1,119,871 10 2 0.0 77 3.9 50 2.5 72 3.6 77 7.7 82 10.2 0.71 6.2 18 2.3 68 6.8 21 2.1 74 5.5 50.8 32
Arua 889,001 7 3 0.0 94 4.7 100 5.0 122 5.0 38 3.8 83 10.3 0.89 7.8 18 2.3 31 3.1 40 4.0 50 3.8 49.8 33
Kasese 553,034 4 3 0.0 74 3.7 92 4.6 67 3.4 62 6.2 78 9.8 0.91 8.0 22 2.8 25 2.5 28 2.8 75 5.6 49.2 34
Ntungamo 394,668 3 1 0.0 98 4.9 100 5.0 126 5.0 0 0.0 85 10.6 0.84 7.3 18 2.3 62 6.2 20 2.0 77 5.8 49.1 35
Bundibugyo 223,869 2 1 0.0 97 4.9 83 4.2 65 3.3 70 7.0 87 10.9 1.07 9.3 16 2.0 28 2.8 15 1.5 43 3.2 49.0 36
Bugiri 447,635 3 1 110 10.0 71 3.5 75 3.8 109 5.0 40 4.0 74 9.3 0.50 4.4 14 1.7 15 1.5 23 2.3 43 3.2 48.7 37
Kaberamaido 127,251 2 1 0.0 91 4.6 50 2.5 86 4.3 64 6.4 82 10.3 0.95 8.3 14 1.8 54 5.4 22 2.2 38 2.9 48.6 38
Pallisa 539,175 4 1 0.0 99 4.9 92 4.6 90 4.5 49 4.9 86 10.8 0.69 6.1 34 4.2 18 1.8 18 1.8 64 4.8 48.4 39
Mayuge 338,030 3 1 0.0 95 4.8 83 4.2 88 4.4 54 5.4 78 9.7 0.60 5.3 16 2.0 47 4.7 22 2.2 75 5.6 48.3 40
Kapchorwa 201,889 3 1 81 8.1 94 4.7 75 3.8 81 4.1 42 4.2 63 7.9 0.78 6.9 12 1.5 14 1.4 18 1.8 47 3.5 47.7 41
Luwero 487,110 4 3 0.0 84 4.2 83 4.2 116 5.0 18 1.8 65 8.1 0.71 6.2 29 3.6 60 6.0 27 2.7 66 5.0 46.9 42
Kayunga 302,933 3 1 0.0 95 4.8 92 4.6 92 4.6 18 1.8 92 11.5 0.59 5.1 22 2.8 40 4.0 18 1.8 74 5.6 46.6 43
Nakapiripirit 162,894 3 1 100 10.0 95 4.8 58 2.9 111 5.0 34 3.4 55 6.9 0.62 5.5 3 0.4 59 5.9 8 0.8 3 0.2 45.7 44
Katakwi 326,836 3 0 93 9.3 64 3.2 58 2.9 89 4.5 59 5.9 54 6.8 0.68 6.0 8 1.0 28 2.8 9 0.9 21 1.6 44.7 45
Kibaale 435,674 3 1 0.0 84 4.2 83 4.2 86 4.3 53 5.3 74 9.3 0.46 4.0 16 2.0 46 4.6 11 1.1 69 5.2 44.0 46
Mubende 727,020 6 2 0.0 90 4.5 83 4.2 89 4.5 44 4.4 80 10.0 0.54 4.7 12 1.5 41 4.1 19 1.9 53 4.0 43.7 47
Moroto 178,776 3 2 0.0 86 4.3 67 3.4 101 5.0 56 5.6 73 9.1 0.69 6.0 12 1.5 54 5.4 23 2.3 10 0.8 43.3 48
127
Dis
tric
t
Pop
ula
tion
No.
of
HSD
s
No
of h
osp
ital
s
% P
HC
fu
nd
s d
isb
urs
ed
that
are
exp
end
ed
% H
/u
nit
s su
bm
itti
ng
com
ple
te H
MIS
ret
urn
s to
th
e D
istr
ict
% D
istr
ict
HM
IS r
etu
rns
sub
mit
ted
tim
ely
Pro
por
tion
of
app
rove
d
pos
ts t
hat
are
fill
ed b
y tr
ain
ed h
ealt
h p
erso
nn
el
Pro
por
tion
of
PH
C f
un
ds
spen
t on
dru
gs
% C
hild
ren
<1
rece
ived
3
dos
es o
f D
PT
acc
ord
ing
to
sch
edu
le
Tot
al G
ovt
and
NG
O O
PD
u
tiliz
atio
n p
er p
erso
n p
er
year
% D
eliv
erie
s in
Gov
t an
d
NG
O h
ealt
h f
acili
ties
Pro
por
tion
of
TB
cas
es
not
ifie
d c
omp
ared
to
exp
ecte
d
% P
reg
nan
t w
omen
re
ceiv
ed 2
nd
dos
e F
ansi
dar
fo
r IP
T
Pit
Lat
rin
e
Cov
erag
e
Tot
al S
core
Ran
kin
g
Lira 784,664 7 2 0.0 73 3.7 83 4.2 82 4.1 27 2.7 52 6.5 0.78 6.8 22 2.7 73 7.3 11 1.1 46 3.5 42.5 49
Masindi 493,593 4 2 0.0 76 3.8 67 3.4 80 4.0 47 4.7 65 8.1 0.64 5.6 20 2.5 39 3.9 24 2.4 39 2.9 41.3 50
Wakiso 1,000,836 7 4 0.0 96 4.8 100 5.0 95 4.8 28 2.8 73 9.1 0.55 4.8 18 2.2 27 2.7 13 1.3 50 3.8 41.3 51
Iganga 739,663 5 1 0.0 80 4.0 92 4.6 96 4.8 16 1.6 77 9.6 0.54 4.7 28 3.5 26 2.6 19 1.9 48 3.6 41.0 52
Kamwenge 304,970 2 0 0.0 84 4.2 58 2.9 40 2.0 27 2.7 70 8.8 0.63 5.5 7 0.9 40 4.0 42 4.2 60 4.5 39.6 53
Yumbe 273,540 1 1 0.0 92 4.6 83 4.2 79 4.0 18 1.8 72 9.0 0.65 5.7 11 1.4 23 2.3 26 2.6 51 3.8 39.3 54
Pader 305,779 2 1 0.0 65 3.2 100 5.0 44 2.2 44 4.4 44 5.5 0.80 7.0 19 2.3 29 2.9 25 2.5 9 0.6 35.7 55
Kotido 652,941 3 2 0.0 93 4.7 67 3.4 89 4.5 32 3.2 57 7.1 0.51 4.5 7 0.8 13 1.3 11 1.1 2 0.2 30.6 56
TOTAL 25,622,458 214 104 96 9.6 89 4.4 85 4.2 88 4.4 58 5.8 82.8 10.4 0.79 6.9 24 3.1 49 4.9 24 2.4 56 4.2 60.2
128
Annex II: Health Sector Budget Performance FY 2003/04
Budget Level Wage Non-Wage Recurrent Domestic
Development
Total GoU Budget including donor budget support
Bu
dge
t
Rel
ease
Per
form
ance
Bud
get
Rel
ease
Per
form
ance
Bu
dge
t
Rel
ease
Per
form
ance
BU
DG
ET
RE
LE
ASE
%
Bu
dge
t
Rel
ease
Bu
dge
t P
erfo
rman
ce
Ministry of Health HQ 3.56 3.08 87% 32.73 30.43 93% 29.15 24.85 85% 133.74 133.74 100 65.44 58.36 89%
Butabika Hospital 1.02 0.93 91% 1.48 1.68 114% 4.81 3.62 75% 11.5 11.5 100 7.31 6.23 85%
Mulago Hospital Complex 7.79 9.39 121% 9.8 11.32 116% 1.64 0.83 51% 0 0 0 19.23 21.54 112%
Health Service Commission 0.37 0.37 100% 0.83 0.83 100% 0.03 0.03 100% 0 0 0 1.23 1.23 100%
Uganda AIDS Commission 0.54 0.54 100% 0.7 0.7 100% 1.4 1.4 100% 21.47 21.47 100 2.64 2.64 100%
NGO Hospitals and LLUs 0 0 17.72 17.04 96% 0 0 0 0 0 17.72 17.04 96%District Primary Health Care 44.67 45.69 102% 23.16 22.15 96% 9.2 8.04 87% 0 0 0 77.03 75.88 99%
District Hospitals 0 0 10.36 10.44 101% 0 0 0 0 0 10.36 10.44 101%
Regional Referral Hospitals 11.6 8.09 70% 6.28 6.54 104% 0 0 0 0 0 17.88 14.63 82%
TOTAL 69.56 68.1 98% 103.05 101.13 98% 46.23 38.78 84% 166.7 166.72 100 218.84 207.99 95%
129
Annex III: Human Resource Inventory FY 2003/04
Clin
ical
O
ffic
ers
Med
ical
O
ffic
ers
Mid
wif
es
Nu
rses
Tot
al
Clin
ical
/
Med
ical
Nur
sing
A
ssis
tan
ts
Dia
gnos
tic
staf
f
Ph
arm
acy
staf
f
Oth
er
Med
ical
R
el.
Tot
al s
taff
Districts Act Norm Act Norm Act Norm Act Norm Act Norm Act Norm Act Norm Act Norm Act Norm Act Norm %
Adjumani 19 13 4 4 20 17 60 65 103 99 107 19 5 10 1 3 5 9 221 140 158%Apac 37 29 5 7 24 20 48 118 114 174 100 69 7 23 4 6 29 25 254 297 86%Arua 28 35 2 4 55 4 97 103 182 146 119 63 5 31 0 4 34 35 340 279 122%Bugiri 16 23 9 6 37 19 57 107 119 155 135 69 11 18 1 5 23 19 289 266 109%Bundibugyo 14 26 5 10 12 36 37 119 68 191 91 32 4 18 1 8 9 18 173 267 65%Bushenyi 19 38 7 6 31 6 76 105 133 155 71 68 9 32 0 6 24 38 237 299 79%Busia 14 13 2 2 7 2 11 36 34 53 31 23 2 11 0 2 11 13 78 102 76%Gulu 31 13 0 3 12 3 18 45 61 64 60 49 2 10 0 3 13 13 136 139 98%Hoima 19 22 2 2 23 2 36 70 80 96 44 46 2 20 1 2 16 22 143 186 77%Iganga 41 36 7 5 70 5 65 121 183 167 98 102 8 31 2 5 37 36 328 341 96%Jinja 31 24 5 4 36 4 42 79 114 111 104 70 6 20 3 4 28 24 255 229 111%Kabale 15 32 5 6 13 6 42 103 75 147 79 94 4 26 0 6 11 32 169 305 55%Kabarole 20 15 2 2 15 2 37 42 74 61 25 25 3 13 0 2 7 15 109 116 94%Kaberamaido 4 9 1 1 12 1 13 24 30 35 15 11 3 8 0 1 7 9 55 64 86%Kalangala 16 9 2 1 11 1 14 24 43 35 25 11 12 8 1 1 13 9 94 64 147%Kampala 34 23 34 5 78 5 99 47 245 80 53 19 36 18 5 5 45 23 384 145 265%Kamuli 36 31 6 5 39 5 33 85 114 126 43 55 3 26 0 5 23 31 183 243 75%Kamwenge 10 26 2 4 20 4 23 74 55 108 11 50 5 22 2 4 11 26 84 210 40%Kanungu 9 18 5 5 4 18 51 72 69 113 0 16 0 14 1 4 9 14 79 161 49%Kapchorwa 28 25 5 6 26 19 38 98 97 148 67 41 6 20 1 5 20 21 191 235 81%Kasese 39 42 3 8 27 34 121 197 190 281 83 92 3 36 5 6 20 34 301 449 67%
130
Clin
ical
O
ffic
ers
Med
ical
O
ffic
ers
Mid
wif
es
Nu
rses
Tot
al
Clin
ical
/
Med
ical
Nur
sing
A
ssis
tan
ts
Dia
gnos
tic
staf
f
Ph
arm
acy
staf
f
Oth
er
Med
ical
R
el.
Tot
al s
taff
Districts Act Norm Act Norm Act Norm Act Norm Act Norm Act Norm Act Norm Act Norm Act Norm Act Norm %
Katakwi 21 18 0 3 17 3 24 43 62 67 32 20 3 15 1 3 11 18 109 123 89%Kayunga 22 24 6 7 35 20 35 79 98 130 42 16 13 18 2 6 20 20 175 190 92%Kibaale 25 32 10 7 27 20 57 109 119 168 86 36 3 26 0 6 19 28 227 264 86%Kiboga 11 22 4 5 22 18 34 93 71 138 58 38 5 18 1 4 15 18 150 216 69%Kisoro 13 22 6 5 15 18 43 85 77 130 27 22 3 18 1 4 10 18 118 192 61%Kitgum 17 26 4 6 31 19 42 95 94 146 53 30 4 21 0 5 3 22 154 224 69%Kotido 26 24 5 9 29 35 65 143 125 211 141 82 5 17 2 7 25 16 298 333 89%Kumi 29 28 5 6 53 19 34 103 121 156 65 36 2 23 0 5 25 24 213 244 87%Kyenjojo 25 23 3 3 15 3 26 62 69 91 28 33 14 20 1 3 22 23 134 170 79%Lira 36 21 2 5 21 5 31 66 90 97 64 67 1 16 1 5 13 21 169 206 82%Luwero 51 48 12 13 70 39 95 170 228 270 189 48 20 37 4 11 28 40 469 406 116%Masaka 27 35 10 7 29 7 47 95 113 144 78 71 4 28 0 7 33 35 228 285 80%Masindi 29 33 8 10 40 36 62 150 139 229 104 59 9 25 1 8 24 25 277 346 80%Mayuge 10 10 1 2 25 2 9 31 45 45 25 28 5 8 0 2 7 10 82 93 88%Mbale 32 44 3 7 26 20 29 141 90 212 77 40 8 38 0 6 17 40 192 336 57%Mbarara 30 59 4 6 32 6 49 173 115 244 175 99 8 53 2 6 30 59 330 461 72%Moroto 11 9 3 4 8 17 25 54 47 84 57 17 5 6 1 3 6 5 116 115 101%Moyo 22 22 7 5 24 18 57 96 110 141 101 44 9 18 2 4 14 18 236 225 105%Mpigi 23 29 8 6 39 19 47 118 117 172 129 61 3 24 1 5 5 25 255 287 89%Mubende 45 41 10 12 58 38 90 167 203 258 112 69 14 31 1 10 27 33 357 401 89%Mukono 27 49 6 9 63 22 72 167 168 247 131 83 6 41 3 8 35 45 343 424 81%Nakapiripirit 9 9 2 2 2 2 14 21 27 34 35 13 2 7 1 2 7 9 72 65 111%Nakasongola 10 10 2 1 13 1 14 36 39 48 36 30 7 9 0 1 8 10 90 98 92%Nebbi 35 23 6 5 33 18 49 110 123 156 94 67 5 19 4 4 20 19 246 265 93%
131
Clin
ical
O
ffic
ers
Med
ical
O
ffic
ers
Mid
wif
es
Nu
rses
Tot
al
Clin
ical
/
Med
ical
Nur
sing
A
ssis
tan
ts
Dia
gnos
tic
staf
f
Ph
arm
acy
staf
f
Oth
er
Med
ical
R
el.
Tot
al s
taff
Districts Act Norm Act Norm Act Norm Act Norm Act Norm Act Norm Act Norm Act Norm Act Norm Act Norm %
Ntungamo 20 24 10 7 25 20 77 91 132 142 120 40 8 18 4 6 20 20 284 226 126%Pader 11 16 0 1 10 1 6 54 27 72 28 36 1 15 0 1 5 16 61 140 44%Pallisa 36 41 11 7 41 20 54 140 142 208 121 53 7 35 3 6 31 37 304 339 90%Rakai 39 50 20 14 48 53 86 239 193 356 225 106 10 39 2 11 21 38 451 550 82%Rukungiri 10 13 1 0 18 0 23 43 52 56 2 21 4 13 0 0 12 13 70 103 68%Sembabule 8 14 4 3 16 3 21 32 49 52 14 18 3 11 0 3 3 14 69 98 70%Sironko 5 28 0 3 13 3 8 73 26 107 61 30 1 25 0 3 15 28 103 193 53%Soroti 16 22 0 3 30 3 13 55 59 83 21 24 0 19 0 3 6 22 86 151 57%Tororo 52 47 9 11 65 37 77 190 203 285 130 77 13 38 1 9 41 39 388 448 87%Wakiso 45 41 10 10 49 23 63 128 167 202 117 53 11 32 8 9 12 37 315 333 95%Yumbe 11 15 3 4 21 17 46 68 81 104 26 15 4 12 1 3 3 11 115 145 79% Total 1,319 1,474 308 304 1,635 798 2,542 5,254 5,804 7,830 4,165 2,606 356 1,208 76 266 988 1,322 11,389 13,232 86%
132
Annex IV: Hospital Performance Assessment FY 2003/04
uts/Outputs Arua Soroti Mbale Jinja Masaka Mb’ra Kabale F/Port Hoima Gulu LiraLacor Nsambya Rubaga
ource Inputs
man Resource
ialist 6 7 18 17 13 8 6 6 3 6
710
7 ical Officers 4 6 13 17 11 5 9 8 5 6
1110
11 d Professionals 32 25 51 57 35 17 37 23 34 28
13732
38 ses/Midwives 159 95 147 170 94 67 73 76 83 123
117165
119 al Health kers
201 133 229 261 153 97 125 113 125 163272
217175
ancial Resources
e 886,215,504 686,736,672
1,078,537,776 1,294,856,016 664,316,076 683,760,000 460,509,648 506,463,876 492,549,468 559,827,384 640,000,000
-Wage 563,000,000 506,000,000
611,000,000 870,000,000 668,000,000 1,063,545,000 506,000,000 607,000,000 405,000,000 506,000,000 639,000,000
dit Lines 176,166,142 167,442,394
183,512,456 223,151,943 192,236,204 167,442,394 182,900,264 151,984,525 167,442,394 187,721,282
al * 1,625,381,646 1,360,179,066
1,873,050,232 2,388,007,959 1,524,552,280 1,747,305,000 1,133,952,042 1,296,364,140 1,049,533,993 1,233,269,778 1,466,721,2823,882,292,494 3,795,190,927 2,462,164,950
d Capacity 356 244 384 500 330 345 250 341 280 265 283474 361 275
ility Outputs
D New 63,560 56,023 40,962 94,693 74,617 57,105 40,625 34,731 39,549 97,346 81,244
D Reattendance 23,665 50,376 4,923 12,172 10,484 14,540 7,134 922 9,358 25,836 74,519159,346 53,665 101,003
rrals 778 373 296 112 2,305 2,807 393 526 293 - 1,848
C 19,360 18,910 16,784 14,767 4,761 12,650 9,601 9,391 4,006 8,469 34,36118,762 25,697 15,211
al Admissions 12,041 20,091 41,161 18,209 14,009 16,433 8,709 10,242 11,258 10,599 15,60829,818 15,306 10,956
OS 15 6 3 6 5 6 8 11 8 10 108 5 5
Occupancy 1 1 1 1 1 1 1 1 1 1 11 1 1
veries 3,156 4,385 4,125 3,981 2,938 4,085 1,797 2,385 2,915 2,515 4,1931,749 4,208 2,831
Rate 0 0 0 0 0 0 0 0 0 0 0
or S/Operations 5,142 1,527 463 565 680 1,519 275 302 293 824
ndard Unit of put**
293,305 407,224 671,697 387,389 297,622 183,200 193,984 219,785 286,407 407,609
616,002 296,109 272,954
ility Care Outcomes
al Death Rate 0 0 0 0 0 0 0 0 0 0 0
ernal Death rate 0 0 0 0 0 0 0 0 0 0 0 0
aria CFR in <5s 0 0 0 0 0 0 0 0 0
* for the PNFPs excludes Training School and Capital Expenditure ** Standard Unit of Output computed as 1 OPD visit (new/reattend) = 1; 1 IP visit = 15; 1 ANC visit = .5; 1 delivery = 5;
133
