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Annual Health Sector Performance Report

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					      THE REPUBLIC OF UGANDA




Annual Health Sector
Performance Report




  Financial Year 2006/2007




        October 2007
Blank Page
Foreword

The health sector in FY 2006/07 implemented the 2nd Year of the Health Sector
Strategic Plan II (HSSP II). The focus has been on scaling up interventions and
consolidating reforms initiated during the HSSP I and in the 1st Year of the HSSP II
in order to achieve the Poverty Eradication Action Plan (PEAP) objectives and
Millennium Development Goals (MDGs). The Uganda Demographic and Health
Survey 2006 shows that there have been improvements in Infant Mortality Rate,
Under5 Mortality Rate and Total Fertility Rate. The data is not conclusive on
Maternal Mortality Ratio. These improvements in health outcomes indicate that it is
indeed possible to make a difference in the life of Ugandans. The improvements in
health outcomes were contributed to by different sectors; however the contribution
of the health sector in terms of stewardship and advocacy, and improved coverage
with good quality services for preventive, promotive and curative has been key.
The AHSPR 2006/07 documents sector performance against agreed HSSP II
indicators and Year II targets. The AHSPR 2006/07 indicates fairly good
performance as shown by the performance against the 8 PEAP and HSSP II
indicators. The sector performance for FY 2006/07 was on or above target for 3
indicators namely: Couple Years of Protection (CYP) a measure of family planning
uptake; Proportion of children below 1 year that have received pentavalent vaccine
3rd dose; and New OPD attendance per capita. Sector performance was below target
for 3 indicators namely: Proportion of deliveries taking place in government and
PNFP health facilities; Proportion of health facilities with tracer medicines all the
time (i.e. without stock outs of tracer medicines); and Sanitation measured by
household latrine coverage. It was not possible to determine sector performance
against 2 indicators namely: Proportion of approved posts filled by trained health
workers; and HIV Sero-prevalence.
The sector’s performance over FY 2006/07 had many challenges including: low and
stagnant levels of funding from the government budget; and increasing but rather
unpredictable and earmarked funds from Donor Projects and Global Health
Initiatives. Given this scenario it is important that we continue improving our
coordination mechanisms within the sector to ensure increased efficiency and
maximum benefit from all resources available to the sector. All stakeholders in the
sector including central and local government leaders (politicians, administrators
and technical staff), development partners, civil society representatives, and private
providers of health services, need to contribute to improved sector performance. The
National Health Assembly and Joint Review Mission present an opportunity for
sharing of ideas among stakeholders.
At the end of December 2007 we will have been through two and a half (2 1/2) years
of the HSSP II. As stakeholders in the sector it is important that we review our Mid-
Term performance and see whether we are in line with the HSSP II and MDGs. If
the current strategies are unlikely to take us where we would like to go, we should
be frank and say so, and come up with more relevant and appropriate strategies.



Dr. Stephen Malinga, MP
MINISTER OF HEALTH




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             iv
5
Pictures from NHA, JRM 2007 and TRM 2007




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7
Table of Contents

Foreword
Acronyms
Illustrations
Executive Summary


Chapter 1      Introduction


Chapter 2      Overview of Health Sector Performance FY 2005/06


Chapter 3      Delivery of the Uganda National Minimum Health Care
Package


Chapter 4      Integrated Health Sector Support Systems


Chapter 5      Implementation of Health Sector Strategic Plan II




Annexes

Annex   2.1:
Annex   3.1:
Annex   4.1:
Annex   5.1:




                                                                     8
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


                                                                      9
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
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


                                                                10
VCT   Voluntary Counselling and Testing
VPH   Veterinary Public Health
WHO   World Health Organization
WP    Wettable Powder Formulation




                                          11
Illustrations

Figures




                12
Tables




         13
Boxes




        14
Executive Summary:




                     15
Chapter 1       Introduction ....................................................................................................... 17

1.1   Background.................................................................................................................... 17
1.2   The framework for achieving sector goals & objectives................................... 17
1.3   The Annual Health Sector Performance Report FY 2006/07 ........................ 17
1.4   Sources of Information............................................................................................... 20
1.5   Outline of the Report .................................................................................................. 21


Figure 1.1:         Framework for the Sector Programme in the HSSP II ..................... 19




                                                                                                             16
Chapter 1 Introduction

1.1   Background

The FY 2006/07 was the second year of implementation of the Health
Sector Strategic Plan II (HSSP II 2005/06 to 2009/10). As per the
Memorandum of Understanding (MoU) for the implementation of the
HSSP II through the Sector Wide Approach (SWAp), the preparation and
discussion of an Annual Health Sector Performance Report (AHSPR) is a
key milestone.

1.2   The framework for achieving sector goals & objectives

In the HSSP II the framework for the sector programme has been
adjusted to reflect the central nature of the delivery of the Uganda
National Minimum Health Care Package (UNMHCP) and the important
and supportive role the programme objectives have. Similarly the
organisation of sector plans and reports like the AHSPR reflect this
restructuring, with the focus in the document on the performance
against the UNMHCP and the supporting Health System (Figure 1.1).

1.3   The Annual Health Sector Performance Report FY 2006/07

The AHSPR 2006/07 objectives are:
o To review the performance of the sector for the FY 2006/07
   identifying achievements and constraints;
o To assess progress towards HSSP II targets – in particular review
   against HSSP II Year II targets.

The HSSP II includes a set of indicators and targets against which sector
performance is reviewed. The indicators were chosen through a thorough
consultative process to reflect:
o Sector policy priorities, based on international and national
   commitments like the Millennium Development Goals (MDGs) and
   Poverty Eradication Action Plan (PEAP), and major sectoral issues;
o available and projected sector resources (financial, human,
   infrastructural and logistical);
o the different levels of responsibility – national, sectoral, programme
   and local government.

The PEAP Uganda’s comprehensive national development framework is
linked to a monitoring and evaluation framework the PEAP Matrix which
includes health and health-related indicators. These include some of the
indicators in the HSSP II indicators that were considered the most
appropriate to monitor sector progress at the national level, and in
addition includes health and health-related outcome indicators. The
performance against the health outcome indicators is contributed to by
more than one sector, with the health sector having a key role in
stewardship and advocacy. The AHSPR 2006/07 provides information on


                                                                      17
some of the health outcome indicators as reported by the Uganda
Demographic and Health Survey 2006.

The process of compiling this report has greatly benefited from the
experience of preparing Annual Health Sector Performance Reports
(AHSPRs) over the HSSP I and Year I of HSSP II implementation. Within
this framework, efforts have been made to:




                                                                  18
             Figure 1.1: Framework for the Sector Programme in the HSSP II



                                             Development Goal
                                         Expanded Economic Growth
                                        Increased Social Development
                                             Poverty Eradication




                                            Programme Goal
                                     Reduced Morbidity and Mortality
                                  from the major causes of ill health and
                               premature death and reduced disparity therein




                                         Health Service Strategy
                                     Effective delivery of an integrated
                              Uganda National Minimum Health Care Package




Programme Objective 1       Programme Objective 2      Programme Objective 3       Programme Objective 4

A Health Care Delivery      To strengthen the          To reform and enforce       An Evidence-based
System that is effective,   Integrated support         the Legal and Regulatory    Policy, Programme,
equitable and responsive    systems                    Framework                   Planning and
                                                                                   Development in place

Components                  Components                 Components                  Components
1. Central level            1. Human Resources for     1. Health Acts              1. Health Policy and
   organization and            Health                                                 Planning
   management                                          2. Professional Councils
                            2. Health Financing           and Associations         2. Health Management
2. Decentralized heath                                                                Information System
   care delivery system     3. Health Infrastructure   3. Private Sector
                                                          Regulation               3. Integrated Disease
3. Public/Private           4. Essential Medicines                                    Surveillance
   Partnerships in             and health supplies     4. Traditional and
   Health                                                 Complementary            4. Quality Assurance
                            5. Diagnostic and Blood       Medicine Practitioners
4. Intersectoral action        transfusion services       Regulation               5. Support and
   for health                                                                         Supervision

5. Effective Community                                                             6. Research and
   Participation                                                                      Development




                                                                                            19
Assess sector performance against the HSSP II 25 indicators;
  o Present highlights of performance against the UNMHCP with the
     application of national, central and district level indicators;
  o Present highlights on the Integrated Health Sector Support
     Systems for the provision of the UNMHCP with the application of
     national, central and district level indicators;
  o Maintain the focus on performance at the district level and making
     comparisons among the districts by use of a League Table
  o Highlight the individual and collective contribution of the National
     and Regional Referral and General Hospitals as well as the PNFP
     hospitals at similar levels;
  o Provide a Health Sector Financial Report for the period under
     review, including a donor expenditure analysis; and
  o Review the progress made towards the 4th National Health
     Assembly      Resolutions and        12th Joint Review Mission
     Undertakings.


1.4   Sources of Information



As with the previous reports, 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 Health

Management Information System (HMIS). Other sources of information

include:

      Reports of Undertakings sanctioned by the November 2006
      GoU/DP Joint Review Mission and the 4th National Health
      Assembly Resolutions.
      Surveys and studies undertaken by various stakeholder
      institutions like the Uganda Demographic Health Survey; and
      specific studies carried out for purposes of the AHSPR 2006/07
      which include: analysis of Functionality of HC IVs; and
      assessment of sector response to the challenges in Northern
      Uganda;
      Specific information requested from districts in areas of inputs
      management – human resources; financing; medicines;
      MoH programmes and other central level institutions reports were
      mainly obtained from quarterly and annual reports;
      Supervision Reports including Area Team, and Yellow Star
      Reports.




                                                                        20
1.5   Outline of the Report

The Report is divided into five chapters. Chapter 1 is an Introduction
and Chapter 2 covers an Overview of the Sector Performance for FY
2006/07 and includes the overall performance of the sector against
HSSP indicators; comparison of district performance using the District
League Table; comparison of hospital performance using the Hospital
League table; and a summary of the financial report.

Chapter 3 is a detailed presentation of the delivery of the Uganda
National Minimum Health Care Package and Chapter 4 outlines the
performance of the Integrated Health Sector Support Systems.
Chapter 5 details the Monitoring of the Implementation of the HSSP
II focusing on three areas of particular interest namely: HC IV
functionality; status of health services in Northern Uganda; monitoring of
SWAp implementation, and a review of the Supervision, Monitoring and
Mentoring framework.




                                                                       21
Chapter 2             Overview of Health Sector Performance FY 2006/07........................... 23

2.1 Performance Against PEAP Health-related Outcome
Indicators.................................................................................................................................... 23
2.2 Performance Against HSSP II Indicators.............................................................. 25
2.3 Summary Financial Report FY 2006/07.............................................................. 38
2.4 Comparing Local Government Performance ....................................................... 40
2.5 Factors Influencing Local Government Performance ....................................... 43
2.6 Hospital Performance Assessment ......................................................................... 45
2.7 Comments on Statistics for the AHSPR for FY 2006/07 ................................ 47


Figures
Figure 2.1:  Variation of New OPD Attendance by District FY
    2006/07 29
Figure 2.2:  Variation of Pentavalent Vaccine Coverage by district
    FY 2006/07.................................................................................................
Figure 2.3:  Variation in proportion of expectant mothers
             delivering in health units FY 2006/07 ................................................. 33
Figure 2.4:  Variation in Medicines spending by districts at NMS
             & JMS against the Indicative Budgets for the FY
             2006/07 .......................................................................................................... 35
Figure 2.5:  Variation of Household Latrine coverage by district
             in FY 2006/07 ..........................................................................36
Figure 2.6:  League Table Top and Bottom Performers for the FY
    2006/07 42


Tables
Table 2.1:               UDHS Health-related Outcomes 1995, 2001 and
    2006                 23
Table 2.2:               Performance against 8 PEAP indicators for the FY
    2006/07              27
Table 2.3:               Total Number of Deliveries in Government and PNFP
    Units                32
Table 2.4:               Public Expenditure on Health FY 2005/06, 2006/07..................... 38
Table 2.5:               District League Table Trends FY 2005/06 and
    2006/07              43




                                                                                                                      22
Chapter 2          Overview of Health Sector Performance FY 2006/07


2.1          Performance Against PEAP Health-related Outcome
             Indicators

The health sector, together with other sectors and institutions both
public and private, contribute to the national performance against
health-related outcomes. The PEAP matrix includes the following health-
related outcome indicators:
    o infant mortality rate;
    o under-5 mortality rate;
    o maternal mortality rate;
    o total fertility rate; and
    o chronic malnutrition as measured by stunting.

Data on health-related outcomes is only available from large surveys like
the Uganda Demographic and Health Surveys (UDHS) or the census. The
UDHS 20061 has provided current information on these indicators for
this report. This information is presented in comparison to UDHS results
of 1995 and 2001 in Table 2.1 and in the context of the PEAP Matrix in
Annex 2.1.

Table 2.1:         UDHS Health-related Outcomes 1995, 2001 and 2006
Indicator                                            1995              2001             20062
Infant Mortality Rate (/1000 live                    85                89               75
births)
Under 5 Mortality Rate (/1000 live                   156               158              137
births)
Maternal Mortality Ratio (/100,000 live              527               505              435
births)
Total Fertility Rate                                 6.9               6.9              6.5
Contraceptive Rate %                                 15.4              18.6             24.4
Stunting (low height for age)%3                                                         38

The UDHS 2006 reported improvement in health outcome indicators
compared to the previous surveys of 1995 and 2001 as shown in Table
2.1, for Infant Mortality Rate (IMR), Under-five Mortality Rate (UMR),
Total Fertility Rate (TFR), and Contraceptive Prevalence Rate (CPR). The
figure for Maternal Mortality Ratio (MMR) reported by the UDHS 2006 for
the 10-year period before the survey is 435 – statistically though the
actual value lies in the wide range of 345 to 524, given the methodology

1   The UDHS 2006 Report is available in hard copy and on the UBOS website
2 Infant Mortality Rate 75(76) & Total Fertility Rate 6.5 (6.7) indicated in the table differ from UDHS
2006 published figures (shown here in brackets), because of adjustments to use only data from
comparable survey areas
3 Changed methodology to new WHO Standards does not allow comparison with previous UDHS

results


                                                                                                    23
and the fact that Maternal Mortality is a relatively rare event. Therefore it
is not certain that there has been improvement in this indicator, as the
range indicated includes the MMR value from the UDHS 2001. The
indicator for nutrition status (stunting) for UDHS 2006 was derived with
a new methodology as per WHO recommendation and therefore is not
comparable to previous figures.

Given the contribution of several sectors and institutions to
improvements in health status, it is difficult to tease out the specific
contribution to these improvements by the health sector. It is however
reasonable to conclude that the many reforms in the sector over the
period of the late 90s and the HSSP I period, that led to improvements in
management, health services inputs and marked increases in health
services output contributed to improvements in health outcomes over the
10-year period prior to the UDHS 2006.

In particular increased access (geographical and financial) to basic health
services coupled with improved services quality (increased medicines
availability and more and better skilled health workers) led to marked
increases in the utilization of preventive, promotive and curative services.
This has been documented elsewhere but is also illustrated by the UDHS
2006 output level data. For example the following improvements were
noted between the 2001 and 2006 surveys: Fully Immunized Children
(FIC) by 12 months increased from 37% to 46%, whereas those who had
received none of the basic vaccines declined from 13 to 7%; children’s
access to treatment/professional advice following an episode of Diarrhea
improved from 45% to 70%; and use of preventive services/goods like
mosquito nets4 13% to 34%; women attending ANC at least once
remained at the high level of 94% whereas those having at least 4 visits
as recommended by WHO increased from 42 to 47%; women delivering
under skilled supervision         increased from 39 to 42% while those
delivering in a health facility increased from 37 to 41%5.

Preliminary analysis of the UDHS 2006 data indicates that a number of
demographic and socioeconomic factors can be associated with variation
in health outcomes as has been the case in the past. These include:
place of residence – urban/rural; UDHS region6; level of education of
woman (or mother); and household income. These indeed indicate the
importance of contributions by other sectors. A woman’s level of
education is particularly seen to be associated with not only increased
utilization of available services, but also higher quality of service
accessed. This together with improved hygiene and child care leads to
much lower morbidity and mortality especially for children born to these
mothers – IMR of children born to women with secondary education was
66 per 1000 live births compared to 104 per 1000 live births for women
with no education; similarly U5MR was 102 per 1000 live births

4 All nets whether treated with insecticide or not
5 These comparisons have not been adjusted for districts that were not surveyed in 2001
6 These are: Kampala; Central 1&2; East Central, Eastern, North, West Nile, Western & South West;

the Internally Displaced Persons (IDPs) and Karamoja within the North were specifically highlighted.



                                                                                                 24
compared to 169 per 1000 live births. The differences are however not as
marked for only primary education – this therefore has implications for
other sectors policy priorities like Universal Primary Education (UPE) and
Universal Secondary Education (USE). In Chapter 5 Section 5.1 the
performance of the Northern Region is compared to the rest of the
country.

Plans are underway for health sector stakeholders working with Uganda
Bureau of Statistics (UBOS) to carry out more in-depth analysis of the
UDHS data to look at: linkages between poverty and health and specific
ways the health sector can tackle inequities in access to services and
health outcomes; further tease out the association between
improvements in health status with current sector policies and
interventions; more thorough analysis of the sexual and reproductive
health data including looking at: unmet need for family planning,
malaria in pregnancy and linkages between Reproductive Health and
HIV/AIDS; typing of anaemia; and producing a detailed gender report. In
future efforts will also be made to relate health outcomes with the local
government administrative levels.


2.2     Performance Against HSSP II Indicators

The performance of the health sector over the FY 2006/07, judged
against the HSSP II indicators is considered good. This opinion is based
on judging the performance of indicators in FY 2006/07 against
performance of the FY 2005/06 and against targets set in the HSSP II for
the second year of implementation as shown in Annex 2.2. The following
provides a brief analysis:

The HSSP II indicators showing improvement between the FY 2005/06
and FY 2006/07 are:
1. The proportion of children under one year who have received 3 doses
   of the pentavalent vaccine as per schedule improved from 89% in FY
   2005/06 to 90% in FY 2006/07; the year’s HSSP II target was 87%.
2. Proportion of expected deliveries in public and PNFP health facilities
   increased from 29% to 32% just short of the year’s target of 35%.
3. Proportion of women receiving a complete dose of Intermittent
   Presumptive Treatment (IPT 2) for malaria increased from 37% to
   42%; the year’s target was 50%.
4. The proportion of health facilities without stock-outs (i.e. health units
   with tracer medicines and supplies all the time) improved from 27%
   in FY 2005/06 to 35% in FY 2006/07;
5. Couple Years of Protection (CYP), a measure of contraceptive uptake
   has improved from 309,757 in FY 2005/06 to 357,021 in FY
   2006/07, which is above the annual target of 325,407.
6. Household coverage of Insecticide Treated Nets in 2006 was reported
   at 34%. This information is from the UDHS 2006 – when compared
   with data from the UDHS 2000/01 value of 13%, this indicates a



                                                                         25
   marked improvement. However note should be made that this is over
   a five year period and the HSSP II target for 2009/10 is 70%.
7. TB cure rate improved from 70.5% in FY 2005/06, to 73% in FY
   2006/07 against the HSSP II annual target of 80%.
8. Proportion of children under five years who receive malaria treatment
   within 24 hours from a Community Drug Distributor (CDD) has
   improved from 60% in FY 2005/06 to 71% in FY 2006/07 against the
   HSSP II annual target of 65%.

The indicators that have stagnated include:
1. New Outpatient Department (OPD) attendance, a measure of
   utilization remained at 0.9 attendances per capita since the beginning
   of the HSSP II. The FY 2006/07 target was set at 0.9;
2. The proportion of households with latrines as proxy measure for
   Sanitation Coverage has stagnated - 58% in the FY 2005/06 and
   58.5% in FY 2006/07.
3. TB notification rate was 50% in FY 2005/06, and again in FY
   2006/07. The target for FY 2006/07 was 60%;
4. Proportion of districts submitting quarterly reports have remained at
   20% since beginning of the HSSP II.

The HSSP II indicator showing decline is:
1. Proportion of districts submitting HMIS monthly returns to the MoH
   on time has declined from 75% to 68% against a FY 2006/07 target of
   95%.

For a number of indicators it is difficult to determine whether there has
been improvement in performance or not because of various reasons.
   1. Proportion of approved posts that are filled by health professionals
      at 38.4% – this figure computed for this report has been based on
      information in 65 district annual reports, and is not comparable to
      the previous figure from the Human Resources for Health
      Inventory (HRHI) of FY 2003/04 and 2004/05.

Data on the following indicators may be available: - to change this as
appropriate
   2. The percentage of the government of Uganda budget that is
      allocated to the health sector
   3. total public financial allocation to the sector;
   4. proportion of the Primary Health Care Conditional Grant (PHC CG)
      released on time to the sector;
   5. proportion of disbursed PHC CG that is expended;

For a number of indicators, data is not available for the AHSPR 2006/07.
These indicators were also not reported on in the AHSPR 2005/06. These
indicators include:
1. Caesarean Section Rate per expected pregnancies;
2. Percentage of population residing within 5 kms of a health facility;
3. Percentage of health units by level providing all components of the
   UNMHCP;


                                                                       26
         4. Percentage of health units providing Emergency Obstetric Care
            (EmOC);
         5. Proportion of surveyed population expressing satisfaction with health
            services;
         6. Percentage of fever or uncomplicated malaria cases correctly managed
            at health facilities;
         7. HIV sero-prevalence, the HSSP II baseline data was derived from the
            HIV Sero-Behavioural Survey and annual data is expected from the
            ANC sentinel surveillance sites. However this has not been available
            for the last 2 years.

         These indicators were considered crucial during the HSSP II development
         process – however it was recognized that data on some of these
         indicators would not be readily available on annual basis. It is important
         that during the Mid-term Review (MTR) of the HSSP II efforts are mad to
         get values for these indicators or these indicators are dropped. Some of
         these indicators like client satisfaction were inherited form the HSSP I
         and for the last 7 years have never been reported on.

         HSSP II and PEAP Health Indicators
         The 8 indicators common to the HSSP II and the PEAP matrix (PEAP
         2004/05 to 2007/08) are:
            • New OPD attendance;
            • DPT/Pentavalent 3rd dose coverage;
            • Proportion of women delivering in public and PNFP health
               facilities;
            • Proportion of approved posts filled by trained health workers;
            • HIV sero-prevalence;
            • Proportion of health facilities without stock-out of 6 tracer
               medicines/supplies;
            • Sanitation coverage/latrine coverage as proxy; and
            • Family Planning uptake measured by Couple Years of Protection
               (CYP).

          Performance against these indicators for the FY 2006/07 as compared to
         the target for Year II of the HSSP II, and the performance in the FY
         2005/06 is presented in Table 2.2, and the PEAP health-related matrix
         and the HSSP II Indicator Table in Annex 2.1 and 2.2 respectively. A
         presentation and discussion on district performance on each of these
         indicators is provided here below.


         Table 2.2:       Performance against 8 PEAP indicators for the FY
                          2006/07
Indicator                                  Baseline     FY 2005/06   FY 2006/07   FY 2006/07
                                           FY 2004/05   achieved     target       achieved
OPD Utilisation in govt. & PNFP units      0.9          0.9          0.9          0.9
DPT 3 / Pentavalent vaccine coverage       89%          89%          87%          90%
Percentage of deliveries taking place in   25%          29%          35%          32%
Health Facilities ( Govt. & PNFP )



                                                                                  27
Proportion of Approved Posts filled by         68%            No new data    85%           38.4%7
Trained Health Workers
National Average HIV Sero – prevalence at      6.1%8          No new data    4.4%*         No new data
ANC Surveillance sites
Proportion of Health facilities without        35%            27%            55%           35%
stock-out of 5 tracer medicines & supplies9
Household Latrine coverage                     57%            58.%           72*           58.5%
Couple Years of Protection (CYP)               234,259        309,757        325,407       357,021
              *target is for end of HSSP II in 2009/10; there was no specific 2006/07 target

         2.2.1 New Outpatient Attendance in Government and PNFP health
         units

         New Outpatient Attendance in government and PNFP units is a measure
         of utilisation of health services, and is used as a proxy measure for both
         the quality and quantity of services (supply side) and the health seeking
         behaviour of the population (demand side). Per capita attendance has
         stagnated at 0.9 per capita for the FY 2006/07 as was for FY 2005/06
         and FY 2004/05. This is a marked difference from the trend of the HSSP
         I.

         During the HSSP I, the initial increase in new OPD attendance per capita
         was attributed to the abolition of user fees in public facilities (and the
         decrease and flattening of fees in the PNFP facilities) the sustained rise
         over the HSSP I was interpreted to be because of the other reforms
         especially increased geographical coverage of health services, and
         increased funding for primary health care inputs (staff, medicines and
         supplies) leading to improved quality of services, which attracted the
         population to use the services. The stagnation of this indicator since the
         FY 2004/05 seems to be related to the stagnation in inputs like financing
         for primary health care services especially for medicines and supplies;
         stagnant funding to the PNFP sub-sector; and the continuing high level
         of medicines stock-outs recorded at the health facilities.

         The performance against this indicator ranges from 0.1 in Kiboga district
         to 2.1 per capita attendance in Abim district. The variation in district
         performance is shown in Figure 2.1 and Annex 2.3. Districts that have
         new OPD attendance of above 1.2 per capita include: Abim, Rukungiri,
         Gulu, Lyantonde, Kabale, Kisoro, Kapchorwa, Tororo, Adjumani,
         Mityana, Amuru, Bududa and Rakai. Some districts previously noted to
         be good performers on this indicator like Adjumani, Gulu, Kabale,
         Kisoro, Rukungiri, and Tororo have maintained these positions. One
         common factor amongst these districts is that they all share borders with
         the neighbouring countries, and could be providing services to some of
         their people. It is more challenging to explain the very high performance
         of Abim and Lyantonde - as new districts this may be because of
         differences between the documented and actual population figures,

         7   This is not comparable to previous data as different methodology was used
         8This is data from the sero-survey; ANC surveillance data for 2005/06 is still to be analysed
         9The tracer medicines and supplies are: (1st -line antimalarials /Fansidar, Depo Provera (injectable
         contraceptive), ORS, measles vaccine, cotrimoxazole)



                                                                                                         28
leading to artificially low denominators; on the other hand it could be
because the new district makes service provision in the catchments
easier.

Figure 2.1: Variation of New OPD Attendance by District FY
            2006/07




Districts that have performance of less than 0.60 new OPD per capita
attendances include: Kiboga, Oyam, Bugiri, Koboko, Kaabong and
Mubende. Of the poor performers on this indicator (below 0.6 per capita)
Oyam, Koboko and Kaabong are districts that have been created in the
recent past that may have a number of challenges; Kibaale, Kiboga and
to a less extent Mubende have consistently performed poorly on this
indicator. Districts that showed particular changes in performance on
this indicator between the FY 2005/06 and 2006/07 are: Mityana
marked improvement; Mpigi marked decline. It is interesting to note that
poor performance on this indicator is associated with poor performance


                                                                     29
in Medicines Management as measured by proportion of EMHS budget
spent at NMS and JMS – more on this in Sections 2.1.6 and 4.4.

2.2.2   DPT 3 / Pentavalent Vaccine Coverage

Coverage of all infants with the third dose of the Pentavalent Vaccine
(previously the vaccine against diphtheria, pertussis and tetanus referred
to as DPT 3) is used as a proxy for overall immunisation performance.
The national performance for FY 2006/07 against the pentavalent
vaccine 3rd dose coverage in infants is 90%. This is a small improvement
compared with the performance of the FY 2005/06 of 89%, and indicates
that the sector has achieved the HSSP II target for FY 2006/07 of 87%.
The high level of coverage that has been maintained for the FY 2006/07
is rather surprising given that there have been challenges in availing
districts with immunisation logistics especially for the maintenance of
the cold chain. Supervision visits have noted that some health units were
not carrying out immunisation at the static and outreach points due to
lack of gas and viable vaccines.

Figure 2.2: Variation of Pentavalent Vaccine Coverage by district
            FY 2006/07




                                                                       30
Variation in district performance is pictorially represented in Figure 2.2
and Annex 2.4. Districts with performance of at least 100% include:
Bududa, Manafwa, Gulu, Kumi, Bukedea, Amuru, Kampala, Jinja,
Dokolo, Mbale, Kotido, Kabarole, Wakiso, Nebbi, Kalangala, Butaleja,
Isingiro, Abim, and Sironko. Of the top performers, Kumi, Mbale, Kotido,
Kabarole, Wakiso, and Sironko were similarly good performers in the FY
2005/06. The district pairs of Bududa, and Manafwa; and Kumi and
Bukedea; previously composing one district each pair are good
performers on this indicator – the old district of Bududa though was a
poor performer on this indicator in the FY 2005/06.

Districts with performance of less than 70% include: Moyo, Oyam,
Nakapiripirit, Kiruhura, Hoima, Namutumba, Apac, Kaabong, Kibaale,
Kapchorwa, and Nakaseke. Moyo, Kiruhura, Hoima, Kapchorwa and
Nakaseke were among the poor performers on this indicator in the FY
2005/06. There is a more detailed discussion about Immunisation under




                                                                       31
Section 3.2 of the Report, including relating the HMIS, EPI Survey and
UDHS data.

2.2.3     Sexual and Reproductive Health and Rights

Sexual and Reproductive Health and Rights continues to be a high
priority in the HSSP II. The sector performance at frequent intervals
(PEAP indicators are monitored quarterly) can be measured by progress
on the 2 indicators: proportion of expected deliveries taking place in
public and PNFP facilities and Couple Years of Protection from unwanted
pregnancy.

Deliveries in Health Facilities

Table 2.3:    Total Number of Deliveries in Government and PNFP
              Units
Financial Year                Baseline     FY 2005/06      FY 2006/07     %
                              FY 2004/05   Values          Values         increase
Total Number of deliveries    340, 095     384,773         440,836        15%
in GoU & PNFP health
facilities
Proportion of all expectant   25%          29%             29%            10%
women delivering in GOU
& PNFP units

The national average for proportion of all expectant mothers delivering in
health facilities (public & PNFP) is 32%, which is an improvement on FY
2005/06 at 29% - an improvement of 10%. The improvement is seen to
be bigger when absolute numbers are considered – 15% increase. The
performance for the FY 2006/07 of 32% is less than the annual HSSP II
target of 35%.

The national average covers a wide range of individual district
performance, ranging from 4% in Kaabong and Nakapiripirit to 73% in
Kampala. District specific information is provided in Figure 2.3 and
Annex 2.5. The best performing districts are Kampala, Kumi, Gulu,
Jinja, Nebbi, Nakaseke, Bukedea, Kisoro, Kitgum, Soroti, Rukungiri,
Kabarole, Butaleja, Pallisa and Mukono with more than 40% of expecting
women in their respective populations delivering in the public and PNFP
health facilities. This is an improvement from the FY 2005/06 where only
8 districts had more than 40% of their expectant women delivering in
public and PNFP health facilities.

It is worth noting that all these districts have at least one hospital and in
most cases as in Gulu, Jinja, Kampala, Kisoro, Mukono, Nebbi and
Rukungiri have more than one hospital each – and in the case of Mukono
and Nebbi functional HC IVs too. Gulu district is of particular interest –
the proportion of women delivering in health facilities has almost
doubled - increased from 33% in FY 2005/06 to 61% in FY 2006/07.
More on this is in Box 3.3 in Section 3.2. The slow but steady


                                                                          32
improvement on this indicator across the country in the medium term
seems to reflect the improved physical access to maternity services and
efforts to improve the quality of services with recruitment of midwives
and availability of supplies e.g. mamma kits.

Figure 2.3: Variation in proportion of expectant mothers delivering
            in health units FY 2006/07




Eighteen districts have reported less than 20% of expected women
delivering in their health facilities in the FY 2006/07, and these are:
Kaabong, Nakapiripirit, Isingiro, Kotido, Kalangala, Kamwenge, Bukwo,
Oyam, Moroto, Dokolo, Amolatar, Mubende, Manafwa, Sembabule,
Kapchorwa, Bugiri, Koboko, Buliisa and Kibaale districts. Kaabong,
Nakapiripirit, Kotido and Moroto are in the Karamoja region, which has
been noted in the past to have very poor performance against this
indicator because of cultural beliefs. The districts of Isingiro, Kalangala,
Kamwenge, Bukwo, Manafwa, Sembabule, Koboko and Buliisa do not
have hospitals and do not have functional HC IVs. The districts of
Amolatar, Bugiri, Kibaale, Mubende and Oyam have hospitals, yet they
are falling in this group.



                                                                         33
Family Planning Uptake

Couple Year’s of Protection (CYP) as a measure of family planning uptake
is one of the recently introduced PEAP indicators reflecting the
importance the government and the sector stakeholders place on
maternal and child health, and the role unwanted pregnancies may play
in this. CYP is an absolute number which is computed using routine
data in the HMIS, considering the uptake of the various methods of
family planning. This considers utilization of contraception services from
public and PNFP facilities but does not usually include services received
in the private-for profit sub-sector.

The total CYP for the country for the FY 2006/07 is 357,021 which is a
marked improvement over the FY 2005/06 performance of 309,757 and
above the year’s target of 325,407. Annex 2.6 provides the information
on CYP by district. The district specific data provides information –
however it is rather challenging to make comparisons between districts
given that CYP is an absolute number and districts have different
population figures. It is notable though that Kampala district has by far
the highest CYPs contributing 33% to the national figure. 31 districts
have less than 1000 CYPs each, and only Kampala, Kamwenge, Tororo
and Bugiri had CYP figures higher than 10,000. Bugiri and Kamwenge
are a surprise in this group as their performance on other Reproductive
Health indicators like proportion of expecting mothers’ delivering in
health facilities is very low.

More of the issues on Sexual and Reproductive Health and Rights are
discussed under Section 3.2 of this report.

2.2.4     Approved posts filled by trained health workers

District Annual Reports for FY 2006/07 have been utilized to provide
information on health workers in post. Complete information was
available from 65 districts, for the levels of the District Health Office
(DHO) and the Health Centres. It has not been possible to include
Hospital (for all levels – General, Regional Referral, National Referral),
and all PNFP personnel. The staffing norms used are the new Local
Government staff norms.

The proportion of approved positions filled by trained health workers
using this data is 38.4%, varying from 10.4% in Kaabong to 92.6% in
Ntungamo. The variation in staff positions filled by trained health
workers for the 65 districts that provided complete information is shown
in Annex 2.7. This figure is not comparable to the previous figures in the
AHSPR of 2003/04 and 2004/05, because in these reports, the indicator
was computed using comprehensive data from all the districts in the
country, with data from public and PNFP facilities and all the levels of
care. In addition the HSSP I norms were used; the current estimates use
the new LG norms which have increased staff positions.



                                                                       34
2.2.5           HIV/AIDS Control

There is no new data on the HIV prevalence indicator for the FY
2006/07. Data used for this indicator for FY 2004/05 was from the
HIV/AIDS Sero-Behavioural Survey; expected figures from the ANC
sentinel surveillance system were not available for FY 2005/06 and FY
2006/07.

The Ministry of Health with the support of various stakeholders has in
the HSSP II embarked on an ambitious programme of scaling up
HIV/AIDS Control activities across the country. This especially includes:
HIV Counseling and Testing (HCT), Prevention of Mother to Child HIV
transmission (PMTCT) and Anti-retroviral Therapy (ART). The HSSP II
targets the provision of HCT and PMTCT at all HC IIIs and higher levels,
and ART at all HC IVs and higher levels. As in the FY 2005/06, an
assessment of the progress against these targets has been made across
the country, and a performance against these targets of: HCT – 42%;
PMTCT – 45% and ART 57% has been achieved. The details by district
and intervention are attached as Annex 2.8, and the composite indicator
of HIV/AIDS Control service delivery is included in the District League
Table. More on HIV/AIDS Control activities is available in Section 3.3.

2.2.6         Essential Medicines Availability

The HSSP II indicator that measures medicines availability (as a proxy
for quality of care) measures the percentage of health units without any
stock-outs of HSSP indicator medicines10 - i.e. a measure for zero
tolerance for medicines stock-out. Information available in the routine
HMIS has not been useful for this analysis, and for the last 4 years a
survey has been done to collect data for this indicator.


Figure 2.4: Variation in Medicines spending by districts at NMS &
            JMS against the Indicative Budgets for the FY 2006/07

For all 6 indicator medicines and supplies, there were only 35% of the
health units surveyed that did not report a stock-out over the 6 months
of the FY 2006/07 that were studied. This is an improvement on the
figure of 27% of the FY 2005/06, but still falls short of the HSSP II Year
II target of 55%. This indicates a major challenge to the health sector and
is very closely related to the stagnation/minimal improvement in a
number of output indicators as medicines availability is a very important
signal of quality of services to the community. However these levels of
medicines stock-outs are not surprising given the stagnant Essential
Medicines and Health Supplies (EMHS) budgets, and the low
expenditures on EMHS local government and hospital budgets.



10   First line antimalarial/Fansidar, ORS, cotrimaxazole, Depo Provera and measles vaccine



                                                                                              35
There is no district specific information on medicines stock-outs as the
data was from a survey. However there is district specific information
about how medicines and supplies are being managed in the districts.
Specifically there is information on how much of the district EMHS
budgets are spent at National Medical Stores and Joint Medical Stores as
per agreed guidelines. Figure 2.4 and Annex 4.??? illustrate the
variation in spending on EMHS at NMS and JMS by the districts.

A number of districts are doing very well with at least 100% of the EMHS
budgets being used to procure medicines and supplies at NMS and JMS.
These include: Bukedea, Kumi, Gulu, Ibanda, Amolatar, Katakwi,
Mbarara, Kiruhura, Nebbi, Pader and Mityana – this is a decline from FY
2005/06 where more than 10 districts spent above 120%. Most of these
districts actually used more than 100% of the EMHS budget – possibly
from using some of the funds that were not ear-marked for EMHS, or by
mobilizing from other sources of funds. This is commendable, as EMHS
are a very key input in health services.

25 Districts have spent less than 40% of the EMHS budget at NMS and
JMS; while 10 districts have spent less than 20% of their budgets
namely: Terego-Maracha, Kaliro, Kamuli, Bukwo, Kanungu, Amuria,
Kisoro, Moroto, Lyantonde and Abim. Terego-Maracha, Kaliro and
Kamuli districts have spent 0% of the EMHS budgets at NMS or JMS.
More information is available on Medicines Management in Section 4.4
in the section on medicines management and financing.

2.2.7   Sanitation coverage


Figure 2.5: Variation of Household Latrine coverage by district in
            FY 2006/07




                                                                     36
Access to appropriate sanitation facilities is one of the HSSP II and PEAP
indicators given that a high proportion of the diseases in the country are
associated with poor sanitation. Latrine coverage is used as a proxy
measure for this indicator. Performance against this indicator has
stagnated with household latrine coverage at 58% in FY 2006/07 and FY
2005/06. The current performance is still short of the HSSP II target of
72%, and way off target for 4th National Health Assembly Resolution of
100%.

The variation in performance against this indicator has not changed
much – ranging from 2% in Abim to 98% in Rukungiri, as dramatically
highlighted in Figure 2.5. The best performing districts are Rukungiri,
Kampala, Bushenyi, Kabale, Masaka, Mukono, Ntungamo and Kabarole
all with coverage of at least 80%. All these districts are either in the
South-west, Western or Central regions of the country. Districts with
household latrine coverage of less than 40% include: Abim, Kotido,


                                                                       37
           Kaabong, Nakapiripirit, Moroto, Kitgum, Amuria, and Pader. The regional
           bias is again obvious with the worst performing districts on this indicator
           from the Karamoja region closely followed by districts in the
           neighbourhood. There is a strong cultural association with this indicator.
           More information about Sanitation is in Section 3.1.


           2.3       Summary Financial Report FY 2006/07

           2.3.1 The FY 2006/07 Resource Envelope

           The total budgetary allocation for the health sector in FY 2006/07 was
           Ug. Shs ?????? of which Ug. Shs. 242.63bn was the GoU budgetary
           allocation including donor budget support, and Ug Shs. was ?????. the
           actual expenditure over FY 2006/07 was Ug. Shs 239.11bn by GoU, and
           ?????? by donor projects. Total Public Health Expenditure (TPHE) over
           FY 2006/07 is therefore Ug. Shs ?????, which is equivalent to Ug. Shs
           ????? per capita or US $ ???????.

           Table 2.4:     Public Expenditure on Health FY 2005/06, 2006/07

FY         GoU       Donor      Total      Per        Per         GoU Exp. On    GoU (Health)   Annual
           Funding   Projects   Public     Capita     Capita      Health as %    Budget         Budget
           Ug. Shs   & GHIs     Health     Exp.       Exp. US $   of total GoU   Performance    Increase
           Bn.       Ug. Shs.   Exp.       Ug. Shs.               Budget
                     Bn.
2004/05    219.56    254.85     474.41     17437      10          9.7            92.8%          5.7%
HSSP II
Baseline
2005/06    229.88    268.38     498.24     18,213     9.98        9              95.7%          4.7%
                     (507.26)   (737.14)   (26,946)   (15)
2006/07    239.11    139.23     381.86     13,518     7.84        9.6%           95.6%
                     (     )

           Brief Discussion on HSSP II Resource Envelope trends


           2.3.2     Budget Performance in the FY 2006/07

           GoU health sector budget performance was 96.8% in FY 2006/07 up
           from 95.7% in FY 2005/06, as shown by grant and level of service
           delivery in Annex 2.9. This includes budget performance against the
           Wage grant of 97.7%, Non-wage recurrent grant of 97.3% and the
           Development grant of 92%. Performance against the Wage grant has
           particularly improved from 91.6% to 97.7%. This reflects new
           recruitment of health workers at the various levels. GoU Budget
           Expenditure on Health as a proportion of Total GoU Expenditure for the
           FY 2006/07 was ????? which is down from 9% in FY 2005/06 and much
           lower than 9.7% at the beginning of the HSSP II. The governments in
           Africa previously agreed to 15% as the optimum level of funding of the
           health sector by countries in the region.



                                                                                           38
Donor Projects and Global Health Initiatives performance has been
analysed considering: donor project funding that is included in the
MTEF; donor project funding that is not in the MTEF; Global Health
Initiatives; and Consolidated Appeal (CAP) funding. In total the Donor
Projects and GHIs including CAP had a budget performance of 210%
against budgets initially declared to MoH; with per capita spending of Ug.
Shs. 19,121/= or US $ 11.08.

Local government funding for health services in FY 2006/07 was
composed of GoU Primary Health Care Conditional Grant (PHC CG) at an
average of 80%; Donor Project funding at 16% and local government
contribution of 4%.

2.3.3   Improving Efficiency over the HSSP II – Aligning Funding
        with HSSP II Priorities, maximizing Outputs from available
        Inputs

Over the HSSP II there has been overall increase in sector funding
compared to the HSSP I. However this does not seem to translate to a
notable increase in sector outputs – most of the key indicators are either
marginally increasing or stagnant. This is related to the declining
funding of basic services especially for District Primary Health Care
Services and PNFP health services. This is because the increase in
funding has been mainly for Donor Projects and Global Health Initiatives
(GHIs) which have prioritized specific areas like: provision of ART;
provision of ACTs; support for the Consolidated Appeal Process (CAP) for
Northern Uganda; support to the private sector; technical assistance and
project management. These are all useful inputs; however in some cases
the focus of the projects and GHIs is not similar to HSSP II agreed
priorities. Analysis of Donor Projects for alignment to HSSP II priorities
for the FY 2006/07 indicates that up to 31% of project spending is on
non-HSSP II inputs including Technical Assistance and parallel project
management.

The Facility-Based Private not for Profit (FB PNFP) sub-sector is a key
component of the health sector, whose outputs are included in the sector
outputs and monitored by the HSSP II and PEAP indicators. The GoU
budget has since 1997/98 provided subsidies for the FB PNFP sub-sector
– the proportion of the GoU funding to PNFP funding peaked at 36% in
FY 2002/03 and has since declined to 22% in FY 2006/07. This has
resurrected marked reliance by these institutions on user fees and donor
funding which are inequitable and unpredictable. This is already being
shown by declining productivity and efficiency in these units as shown
by the PNFP Hospital outputs in Sections 2.6 and 3.4. This is
contributing to the overall stagnating sector outputs.

2.3.4   Financial Management Monitoring

The government procedures are followed for sector financial monitoring.
The bulk of the funds used for service delivery in the public sector is


                                                                       39
from the GoU budget and are released by the MoFPED directly to
implementers. The Auditor General continues to provide annual reports,
and the Auditor General’s Report of FY2005/06 is to be presented to the
Joint Review Mission together with this AHSPR.

At the level of the health sector monitoring is carried out at the central,
regional and local government levels. Monitoring of financial
management at the local government levels is carried out by the
integrated teams form the Ministry of Health, the Area Teams and in
specific instances separately by the Accounts Section of the MoH. Some
of the findings by the Teams in the FY 2006/07 include:
• The release of funds to the districts by the MoFPED continues to
    improve in timeliness and completeness. However there are still a
    number of challenges at the district level with marked delays in
    disbursements between the district collection account and sector
    account; and the release of funds to implementers.
• There is often poor information flow in the districts with a number of
    districts not publishing PHC CG releases at all levels – district, heath
    sector, HSD and health facility.
• There is inadequate and often poor quality data passed on to MoH in
    the monthly HMIS and annual reports submitted.

Figures on timeliness of releases and expenditure from Olle write up this
space should be enough.


2.4     Comparing Local Government Performance

During the HSSP I it was recognized that average national performance
against HSSP II indicators masks marked variation between the local
governments. It was also noted that studying the pattern of performance
across a set of given priority indicators would provide information about
possible associations between good performance and local government
characteristics. This would enable the sector to learn lessons and best
practice. Thus the District League Table (DLT) was developed in the
AHSPR 2002/03, in the HSSP I, and maintained over the HSSP II, with
some adjustments. To be relevant the DLT is likely to keep evolving with
the possibility of including assessment of performance in the
municipalities in future.

2.4.1   The Purpose of the District League Table

The District League Table (DLT) was put in place to facilitate the
following:
       Comparison of sector performance between districts to enable
       ranking of district performance;
       Provision of information to facilitate the analysis of circumstances
       behind good and poor performance at the district level, and thus
       enable appropriate corrective measures;



                                                                         40
        Design of appropriate corrective measures which may range from
        increasing the amount of resources (funds, infrastructure,
        equipment or staff) to the local government, to more frequent and
        regular support supervision as required;
        Increase Local Government ownership for achievements – the
        AHSPR is discussed at the NHA where political, administrative
        and technical leadership of the districts are in attendance;
        Encourage good practices – e.g. good management, innovations
        and timely reporting.

The League Table is not meant to embarrass local government leaders 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.

2.4.2      Composition of the League Table

A number of HSSP II and other district health sector monitoring
indicators have been used for the DLT as applied in the HSSP II. These
are:
   Management Indicators (decisions/actions taken by the local
   government that influence health services delivery):
       o Management of the PHC-CG – measured by proportion of
          received funds (quarterly) that has been spent – which is
          influenced by timeliness of reporting and/or requests;
       o Expenditure on key inputs – measured by proportion of
          indicative PHC CG budgets spent on medicines at NMS and
          JMS as by agreed guidelines;
       o Applying the flexibility provided by the Fiscal Decentralisation
          Strategy (FDS) in favour of the health sector – as a measure of
          the local government’s appreciation of health services as a
          priority area; and
       o Management of health data – measured by timeliness of HMIS
          reporting;
   Service Delivery Output Indicators (a combination of the local
   governments capacity to deliver services, and the demand of the
   population for services)
       o DPT3/Pentavalent vaccine coverage;
       o New OPD attendances per capita;
       o Proportion of expectant mothers delivering in GoU and PNFP
          units;
       o Proportion of expected TB cases that are notified;
       o Proportion of pregnant women receiving IPT 2 [2nd dose of
          Sulphadoxy-pyrimethazine (SP commonly referred to as
          Fansidar) in Pregnancy]; and
       o Pit Latrine coverage as a measure of sanitation coverage; and
       o Availability of HIV/AIDS control activities by level.




                                                                      41
2.4.3 The League Table Scores for FY 2006/07

The national average performance on the DLT for the FY 2006/07 is a
score of 60.5, which is a slight improvement from the FY 2005/06
performance of 60.2. There is wide variation in performance ranging from
77.2 for Gulu at the top to 38.2 for Bukwo at the bottom of the table.
Given the marked increase in the number of districts over the recent past
from 56 to 80, the districts highlighted in this report have been increased
from 20 to 30 – considering the top 15 and bottom 15 performers of the
DLT. Pictorial presentation of the top and bottom 15 districts is shown in
Figure 2.6, and the detailed District League Table including explanatory
notes is in Annex 2.10.

The top 15 performers are: Gulu, Jinja, Mbarara, Kampala, Tororo,
Katakwi, Mityana, Kumi, Pader, Bundibugyo, Kabarole, Masaka, Wakiso,
Kabale and Rukungiri. The bottom 15 performers are Bukwo,
Nakapiripirit, Kaabong, Terego-Maracha, Mubende, Budaka, Amuria,
Kotido, Moroto, Kibaale, Kisoro, Yumbe, Kamuli, Oyam and Kiboga
districts.

Figure 2.6: League Table Top and Bottom Performers for the FY
            2006/07




                                                                        42
Table 2.5 presents an analysis of consistently very good performers over
the HSSP II period and in the case of Jinja ever since the DLT was put in
place in FY 2002/03. The consistently poor performers for the HSSP II
period are also indicated. In addition to considering good and weak
performance in relation to the top 15 and bottom 15 positions on the
DLT, it is worthwhile to note the districts that have shown particular
improvements and those that have markedly declined.

Table 2.5:    District League Table Trends FY 2005/06 and 2006/07
League       FY 2005/06        FY 2006/07                For 2 years    Particular mention
Table
Position
Top 10/15    Jinja,  Tororo,   Gulu, Jinja, Tororo,      Jinja, Gulu,   Jinja is the only district
             Kampala, Mbale,   Kampala,       Katakwi,   Tororo,        that has been amongst
             Nebbi,   Mpigi,   Mityana,      Kabarole,   Kampala,       the best (10 or 15)
             Kumi, Mbarara,    Bundibugyo, Masaka,       Mbarara, &     performers since the
             Gulu         &    Mbale,           Pader,   Mbale          beginning of the DLT in
             Ntungamo          Mbarara,        Wakiso,                  FY 2002/03
                               Nakasongola, Arua
Bottom       Kaabong,          Nakapiripirit, Bukwo,     Kaabong,       3 of the 6 districts
10/15        Manafwa,          Kaabong,         Oyam,    Bukwo,         appearing in the least
             Kaliro,           Kibaale,       Budaka,    Amuria,        performing districts for
             Kiruhura,         Kotido,        Amuria,    Kamuli,        both years of the HSSP
             Amuria, Moroto,   Terego-Maracha,           Moroto,        II are all new districts
             Iganga, Bukwo,    Yumbe,       Mubende,                    (new – created in the
             Koboko, Kamuli    Moroto,         Kisoro,                  last 2 years); Moroto is
                               Kamuli, Kiboga                           from Karamoja; Kamuli
                                                                        is an exception

Districts recording particular improvements include: Mityana, Wakiso,
and Masaka who have all moved from the bottom half of the DLT to the
top 15. This may be explained by a number of factors including: more
complete submission of information and improved management of EMHS
budgets. Some districts have showed decline in performance, including
Nebbi and Mpigi districts from top 10 positions to below average, which
is largely explained by poor performance on the EMHS management
indicator.


2.5      Factors Influencing Local Government Performance

The purpose of the DLT as indicated above is not just to gauge
performance of the districts but to also tease out possible reasons for
good and poor performance. This would make it possible to identify
factors that are facilitating good performers and those hindering poor
performers which would make it possible for the different levels of
government and other stakeholders to transfer/duplicate good lessons
from the good performers and map out possible ways of solving the
challenges facing poor performers.




                                                                               43
Analysis of the performance against the DLT of FY 2006/07, just like
with previous DLTs, shows that a number of factors are associated with
the performance of the different districts. These include:
   • Level of development of the district;
   • Peculiar circumstances;
   • The local government management capacity;

2.5.1   Level of Development of the Local Government

The weak performance of many of the new districts is glaring. Of the 15
bottom performers, 6 of them are among districts created in the recent
past namely: Kaabong, Oyam, Budaka, Bukwo, Terego-Maracha and
Amuria. Conversely there is no new district amongst the top 15
performers. The explanations for this are not all known, but include:
• New districts were previously marginalized parts of the more
   established districts. This argument is supported by the fact that
   some old districts’ performance has markedly improved on separation
   from the new districts e.g. Arua (Nyadri); Mbarara (Kiruhura, Ibanda,
   Isingiro); and Tororo (Butaleja). The marginalization often translates
   into gaps in health inputs like infrastructure and human resources.
• The management is the new district is still facing many challenges as
   many of the offices get manned, and systems are put in place. For
   example many new districts have District Health Officers (DHOs) in
   acting capacity and lack most members of the District Health Team
   (DHT), and infrastructure and logistics – e.g. transport. This may be
   part of the explanation for the many gaps in information from these
   districts and poor performance on indicators like proportion of funds
   spent on medicines and supplies.

2.5.2   Local Government with peculiar circumstances

It was previously noted that districts with particular circumstance were
less likely to perform well on the DLT. Such circumstances were noted as
local governments in conflict or post-conflict situations; and districts
with peculiar cultures and norms. The DLT of 2005/06 and the current
one of FY 2006/07 shows marked improvement in the performance of
districts in mid-North with Gulu and Pader in the top 15, and many of
the other districts performing fairly well (except new districts ). This is
good news and can be attributed to:
    • Improved security in the region, with improved service delivery;
    • Specific interventions for the region by government and partners;

However the challenges in Karamoja are still pertinent – Nakapiripirit,
Kaabong, Moroto and Kotido are still in the bottom 15 of the DLT, and
critical examination of performance against specific indicators like
household latrine coverage, and proportion of expected women delivering
in health facilities shows particularly poor performance by the districts of
Karamoja. More on the improvements and challenges in Northern
Uganda is presented in Section 5.1.



                                                                         44
2.5.3 Local Government Management Capacity

Close scrutiny of the DLT shows that top performers tend to be
consistent in their performance across the range of management
(including information management) and service delivery indicators. This
as in previous AHSPRs seems to point to robust district management – at
the political, administrative and technical level. A few districts continue
to provide information late and incomplete despite frequent reminders
and the experience of the last 5 years. This is true especially of
information on the PHC CG expenditure. Information management is a
key tool in health services management, and needs to be applied more
often for monitoring at all levels.

2.5.4 Responding to the District League Table Performances

It is necessary for all stakeholders to use the information from the DLT to
make the necessary decisions at the various levels. These actions should
include but not necessarily be limited to:

o   Level of Development of Local Government – the Ministry of Health
    and Development Partners need to prioritise new and otherwise
    disadvantaged districts. This should be translated into affirmative
    action in allocation of resources – financial; human and
    infrastructure; and more support supervision, monitoring and
    mentoring. Specifically districts without Hospitals should be
    supported and supervised to make sure there HC IVs are functional.
o   Efforts should continue to relate to peculiar circumstances –
    interventions need to be planned and implemented especially for the
    Karamoja region.
o   There is need for the MoH to compile and share best practices and
    experiences from good performers and encourage peer support. A
    study is planned under the Mid-term review to further explore some
    of the issues surrounding good performers on the DLT.


2.6     Hospital Performance Assessment

The hospitals are a major component of the health system and utilize a
big proportion of the health sector resources in the form of
infrastructure; human resources and funds for medicines and supplies
and other goods and services. The Annual Hospital Report has been part
of the AHSPR for the last 5 years. This has been evolving – initially
specific information was only available for the National and Regional
Referral Hospitals. However in the AHSPR of 2005/06 and in this report
it has been possible to extend individual hospital analysis and
comparison with similar hospitals to the level of the General Hospital.




                                                                        45
A more in-depth discussion of the Annual Hospital Report is available in
Section 3.4 and a stand alone report is available11. The analysis has
been done at the General Hospital; Regional Referral Hospital and
National Referral Hospital levels12.

2.6.1 General Hospitals

The General Hospitals (GHs) reported an average income of Ug. Shs.
258,891,142. However this is recognized as an underestimate as in many
public hospitals the wage component was not included in the
submissions. More than 50% of the expenditure at the GHs is on
employment costs, with 61% of recommended staffing positions filled,
but only 49% for the medical staff13. Pharmacy and dental units have the
highest proportion of unfilled positions.
Iganga hospital registered the highest outputs as measured by the
Standard Unit of Outputs (SUO)14, similar to FY 2005/06; while Kuluva
Hospital emerged best on quality assessment. The final Hospital League
Table (HLT) is produced using a composite indicator that considers the
magnitude of outputs (measured by the SUO), efficiency and quality of
services. For the HLT FY 2006/07 Iganga, Atutur, Bwera, Kawolo, and
Adjumani are the top 5 performers, while Kaabong, Amudat, Moroto,
Nyenga and Tororo Hopsitals emerge the bottom 5.

2.6.2 Regional Referral Hospitals

The analysis of Regional Referral Hospitals (RRHs) includes 4 PNFP
hospitals with high volume outputs and a high degree of specialization
namely: Nsambya, Rubaga, Mengo and Lacor hospitals. The combined
income of 12 RRHs was 43,073,293,517 of which 43% was from
government grants, 30% from user fees (both private wings and PNFP
fees) and 27% from donors. Employment costs used 51% of the funds,
medicines and supplies 15% and 12% for capital expenditure. 75% of the
established positions were filled, with 61% of medical staff positions
filled. 6 hospitals reported stock-out of at least one time in a quarter.
Some of the RRHs are not able to carry out major operations or diagnosis
using X-ray machines. This is a major gap. Lacor Hospital had the
highest number of outputs, and Kabale the least. On quality assessment,
Nsambya hospital scored highest and Soroti the lowest. Masaka RRH
scored highest on the overall RRH League Table and Fort Portal as the
lowest.




11 the detailed Annual Hospital Report will be available at the JRM, and can also be accessed from

the Department of Clinical Services; MoH Library/Resource Centre and Health Planning
Department.
12 PNFP hospitals are assigned to one of the levels given the size, complexity and specialisation

levels.
13This excludes administrative staff; support staff and nursing assistants.
14The computation of the SUO and the efficiency and quality parameters is explained under Section
3.4


                                                                                                46
2.6.3 National Referral Hospitals

Butabika National Psychiatric Referral Hospital had a total income of
Ugshs     13,240,522,792    of   which     Development      was    Ugshs
10,143,295,109. 75% of staff positions are filled; however the hospital
had stock-outs of at least one indicator medicine in each quarter. The
hospital continues to provide specialist psychiatric services and general
outpatient services; and training of psychiatric nurses, clinical officers
and specialists.

Mbarara National Referral Hospital received Ugshs 3,167,179,979, which
was evenly distributed between wage and non-wage recurrent spending.
80% of staff positions are filled; the hospital had a stock-out of one
medicine in one quarter. The hospital provides a range of specialized and
general inpatient and outpatient services plus training of health workers
of the nursing, medical officer and postgraduate categories.

Mulago National Referral Hospital did not provide an Annual Report.

2.6.4 PNFP Hospitals

Over the HSSP I the PNFP hospitals recorded improvement in a number
of parameters especially the volume of services and efficiency in
production of services by maximizing outputs form available human and
financial resources15. Over the 2 years of the HSSP II however, there has
been a worrying trend of reversal with overall declining outputs,
including OPD, IP and Primary Health Care services like Antenatal Care
and immunisation; increase in User Fees; and decreased staff
productivity. This is attributed to 2 main factors: the decline government
grants to the PNFP hospitals (in absolute and especially in proportional
terms); increased cost of service delivery especially employment costs.
This is an important phenomenon that should be noted for appropriate
decision-making by sector stakeholders.


2.7          Comments on Statistics for the AHSPR for FY 2006/07

During the HSSP I work methods were established to get information
from the different implementing levels and institutions. Data availability
improved over the period of the HSSP I. However in the preparation of the
AHSPR it has been quite challenging to get data from the different levels
– district, hospital, and central level institutions. This coupled with the
increase in HSSP II indicators from 18 to 25 has resulted in gaps in the
HSSP Indicator table and the PEAP Indicator table. More is discussed on
this, and the Monitoring of the HSSP II in Section 5.4 of this report.

Data Quality is another issue of concern given the maturing of sector
monitoring, and the decline in performance of the Health Management

15   this is documented in previous AHSPRs



                                                                        47
Information System (HMIS) indicators of timeliness and completeness.
The later has led to dependence on local government and hospital annual
reports rather than the accumulated monthly reports. In September
2006 the MoH (Resource Centre and Expanded Programme for
Immunisation EPI), and WHO carried out a Data Quality Self Assessment
(DQSA) on immunisation data covering 8 districts. The DQSA recorded
an Accuracy Ratio AR16 of 61% for pentavalent vaccine 3rd dose and 75%
for the measles vaccine. An AR of < 100% indicates over reporting,
whereas >100% indicates under-reporting. The DQSA therefore noted a
fairly high level of over-reporting from the lower levels. A validation
exercise carried out for the AHSPR 2006/07 reported similar findings.

It is recommended that more information be sought on health sector data
quality under the MTR – a more comprehensive Data Quality Assessment
should be carried out preferably by an independent entity like Uganda
Bureau of Statistics (UBOS) or institutions from Academia. This would
provide the basis for more concrete recommendations.




16Accuracy Ratio = (no. of vaccine doses e.g. measles counted at health facility level from tally
sheets/no. of vaccine doses for measles reported in HMIS reports at HSD or district level for the
same period)*100



                                                                                              48
Chapter 3            Delivery of the Uganda National Minimum Health Care
Package              51

3.1  Health Promotion, Disease Prevention and Community
     Health Initiatives ..................................................................................................... 51
3.2 Maternal and Child Health .................................................................................. 60
3.3 Prevention and Control of Communicable Diseases ................................... 71
3.4 Prevention and Control of Non-communicable Diseases /
Conditions ............................................................................................................................. 93


Figures
Figure 3.1:              Trends in Infant and Under 5 Mortality Rate............................................64
Figure 3.2:              U5MR-MDG4, Actual and Accelerated Performance...............................64
Figure 3.3:              Reported NNT cases by year in Uganda, 2002 – 2007
                         (Source HMIS) ......................................................................................................69
Figure     3.4:          Trends in uptake of PMTCT services 2004 – June 2007 .......................74
Figure     3.5:          Trends in number of person on ART – 2003 - 2007................................76
Figure     3.6:          Number of TB cases notified ...........................................................................79
Figure     3.7:          TB treatment outcome ......................................................................................79
Figure     3.8:          Trends in Malaria morbidity – 1999 - 2006...............................................83
Figure     3.9:          Number of nets re-treated ...............................................................................85
Figure     3.10:           Malaria-positive Blood Smears, Kihihi HC IV, Kanungu
                           District Aug 06-June 07 ..............................................................................86
Figure 3.11:               Income for General Hospitals FY 2006/07 ..........................................100
Figure 3.12:               Overall Quality in General Hospitals FY 2006/07 ............................102
Figure 3.13:               Expenditures from Regional Referral Hospitals FY
    2006/07                104
Figure 3.14:               Volume of outputs (SUO) from Regional Referral and
                           large PNFP .................................................................................105
Figure 3.15:               Quality Score for Regional Referral Hospitals.....................................106
Figure 3.16:             Outputs from PNFP Hospitals 1997/98 – 2006/07 ..............................110


Tables
Table 3.1:               Health Promotion and Education key outputs - FY
    2006/07              52
Table 3.2:               Environmental Health key outputs - FY 2006/07...................................54
Table 3.3:               Control of Diarrhoeal Diseases key outputs - FY 2006/07 ..................56
Table 3.4:               School Health key outputs - FY 2006/07...................................................57
Table 3.5:               Occupational Health key outputs - FY 2006/07......................................59
Table 3.6:               Reproductive Health key outputs - FY 2006/07 ......................................60
Table 3.7:               Newborn Health key outputs - FY 2006/07 ..............................................65
Table 3.8:               IMCI key outputs - FY 2006/07 ....................................................................66
Table 3.9:               Expanded Programme on Immunisation key outputs - FY
                         2006/07.................................................................................................................67
Table 3.10:              Nutrition key outputs - FY 2006/07 ............................................................70
Table 3.11:              HIV/AIDS key outputs - FY 2006/07 ..........................................................72
Table 3.12:              Health facilities providing PMTCT by level.................................................73


                                                                                                                           49
Table 3.13:             HCT Coverage by Health facility levels in 2006/07.................................75
Table 3.14:             Number of Health Facilities accredited for providing ART
                        in 2006 and 2007 ...............................................................................................76
Table 3.15:             Tuberculosis control key outputs - FY 2006/07......................................78
Table 3.16:             Malaria Prevention and Control key outputs - FY
    2006/07             82
Table 3.17:             HBMF performance in 4 selected districts (FY 2006/07) ......................83
Table 3.18:             IRS performance in selected districts ..........................................................86
Table 3.19:             Veterinary Public Health key outputs –FY 2006/07...............................87
Table 3.20:             Guinea Worm key outputs - FY 2006/07...................................................89
Table 3.21:             Onchocerciasis Control key outputs - FY 2006/07 ................................92
Table 3.22:             Non-Communicable Diseases key outputs - FY 2006/07.....................93
Table 3.23:             Disability, Injuries and Rehabilitative Health key outputs
                        - FY 2006/07 .......................................................................................................94
Table    3.24:          Mental Health key outputs - FY 2006/07 ..................................................96
Table    3.25:          Staff in general hospitals ...............................................................................100
Table    3.26:          Outputs from the General Hospitals FY 2006/07 .................................101
Table    3.27:          Staff in Referral Hospitals..............................................................................104
Table    3.28:          Ranking of Regional Referral and Large PNFP Hospitals ....................107
Table    3.29:          Outputs from Mbarara Hospital ..................................................................109
Table    3.30:          Oral Health key outputs - Year 2006/07..................................................111


Boxes
Box 3.1:     Kaliro District: The move to increase household sanitation
             coverage to 100% ....................................................................................................55
Box 3.2:     A discussion on Reproductive Health Indicators trends in
             the Uganda Demographic and Health Surveys .............................................62
Box 3.3:     Innovations to increase supervised deliveries in Gulu
    District 63
Box 3.4:     Comparison of data from various sources......................................................68




                                                                                                                       50
Chapter 3    Delivery of the Uganda National Minimum Health Care
             Package

The Uganda National Minimum Health Care Package continued to
constitute the priority health care interventions for addressing the high
disease burden in Uganda during year two of HSSP II. The interventions
in the package continued to be implemented in clusters in order to
enhance the integrated approach to service delivery and to encourage
increased coordination in planning, budgeting and implementation of the
interventions at all levels of care.

This chapter discusses the achievements and progress that has been
attained in the delivery of the UNMHCP and the challenges experienced
during year two of HSSP II in each of the interventions of the following
clusters:
    • Cluster 1 – Health Promotion, Disease Prevention and Community
       Health Initiatives
    • Cluster 2 – Maternal and Child Health
    • Cluster 3 – Prevention and Control of Communicable Diseases
    • Cluster 4 – Prevention and Control of Non Communicable
       Diseases


3.1     Health Promotion, Disease Prevention and Community
        Health Initiatives

The burden of disease remains high in Uganda and continues to be
caused by mainly preventable diseases. Appropriate and timely public
health and preventive measures could therefore reduce the high disease
burden in Uganda. Health promotion, disease prevention and community
health initiatives offer effective interventions in increasing community
awareness and health literacy on disease prevention and promotion of
health lifestyle in order to have a health and productive population.

The cluster on Health promotion, Disease Prevention and Community
Initiatives includes the following interventions; Health Promotion and
Education, Environmental Health, Control of Diarrhoeal Diseases, School
Health and Epidemic Disease Prevention, Preparedness and Response.

3.1.1 Health Promotion and Education

Health Promotion and Education is increasingly being appreciated and
acknowledged to be effective in reducing the burden of disease and
mitigating the social and economic impact resulting from ill health.
Health Promotion and Education and disease prevention help in
increasing health awareness, increase community participation and
involvement in promoting health, increase demand and utilisation of
available health services in addition to adoption of health promotive and



                                                                      51
disease preventive lifestyle. Its major aim is to make health choices easy
choices for the general public.

Main achievements during FY 2006/07:

Table 3.1:      Health Promotion and Education key outputs - FY
                2006/07
 Indicator                      Baseline FY     Target FY
                                2005/06         2006/07     Achieved   Comments
 Central level programme performance indicators
 Quarterly performance                1              4          1
 reports
 Technical programme                  4              12         4
 meetings
 Proportion of media                 20%            20%                Materials were provided to
 institutions participating in                                         media institutions for
 health promotion and                                                  public education
 education
 District level (Service delivery level) indicators
 Proportion of Village Health        25%            25%                Supported 34 districts to
 Teams trained                                                         conduct training of VHTs.
 Proportion of health                20%            10%                Produced & distributed
 facilities and community                                              leaflets & posters on
 institutions with health                                              cholera, booklets on Avian
 promotion materials                                                   Influenza & posters on
                                                                       Injection safety.
 Proportion of political and       58%
 cultural institutions
 promoting health
 Proportion of population
 seeking health services
 according to national
 standards

Behaviour Change Communication
• Developed, translated and disseminated posters, leaflets, brochures,
   fliers to promote various interventions such as Child Days Plus,
   cholera, avian flu.
• Developed and disseminated radio messages on various health
   interventions.
• Developed and disseminated radio spots and programmes to promote
   Child Days Plus.
• Held talk shows for promoting family planning on 6 radio stations.

Capacity Building
• Supported 12 district based Health Educators to pursue advanced
  training in Health Promotion and Education at Uganda Martyrs
  University, Nkozi.
• Supported thirty four districts to establish and conduct initial
  training of the Village Health Teams.

Community mobilization




                                                                                 52
•   Held community film shows in all districts to raise awareness on
    reproductive health issues, avian flu, malaria, cholera, STD/AIDS
    and sanitation.
•   Oriented District Health Educators from 10 districts on various family
    planning issues in order to mobilize their communities.

Advocacy for the Health Sector Strategic Plan
• Organised press conferences to provide information on priority health
  issues highlighted in the press.
• Disseminated fortnight press releases on various health conditions.
• Held interactive meeting addressing Reproductive Health issues with
  representatives of media houses.
• Coordinated the publicity activities for the World Health Day, Africa
  Malaria Day, Safe Motherhood day, launching of RH communication
  strategy.




          World Health Day “Invest in Health – Build a Safer Future”
                      Kampala District 13th April 2007

Major challenges
• Inadequate funding to support media educational programmes,
  Evidence Based Health Promotion, production of IEC materials and
  VHT roll out programmes.
• Inadequate human resources to coordinate various Health Promotion
  and Education Programmes.
• Low implementation of community based health promotion initiatives.
• Unable to utilize the printing unit because of lack of funds,
  inappropriate location and inadequate staffing.
• Lack of reliable transport for support supervision.

3.1.2 Environmental Health

In Uganda, poor sanitation and hygiene has remained a major
predisposing factor to the high burden of disease. It is estimated that 70
- 80% of Uganda’s disease burden is preventable and is associated with



                                                                       53
poor sanitation and hygiene and poor living conditions. A significant
indicator has been the cholera and dysentery outbreaks in many districts
of Uganda during the year. The mission of Environmental Health
therefore is to contribute to a significant reduction of environmental
health related morbidity, mortality and disability among the people of
Uganda. It was planned that this would be achieved through increased
access to sanitation and hygiene services and facilities. The
Environmental Health programme therefore continued operating a policy
of strengthening an integrated and multi–sectoral approach to
environmental     health    management.     This     encompasses     the
implementation of a comprehensive legal framework and related
regulations for environmental health promotion at local government level.

Achievements during FY 2006/07:
Table 3.2: Environmental Health key outputs - FY 2006/07
 Indicator                       Baseline             Target for
                                 FY 2005/06           FY           Achieved   Comments
                                                      2006/07
 HSSP II indicators
 Percentage of Households with             58%          100%**       58.5%    2007 DHIs Annual
 pit latrines                                                                 Conference report
 Central level programme performance indicators
 Quarterly performance reports              0             4            1
 Technical programme meetings               4             12           5
 Proportion of districts                   20%           22%          25%     See districts
 implementing Water Quality                                                   covered in WQS
 Surveillance and promotion of                                                above
 safe water consumption
 Proportion of districts                   10%           20%          30%     Tools ready for
 implementing EHMIS using                                                     dissemination in all
 HAB                                                                          districts of Uganda
 District level (Service delivery level) indicators
 Percentage of persons washing             0%             0%          14%     Baseline Report on
 hands with soap                                                              Hand washing by
                                                                              The Steadman
                                                                              Group. This is a
                                                                              new initiative
** Target set by the 2006 National Health Assembly

Sanitation:
• Successfully held the Annual Sanitation Conference for District
   Health Inspectors and other Sanitation stakeholders. The conference
   reviewed the national latrine coverage and noted that it had stagnated
   at 58% for three consecutive years. It should be noted that the
   ambitious target of achieving 100% latrine coverage by all districts set
   by the 2006 National Health Assembly could not be achieved.
• Finalised and printed 5,000 copies of the Household Assessment
   Books (HABs). This is to facilitate district based Environmental
   Health Management Information System (EH-MIS).
• Finalised the 10 Years Improved Sanitation and Hygiene (ISH)
   Financing Strategy.




                                                                                  54
Food Safety and Hygiene:
• Finalised and officially launched the Food Safety Strategic Plan. The
   plan emphasizes the need to create consumer awareness about food
   safety and quality issues and to upgrade the skills of food control
   inspectors.

Water Quality Surveillance:
• Conducted training of district staff on Water Quality Surveillance
  techniques for 90 health workers in the 9 districts of Pader, Kitgum,
  Gulu, Amuru, Nebbi, Adjumani, Yumbe, Moyo and Arua. Oriented 11
  DHIs from the districts of Nebbi, Arua, Yumbe, Moyo, Adjumani, Lira,
  Apac, Kaberamaido, Soroti, Katakwi and Nakaprirpirit. The districts
  were also equipped with water testing kits, reagents and surveillance
  tools and manuals.
• Conducted technical support supervision to districts with emphasis
  on district planning for safe water chain including the water testing
  kits and reagents.
• Distributed Safe Water Chain promotional materials

Hand Washing Campaign
• Initiated a national Hand Washing Campaign, through the public
  private partnership arrangement. The campaign aims at improving
  hand washing practices and targets caregivers of children below
  5years, children between 6-14 years and the general public.

Box 3.1:    Kaliro District: The move to increase household
            sanitation coverage to 100%




                                                                    55
Challenges/Constraints
• Inadequate resource allocation to hygiene promotion and sanitation
  at all levels which limits implementation of environmental health
  programmes.
• Existence of very high level of poverty in the country makes co-
  funding of environmental health projects with contribution from the
  community almost impossible.
• Inadequate information management especially at lower local
  governments makes it difficult to establish the actual environmental
  health situation on the ground leading to inadequacies in planning.
• Poor enforcement mechanisms for public health regulations.
• The growing population and economic activities are progressively
  degrading the environment, resulting in negative economic and health
  implications.
• Lack of log-term support to ensure sustained behavior change.
  Sanitation/hygiene involves behavior change, which takes time.
• Households do not consider sanitation to be a priority; yet household
  sanitation is considered an individual responsibility. This is a fallacy
  as an individual’s irresponsibility or lack of means can have an
  adverse effect on an entire community.
• Although the provision of water is largely subsidized, there is no
  subsidy for household sanitation, apart from what goes into
  promotional messages. It is time government reviewed the pro-poor
  strategy and evaluated the provision of targeted sanitation subsidies
  to the very poor (terminally ill, child headed households, the elderly,
  women headed households, PWDs)


3.1.3 Control of Diarrhoeal Diseases

Diarrheal diseases and outbreaks (cholera and dysentery) remain among
the five major causes of morbidity and mortality in the country. During
last financial year, the health sector focused on promotion of
interventions that prevent diarrhea in general and ensure proper case
management for the sick.

Achievements during FY 2006/07

Table 3.3:     Control of Diarrhoeal Diseases key outputs - FY
               2006/07
 Indicator                                   Baseline     Target
                                             FY 2005/06   FY 2006/07   Achieved    Comments
 Central level programme performance indicators
 Quarterly performance reports                     2          4           1
 Technical programme meeting                       2          12          4
 Incidence of annual cases of epidemic         3/1000
 diarrhoeal diseases
 Cholera specific case fatality rate             2.4%         2.0       2.0%
 District level (Service delivery level) indicators
 Proportion of patients with epidemic
 diarrhoea receiving appropriate



                                                                                  56
    treatment within 12 hours of onset of
    symptoms

•     Initiated the process of reviewing the CDD policy and introduced new
      innovations into the management of diarrhoea i.e.
      o Zinc National Task Force was formed and is functional,
      o Zinc and Low osmolarity ORS were included in the 2006 Uganda
          Essential Medicines List (UEMEL),
•     Provided timely technical, logistical, and financial support to 27 (out
      of the 80) districts which reported Cholera outbreak. The Cholera
      outbreaks were controlled.
•     Built capacity to manage cholera cases. Standard guidelines for
      cholera outbreak prevention and control were printed and distributed
      to affected districts. Thus, cholera case fatality rate reduced
      significantly from 2.4% during FY 2005/06 to 2.0% in 2006/07. The
      same efforts used to control cholera also checked dysentery
      outbreaks in the country.

Challenges/Constraints
• Complacency, hence loss of continued mobilization and good
  practices in the management of diarrhoea among both health workers
  and caretakers
• Poor sanitation and low safe water coverage especially in affected
  areas (Kampala and IDP camps i.e. coverages below 50% in some
  districts)
• Continuous migration across country borders (Sudan and Democratic
  Republic of Congo)
• Inadequate enforcement of bye-laws at local levels

3.1.4 School Health

School Health programme was introduced to create an enabling
environment for delivering quality education, for inculcating healthy
habits and practices in children in their formative years when they are
most receptive. With the implementation of Universal Primary School
Education (UPE) and Universal Secondary School Education (USE), a
sizable population close to 40% is currently in the education sector. The
goal of the School Health program is “Healthy school children, staff and
healthy school environment”. Healthy school children and staff are likely
to perform better in all curricular and non-curricular school
programmes.

Achievements during FY 2006/07:

Table 3.4:        School Health key outputs - FY 2006/07
    Indicator                                Baseline     Target
                                             FY 2005/06   for FY    Achieved        Comment
                                                          2006/07
    Central level programme performance indicators
    Quarterly performance reports                  2         4          1



                                                                               57
    Technical programme meeting                         4             12           6
    Technical support supervision to districts          2             4            2
    District level (Service delivery level) indicators
    Proportion of primary and secondary                40%           100%       50%          Something
    schools implementing the main components                                                 being in
    of Health Promoting School initiative (HPSI)                                             each
                                                                                             component.
    Proportion of primary and secondary                                                      Source:
    schools having healthy physical                                                          MoES
    environment with latrine and safe water                                  Some            Survey
    facilities that meet the national guidelines:                            progress in     report,
    - pupil per latrine stance ratio 40:1 or better        50%       56.8%   quantity        2006
    - hand washing facilities,                             20%        23%    but not in
    - safe water within 0.5 km radius of                   60%        60%    quality
    institution
    Proportion of schools providing basic school
    health services

•      Finalized arrangements to start mass School Based Tetanus Toxoid
       Immunization for school girls aged 10-24 years in upper primary,
       secondary and tertiary schools. The relevant guidelines and IEC
       materials were developed and printed.
•      Implemented bi-annual de-worming programme for children aged 1-
       14 years. Besides getting the tablets, children were educated on
       personal and domestic hygiene.
•      Developed First Aid booklets for primary schools, and developed IEC
       messages on school health.
•      Started mass screening of school children in a number of districts
       such as Mpigi, Bushenyi and Kasese.

Challenges/Constraints
  • Delays in finalization of School Health Policy and Memorandum of
      Understanding between Ministries of Health and Education &
      Sports.

3.1.5 Epidemic             and      Disaster          Prevention,   Preparedness       and
      Response

Epidemic and Disaster Prevention, Preparedness and Response aims at
improving emergency preparedness and response both at national and
district levels in order to promote health, prevent disease and reduce
death among the affected population. Emergencies were routinely
handled through early surveillance and mounting a national response as
discussed below.

Achievements during FY 2006/07

Prevention and control of epidemics

i.    Cholera
Controlled cholera epidemics in 15 border districts with Sudan and DR
Congo. A cumulative total of 5,194 cases with 105 deaths were reported.
The last districts to be affected were Kitgum, Pader Kampala and


                                                                                        58
Ntungamo (specific details are on CDD section). The focus is now on
addressing the main root causes such as poor sanitation, poor hygiene
and inadequate safe water through inter-sectoral linkages and health
education.

ii.     Meningitis outbreak
Contained the meningitis epidemic in Kotido and districts of West Nile. A
cumulative total of 3,324 cases and 73 deaths were reported giving a
fairly low case fatality rate of 4%. The epidemic was controlled by active
case search, vaccination of vulnerable population and effective treatment
of cases.

iii.   Plague outbreak
Instituted control measures in Arua, Nebbi and Masindi for plague
outbreak. A cumulative total of 22 cases with 10 deaths were confirmed.

iv.   Alcohol Poisoning
49 people died of alcohol poisoning in the districts of Kampala, Mukono,
and Mubende following poisoning by alcohol. This was later confirmed to
be contaminated with methyl alcohol (methylated spirit). Steps were
taken jointly with the Police, the Uganda National Bureau of Standards
to apprehend culprits and ensure control measures.


3.1.6 Occupational Health

The overall objective of Occupational Safety and Health Programme is to
prevent occupational accidents, diseases and injuries in Health facilities
and other workplaces, ensure maximum awareness of occupational
safety and health issues among workers and employers.

Achievements
• Developed and finalized policy and guidelines on Occupational Health
   services,

Table 3.5:     Occupational Health key outputs - FY 2006/07
 Indicator                                 Baseline     Target for
                                           FY 2005/06   FY 2006/07   Achieved    Comments
 Central level programme performance indicators
 Quarterly performance reports                   2          4            1
 Technical programme meeting
 Technical support supervision to                1          4            4
 districts
 District level (Service delivery level) indicators
 Proportion health workers in the              30%         50%
 formal sector accessing Occupational
 health services
 Proportion health workers in the              30%         50%
 informal health sector accessing
 Occupational health services
 Proportion of workers made aware



                                                                                59
  and sensitized on OH&S.
  Proportion of workers accessing OH
  services


Challenges/ Constraints
• Inadequate funds to roll out the programme
• Bureaucracy in the policy formulation procedures


3.2         Maternal and Child Health

The Maternal and Child Health Cluster constitutes the priority health
care interventions for addressing the disease burden especially in women
and children. Perinatal, maternal and childhood conditions constitute
the biggest proportion of the national disease burden. The priority health
care interventions for addressing the maternal and childhood conditions
which are planned and implemented together because of the
interdependency and close linkage between mothers and children are
Sexual Reproductive Health and Rights and Integrated Child Survival.
The specific interventions within Integrated Child Survival include;
Newborn Health and Survival, Management of Common Childhood
Illness, Expanded Programme on Immunisation and Nutrition.


3.2.1 Sexual Reproductive Health and Rights

The HSSP II prioritized Sexual Reproductive Health and Rights (SRH)
programme and together with the Reproductive Health Strategy (2005-
2010) identified three priority areas to accelerate implementation of
reproductive health strategies. These include (i) Increasing access to
institutional deliveries and emergency obstetric care (EmOC) and (ii)
Strengthening of Family Planning (FP) services. The 2006 Joint Review
Mission also re-emphasized the importance of Reproductive Health and
agreed on two Undertakings to be achieved by October 2007 namely; i)
provision of CEmOC in 100% of hospitals and 50% of HC IVs and
BEmOC in 50% of HC IIIs and ii) Zero tolerance for stock out for
contraceptive supplies.

Achievements during FY 2006/07

Table 3.6:       Reproductive Health key outputs - FY 2006/07
Indicator                                 Baseline FY   Target for
                                          2005/06       FY 2006/07   Achieved        Comments
HSSP II indicators
Percentage of health units providing                       30%
EmOC
Couple of Years Protection                  309,757       325,407     357,021
Percentage deliveries taking place in a       29%           35%         32%
health facility
Caesarean Sections per expected                             7%
pregnancies (hospital)



                                                                                60
Proportion of pregnant women receiving a          37%   50%       42%
complete dose of IPT2
Central level programme performance indicators
Quarterly performance reports                      1     4         1
Technical programme meetings                       6     12        6
Contraceptive Prevalence Rate (CPR)               23%   31%      23.6%
Adolescent Pregnancies (Teenage                   32%   26%       25%
pregnancy)
Total Fertility Rate (TFR)                                        6.5
Maternal Mortality Ratio (per 100,000 live        505   445       435
births)
Unmet EmOC needs                                  86%   68%       65%
District level (Service delivery level) indicators
Proportion of women attending 4 ANC               42%   46%       47%
visits

Scaling up of EmOC
• Procured and distributed 30 ambulances to Health Centres IVs and
   IIIs in 9 northern districts
• Procured and distributed EmOC equipment to 9 northern districts:
              RH kits consisting of Delivery kits, Caesarean section kits,
              MVA kits, FP kits, TBA kits.
              Assorted EmOC equipment (Vaginal specula, scissors,
              artery forceps, B.P. machines, Needle Holders, Mucus
              extractors etc.)
              Supplies and protective wear (gloves, gynaecological gloves,
              Gum boots, Aprons etc)
• Procured a total of 30,793 Safe Delivery Kits (Mama Kits) and
   distributed them to districts through NMS and JMS. Annex 3.1
   provides the distribution lists of Mama Kits to the districts during FY
   2006/07.
• As a result of the improved referral for maternity services and
   increased availability of logistics and supplies for safe delivery in
   health facilities, the proportion of expectant mothers delivering in
   health facilities increased from 29% in FY 2005/06 to 32% in FY
   2006/07. The achievement nearly reached the year’s target of 35%.
• Established an equipment credit line by which health facilities will
   obtain the obstetric equipment required at different levels for the
   provision of services.
• Carried out technical support supervision visits and on-job skills
   development for EmOC in all hospitals in order to scale up EmOC.

Revitalisation of Family Planning
• Conducted training in basic Family Planning in 24 districts. A total of
  200 service providers were trained and a total of 220 Community
  Reproductive Health workers were trained in the community based
  distribution of family planning methods mainly pills and condoms.
• Quantified national contraceptive requirements and procured
  sufficient amounts. Held monthly meetings with partners especially
  DELIVER, FPAU, UNFPA, USAID and National Medical Stores to
  streamline contraceptive procurement, storage and distribution.




                                                                         61
•   There was improvement in Couple Year’s Protection (CYP) – a measure
    of family planning uptake, which increased from 309,757 in FY
    2005/06 to 357,021 in FY 2006/07. The achievement surpassed the
    year’s CYP target of 325,407.
•   Recruited a Reproductive Health Commodity Security Coordinator
    and set up an effective monitoring system of the supply chain for RH
    commodities to reduce the stock outs at the service delivery points.

Other achievements
• Costed and finalized the roadmap for reduction of maternal mortality
   and newborn. This was discussed and endorsed by Top Management
   Committee of Ministry of Health.
• Revised and updated the training curricula for Life Saving Skills and
   Family Planning.
• Established Obstetric Fistula training centres at the National Referral
   hospital Mulago and the Regional Referral hospitals of Soroti, Mbale,
   Arua, Gulu, Masaka, Kabale and Kitovu.
• Established Youth Friendly services in 5 Health Centres IVs
   supported by adolescent Peer Educators in the surrounding sub-
   counties. 30 service providers have been trained in the provision of
   Youth Friendly Services; 15 in the northern region and 15 from the
   eastern, central, southwest, Karamoja and north west regions




           Safe Motherhood Day “A Planned Pregnancy – A Joyful Birth”
                        Soroti District 11th October 2006

Box 3.2:       A discussion on Reproductive Health Indicators trends
               in the Uganda Demographic and Health Surveys




                                                                        62
Box 3.3:     Innovations to increase supervised deliveries in Gulu
             District




Challenges/Constraints
• Inadequate      staffing especially    midwives,    medical     officers,
  anaesthetists and laboratory technicians for Health Centers IVs
• Insufficient funds to scale up EmOC to Health Centers IVs and IIIs;
  and make repeat visits to hospitals. Training of FP providers, Life
  Saving Skills is expensive and the districts do not allocate funds to
  these activities. Consequently the trained ToTs are not active and may
  lose their skills.
• Ensuring contraceptive commodity security is a big challenge. The
  pull system through which districts are supposed to get these
  supplies needs to be strengthened through training and regular
  technical support supervision.

3.2.2 Integrated Child Survival

The health status of children in Uganda continues to remain poor. There
are however cost effective interventions which if well and widely applied
can address the major causes of morbidity and mortality in children.
HSSP II therefore aims at scaling up the proven and cost effective
interventions for addressing the burden of disease among the children
and ensuring their integrated delivery. The following are the priority child
survival interventions:




                                                                         63
   •   Newborn Health and Survival
   •   Management of Common Childhood Illness
   •   Expanded Programme on Immunisation and
   •   Nutrition

Although childhood mortality is still high, recent information from the
2006 Uganda Demographic and Health Survey (2006 UDHS) shows that
there is a slight decline in both Under 5 and Infant Mortality Rates.
Under 5 Mortality Rate has declined from 152 in 2000 to 137 deaths per
1,000 live births in 2006, while Infant Mortality Rate has declines from
88 in 2000 to 76 deaths per 1,000 live births in 2006. Figure 3.1 below
shows the trends in Under 5 and Infant Mortality Rates over the last ten
years. The national aim is to reduce these rates and achieve the
Millennium Development Goals (MDGs) of reducing Under-five Mortality
Rate to 51 per 1000 live births and IMR to 29 per 1000 live births by
2015.

Figure 3.1: Trends in Infant and Under 5 Mortality Rate
                        147            152
                                                        137
                                             IMR
                                             Under 5



                                 88
                81
                                                   76


                            5




                                                              39
                     1995         2000-01           2006*



In order to achieve a sustained scaling up of known/new and cost
effective child health care interventions, a comprehensive Child Survival
Strategy is being developed to promote national wide and integrated
delivery of child health interventions particularly the prevention of ill
health and management of sick children. The strategy addresses the
gaps within the current survival interventions such as Home Based Care
for treatment of common childhood illnesses, immunization, and
promotion of good nutrition. It is hoped that cost effective interventions
will be implemented on a national scale to ensure that Uganda attains
the Millennium Development Goal No. 4 of Reduced Child Mortality Rate.
Figure 3.2 shows the anticipated progress towards the attainment of
MDG 4 with the implementation of Child Survival Strategy.

Figure 3.2: U5MR-MDG4, Actual and Accelerated Performance




                                                                       64
    180

                      167
    160
                                                      152
                                  147
                                  144.8
    140
                                                                       137

                                                      122.6                              122
    120

                                                                                                   107
    100                                                                100.4
                                                                                         97


     80                                                                                  78.2


     60
                                                                                                   56


     40



     20



      0
      1985         1990        1995                2000            2005               2010      2015        2020

                                          Actual     Projected   Accelerated    MDG



Source: Child Survival Strategy for Uganda 2007

Uganda is implementing the Child Days Plus (CDP) strategy, one of the
key interventions within the Child Survival Initiatives, for accelerating
the implementation of child survival interventions particularly Vitamin A
supplementation, de-worming children aged 1-14, immunization, and
promotion of key family care practices. Two rounds of Child Days Plus
(November 2006 and April 2007) were successfully implemented by all
districts with very good coverages.

             a).            Newborn Health and Survival

About half of deaths in infants occur in the neonatal period (first 28 days
after birth). Of these nearly 2/3 die in the first week of life, and 2/3 of
those deaths occur within the first 24 hours after birth. HSSP II therefore
prioritized newborn health interventions and are being integrated in the
maternal and child health care.

Achievements FY 2006/07

Table 3.7:                  Newborn Health key outputs - FY 2006/07
Indicator                                                                      Baseline                Target for
                                                                               FY 2005/06              FY 2006/07   Achiev   Comments
                                                                                                                    ed
Central level programme performance indicators
Quarterly performance reports
Technical programme meeting
Technical support supervision to districts         1                                                       4
District level (Service delivery level) indicators
Percentage reduction of low birth weight          25%                                                     10%        8%
Percentage reduction of neonates seen in          45%                                                     20%        5%
health facilities with septicaemia/severe
disease

•         Conducted a situation analysis for newborn health in preparation for
          development of a framework for implementation.


                                                                                                                             65
•   Developed guidelines for community based newborn care for
    Community Resource Persons trainers
•   Trained a team of 6 national facilitators for newborn health and 24
    district trainers in integrated community based newborn care in
    seven districts
•    Established a national steering committee on newborn health

        b).     Management of Common Childhood Illness

The Integrated Management of Childhood Illness (IMCI) is a key strategy
for delivery of integrated child health through improvement of health
worker skills in regard to integrated assessment and management of
malaria, acute respiratory infections, diarrhoea, and malnutrition, which
contribute to over 70% of overall child mortality. During HSSP II the
main focus of IMCI is to strengthen district capacity to roll out and
sustain IMCI, mobilise resources for implementation and monitor
outcomes of key activities at institutional, population level and
community level in line with the delivery approaches agreed upon in the
Uganda child survival strategy.

Achievements during 2006/07

Table 3.8:      IMCI key outputs - FY 2006/07
Indicator                                    Baseline FY   Target FY
                                             2005/06       2006/07     Achieved    Comments
Central level programme performance indicators
Quarterly performance reports                      2           4           1
Technical programme meeting                        2           12          4
Technical support supervision to districts         1           4           1
District level (Service delivery level) indicators
Proportion of sick under-fives seen by a          45%         55%         60%
health worker using IMCI guidelines.
Proportion of under fives with fever,             30%         40%         54%
diarrhoea and pneumonia seeking care
within 24 hours
Proportion of under-fives with acute              37%         45%         43%
diarrhoea receiving ORT.
Proportion of under-fives with pneumonia          30%         45%         47%
receiving appropriate antibiotic treatment
Percentage reduction of missed                    45%         75%         33%
opportunities for immunization among
sick under fives.

•   Initiated the process for reviewing and scaling policy for community
    pneumonia treatment
•   Conducted a study towards improving presumptive diagnosis of
    childhood malaria and pneumonia in lower level health facilities
•   Developed training guidelines for home based care of malaria,
    pneumonia, diarrhoea and newborns
•   Trained 145 district trainers for home based care and community
    newborn care in seven districts




                                                                                  66
•     Trained 45 national and district trainers for early diagnosis and
      treatment of paediatric HIV using the IMCI complementary course
      guidelines
•     Conducted a post UDHS verbal autopsy study to ascertain causes of
      child deaths in the country
•     Conducted a national level stakeholder advocacy meeting for
      integrating newborn health into reproductive and child health

Challenges/Constraints
• Inadequate human resources especially at implementation levels
• Lack of vehicles for field activities
• Severe shortage of funds to support the programme activities
• Limited capacity in the newly created districts

          c).   Expanded Programme on Immunisation

Immunization is a nationwide programme targeting mainly infants and
women of childbearing age (15 - 49 years). The mission of UNEPI is to
contribute to the reduction of morbidity and mortality due to childhood
diseases to levels where they are no longer of public health importance.
The programme goal and objective in HSSP II is to ensure that all
children are fully immunized against the targeted vaccine preventable
diseases before their first birthday and all babies are born protected
against neonatal tetanus.

Achievements during FY 2006/07

Table 3.9:      Expanded Programme on Immunisation key outputs -
                FY 2006/07
    Indicator                           Baseline       Target for
                                        FY 2005/06     FY 2006/07   Achieved   Comments
  HSSP II indicators
  Percentage of children <1 year                89%       87%         90%
  receiving 3 doses of DPT/pentavalent
  vaccines
  Central level programme performance indicators
  Quarterly performance reports                  1         4           1
  Technical programme meetings                   3         12          5
  Technical support supervision to               2         4           2
  districts
  District level (Service delivery level) indicators
  Fully immunized children                      41%       64%        * 46%
  Measles coverage                              91%       87%         88%
  Reduction of DPT 1 –3 drop out rate           16%       11%         11%
* Results of UDHS 2006

•     The GoU continued to contribute 100% towards the procurement of
      the BCG, OPV, TT and measles routine immunization vaccines and
      their related injection safety materials. DPT-HepB + Hib vaccines are
      being provided by GAVI in-kind.
•     Carried out monthly delivery of vaccines, injection safety materials,
      gas and other EPI logistics to the districts. The districts and HSDs


                                                                               67
   distribute the logistics to the health facilities that carry out
   immunization at static and outreach sessions.

Box 3.4:     Comparison of data from various sources




Diseases targeted for eradication and elimination

Polio eradication
There has been no reported case of wild poliovirus infection since 1997
due to the concerted efforts of the GoU, Development Partners and
NGOs. The African Regional Certification Commission (ARCC) declared
Uganda polio-free in October 2006. The polio surveillance indicators
have remained above the target with the Non-Polio AFP rate of 2.11.

Measles Control
A decline in measles cases was realized following the successful
implementation of the under-15 mass measles campaign in 2003. An
upsurge in the number of confirmed measles cases was observed at the
beginning of the financial year. Most of the affected children were below
5 years and were un-immunized. In response, a nationwide measles
campaign targeting children 6 months to 5 years was implemented in
August – November 2006 and nationwide coverage of 99.5% was
achieved. There has been a decline in the reported measles since the
campaign.

Maternal and Neonatal Tetanus Elimination
The programme has been implementing the 5-year MNT elimination
strategic plan since 2002. The strategy involves carrying out 3 rounds of



                                                                      68
TT mass vaccination targeting WCBA (13 – 49 years) in high-risk districts
with the target of 80% coverage in each round. The mass vaccination was
carried out in 3 phases and was concluded with the implementation of
the 3rd round in the nine 3rd phase districts in November 2006. A decline
in neonatal tetanus cases has been observed since UNEPI started
implementing the strategic plan as shown in Figure 3.3 below.

Figure 3.3: Reported NNT cases by year in Uganda, 2002 – 2007

                   800


                                 1st SIAs
                   700
                           667


                   600


                                                          2nd SIAs
                   500
      # of cases




                   400                      406

                                                                           3rd Phase
                   300

                                                    258

                   200

                                                                     158
                                                                                 143

                   100

                                                                                         44

                    0
                         2002         2003        2004           2005         2006     2007
                                                          year


                         (Source HMIS)

Major Challenges/Constraints

Inadequate funding for UNEPI operational activities both at the national
and district levels which has resulted in;
• Irregular delivery of vaccines and other logistics from the center to
   districts leading to vaccine shortages.
• Uneven distribution of vaccines and supplies from districts to lower
   level health facilities.
• Irregular functioning of outreaches.
• Lack of support supervision from center to districts and from districts
   to lower levels.
• Lack of regular cold chain maintenance at all levels leaving some
   fridges not functioning.

This has further been compounded by the creation of new districts that
need new infrastructure to be set up.

       d).               Nutrition




                                                                                              69
Nutrition is a crucial, universally recognized component of the child’s
right to the enjoyment of the highest attainable standard of health as
stated in the Convention on the Rights of the Child. These rights have
however not yet been realized in many environments. Malnutrition has
been responsible directly and indirectly for 34 percent of the 6.2 million
deaths annually among children under five. The overall objective of
Nutrition Programme therefore is to improve the nutritional status of the
population with emphasis on the vulnerable groups of the children and
mothers. Nutrition is a cross cutting programme and therefore
collaboration and partnership with UN agencies, various relevant
ministries and departments, NGOs, Industries, University Departments
and other bodies in the implementation of activities is crucial.

Achievements during FY 2006/07
Table 3.10: Nutrition key outputs - FY 2006/07
 Indicator                                 Baseline     Target FY
                                           FY 2005/06   2006/07     Achieved     Comment
 Central level programme performance indicators
 Quarterly performance reports                   1          4            1
 Technical programme meetings                    3          12           4
 Technical support supervision to                1          4            1
 districts
 District level (Service delivery level) indicators
 Increase the prevalence of exclusive                               61% (UDHS
                                               62%         64%
 breastfeeding                                                        2006)
 Reduce the prevalence of underweight                               16% (UDHS
                                             23%           20%
 among under fives                                                    2006)
 Increase Vitamin A supplementation
                                             37%           70%         60%
 uptake for 6-59 months
 Attain and sustain 100% household
                                            94.8%         100%       Over 95%
 consumption of iodized salt


Infant and Young Child Feeding
• Efforts were made to streamline the implementation of Infant and
   Young Child Nutrition especially in co-ordination and integration of
   the various component activities with other programmes such as
   PMTCT and Reproductive Health. The programme has consequently
   made some progress especially in improving the skills of health
   workers in counseling women on feeding infants 0-6 months both
   under normal circumstances and when affected with HIV/AIDS.
• Reviewed the policy on feeding infants and young children in the
   context of HIV/AIDS to include all the aspects of Infant and Young
   Child Feeding.
• Revised guidelines on the management of severe malnutrition to
   include HIV/AIDS and Community Therapeutic Care (CTC).
   Researches in the African region including Uganda have shown that
   management of uncomplicated malnutrition (about 75%) is feasible in
   the communities through an innovative approach involving highly
   fortified, Ready to Use Therapeutic Feeds (RUTFs). A training manual



                                                                                70
    on managing malnutrition has been developed to accompany the
    guidelines.
•   Regularly conducted Nutrition Surveys in northern, eastern and the
    Karamoja region. The levels of malnutrition have reduced
    considerably although the living conditions in the camps are still
    poor. The assessment results have been used to revise and re-
    calculate food rations, as well as improve on the health and nutrition
    related interventions and for advocating for other non-food
    interventions.
•   Successfully celebrated the 2006 World Breastfeeding Week whose
    theme was “Regulate the Marketing of Infant Foods: Protect,
    promote and support breastfeeding”. Several activities were carried
    out at both national and district levels to mark the event. The aim of
    WBW is to advocate for the implementation of interventions to
    promote appropriate infant and young child feeding practices at all
    levels.

Prevention and Control of Micronutrients Deficiencies
• In collaboration with Uganda National Bureau of Standards (UNBS)
   and Uganda Revenue Authority (URA), the Ministry of Health has
   successfully sustained the programme of Universal Salt Iodation. This
   is evident from a number of border monitoring exercises of nine
   districts namely; Rakai, Kisoro, Kabale, Kasese, Masindi, Hoima,
   Tororo, Busia and Nebbi. The use of adequately iodized salt by
   households remains at 95%.
• The proposal submitted to Global Alliance for Improvement of
   Nutrition (GAIN) was successful and the grant has been awarded.
• Held the Iodine Deficiency Disorder (IDD) awareness activities at both
   the national and district levels. The climax of the activities was a
   national event in Tororo District. Other activities included Press
   Conference, media personnel sensitization meeting of 30 people, Film
   van shows
• Developed and distributed various IEC materials during Child Days
   Plus

Challenges/Constraints
• Inadequate prioritization of nutrition activities in the district health
  plans resulting in inadequate funding for nutrition activities
• Inappropriate deployment of Nutritionists to Regional Referral
  Hospitals and not at the district. This limits their work to mainly
  clinical services and leaves a gap in public health nutrition
  interventions.


3.3      Prevention and Control of Communicable Diseases

Uganda’s disease burden is mainly due to communicable diseases. HSSP
II therefore prioritized the prevention and control of communicable
diseases in order to reduce the high national disease burden. The


                                                                       71
priority health care interventions being implemented in HSSP II to
prevent and control communicable diseases include; Prevention and
Control of STI/HIV/AIDS, Prevention and Control of Malaria, Prevention
and Control of Tuberculosis and elimination and/or eradication of some
particular diseases such as Leprosy, Guinea Worm, Onchocerciasis,
Trachoma, Lymphatic Filariasis, Trypanosomiasis and Scistosomiasis.

3.3.1 Prevention and Control of STI/HIV/AIDS

HIV/AIDS continues to pose serious public health and development
challenges in Uganda. The implementation of HIV/AIDS and STDs
programme continued to be challenging because HIV/AIDS remains a
complex disease and incurable, while STDs are becoming complicated by
the herpes simplex virus type 2 (HSV-2) which has contributed to HIV
infection. During FY 2006/07, there was an increase in new HIV
infection of 120,000 individuals. The scale up of universal access to
antiretroviral treatment had a noticeable improvement in reducing AIDS
related morbidity and mortality. The stagnation of HIV prevalence
continued.

Achievements during FY 2006/07
Progress was made in implementation of the following interventions:
Table 3.11: HIV/AIDS key outputs - FY 2006/07
Indicator                                  Baseline     Target FY
                                           FY 2005/06   2006/07     Achieved    Comment
HSSP II indicators
Urban/rural specific HIV sero-prevalence         6.4%
rats
Central level programme performance indicators
Quarterly performance reports                      1        4           1
Technical programme meetings                       4        12          4
Technical support supervision to districts         2        4           4
Proportion of districts with at least one
                                                 100%     100%        100%
PMTCT site
District level (Service delivery level) indicators
Proportion of health facilities from HC III
                                                                       42%
and above that are providing HCT
Proportion of health facilities from HC IV
                                                                       57%
and above that are providing ART
Proportion of health facilities from HC III
                                                  32%      40%         45%
and above that are providing PMTCT.
Proportion of new ANC clients tested for
                                                  58%      70%         79%
HIV
Proportion of expected pregnant women
                                                  24%      35%         40%
tested for HIV during pregnancy
Proportion of expected        HIV positive
pregnant women who received ARVs for              19%      30%         36%
PMTCT
Proportion of HIV positive pregnant
                                                  70%      70%         78%
women given ARVs for PMTCT




                                                                               72
Information, Education, Communication and Behaviour Change
Promotion (IEC/BCC)
•   Developed, printed and disseminated the HIV/AIDS handbook for life
    planning skills for health educators
•   Developed and pre-tested IEC/BCC materials for ART advocacy (4
    posters & 2 leaflets). This awaits printing and dissemination.
•   Disseminated HIV prevention road map in South Eastern and
    Western regions to 50 district leaders
•   Conducted film shows in 15 selected districts with fishing
    communities to sensitize them on HIV prevention messages.
•   Printed and distributed 5,000 leaflets, 5,000 posters for TB/HIV
    collaborative activities to districts of Northern Uganda.
•   Airing of TV spot, Talk show as well as Radio spots to inform the
    public about measures taken to ensure quality of all condoms in the
    country including the re identified “Engabu”.
•   Production and dissemination of Video on Condom testing in Uganda.
•   Production and distribution of 1,000 “Support ABC for prevention”
    bags for Community Condom distributors
•   Carried out assessment of condom availability, distribution, storage
    status in 35 districts
•   Trained 60 district condom focal persons in logistics management
•   Trained 175 trainers for Community Condom distributors in 7
    districts ie Nakapiripirit, Kabale, Kasese, Arua, Pader, Mayuge and
    Masaka.
•   Training 840 community condom distributors in 6 districts i.e.
    Kabale, Kasese, Arua, Pader, Mayuge and Masaka.
•   Printing of 500 copies of the National Condom distribution guidelines
•   Distributed 85 million public sector condoms through National
    Medical Stores

Prevention of Mother to Child Transmission of HIV (PMTCT)
• Continued scaling up and strengthening of PMTC programme with
   particular focus on strengthening postnatal care. Table 3.8 shows the
   proportion of health facilities by level providing PMTCT services.

Table 3.12: Health facilities providing PMTCT by level.

Health facility level   Total   Coverage (2006)   Coverage by June 2007

Hospital                101        95(94%)               98(97%)

HC IV                   165        143(87%)             151(92%)

HC III                  905        183(20%)             258(29%)

HC II                   1887          32                   61


•   The quality of PMTCT services has greatly improved across many
    districts. The number of health facilities providing routine HIV
    counselling and testing for pregnant women increased, raising HIV
    test uptake from 70% of all clients attending ANC at health facilities


                                                                          73
    providing PMTCT in 2005/06 to 80% in 2006/07. Figure 3.4 shows
    trends in uptake of PMTCT services. In addition missed opportunities
    in administration of antiretroviral drugs to HIV positive mothers has
    greatly reduced; 81% of all clients diagnosed HIV positive are given
    ARVs as opposed to 58% of clients tested HIV positive in the period
    Jan – June 2006

Figure 3.4: Trends in uptake of PMTCT services 2004 – June 2007

                 100

                                                                            95
                                                             93
                 90
                                  86          87

                 80                                                         81
                                                                            80
                          78
                                                             76
                                                             75
                                  72
                 70                           70

                          63      64
                 60
                                              58
                          56                                                           ew
                                                                                    % N ANC counselled
    Percentage




                                                                                    % of New ANC tested
                 50
                                                                                       IV
                                                                                    % H + given ARVs
                                                                                    % Baby given ARVs
                                  42          41             42             41
                 40

                          33
                 30


                 20



                 10


                  0
                       2004    2005    Jan - Jun 06   Jul - Dec 06   Jan - Jun 07




•       Developed PMTCT policy and clinical guidelines based on the New
        WHO recommendations.
•       Developed and launched the ‘National Guidelines for Implementation
        of Family support groups in Prevention of Mother to Child HIV
        Transmission.
•       Developed and printed Guidelines for Health workers for Early HIV
        Diagnosis and Care among Infants
•       Launched guidelines for nutrition among people with HIV/AIDS –
        (‘improving the Quality of Life through Nutrition: A guide for Feeding
        People Living with HIV/AIDS).
•       Finalised the PMTCT Training package i.e. The facilitator and
        participant manuals for ‘Training Health Workers on Strategies for
        Prevention of Mother to Child HIV Transmission – December 2006).
•       Developed, printed and now disseminating data collection registers
        (integrated antenatal register, delivery register and postnatal
        register). This allows for integrating routine reproductive health data
        and HIV/AIDS services.



                                                                                        74
HIV Counselling and testing
•  Successfully rolled out Routine Testing in the clinical settings (RCT)
   starting with the Regional Referral Hospitals. Table 3.13 shows HCT
   coverage by health facilities levels in FY 2006/07.

Table 3.13: HCT Coverage by Health facility levels in 2006/07

Level of     Total no. in   No. of HCT    % coverage   No. of HCT
Health           the        sites as of    in 2006     sites as of   % coverage in
facility      Country       June 2006                  June 2007         2007
Hospitals        101           101           100          101            100
HC4              152           142           88           152            100
HC3              799           137           17           259             30

•   Finalized the HCT Policy Implementation Guidelines
•   Integrated HIV Counselling and Testing data into the HMIS
•   Developed HCT training standards

Control of Sexually Transmitted Diseases/Infections
•  Trained 60 district STD trainers from 10 districts.
•  Supported 10 condom outlet points for the most at risk populations
   (Commercial sex workers, Fishing communities and long distance
   truck drivers stop areas)
•  Continued with the on-going community surveillance study on HSV2
   in Kawempe division - Kampala District.
•  Introduced and provided RCT (routine counseling and testing) to
   6,000 clients at the national STD/Skin clinic.

Infection Control (Universal Precautions)
• Carried out auditing of infection control and injection safety practices
   in 4 districts of Jinja, Kamuli, Kayunga and Kampala covering 24
   health sub districts.
• Sensitised 60 members of the District Health Management Teams and
   District leaders in Kamuli on infection prevention and injection safety.
• Developed post exposure prophylaxis (PEP) policy and implementation
   guidelines. Drafts are available awaiting printing and dissemination.
• Trained 20 Home Based Care trainers in infection control, PEP and
   injection safety at Health units and community level.

Comprehensive HIV/AIDS Care
• Sustained the increase in the number of persons receiving ART since
  the launching of universal access in 2003. The increase has been
  slow in children due to difficulties in administering peadiatrics
  formula, early identification of children with HIV (diagnosis) and
  capacity of health care providers to manage peadiatric HIV/AIDS.
  Figure 3.5 shows the trends in the number of persons on ART since
  2003.


                                                                                75
Figure 3.5: Trends in number of person on ART – 2003 - 2007

                       Trends of patients on ART (Children <14 yrs Vs. Total -2003-
                                                  2007)

                 120,000


                 100,000


                  80,000
    No. on ART




                  60,000


                  40,000


                  20,000


                      0
                           2003 Dec 2004 June 2004 Dec 2005 June 2005 Dec 2006 June 2006 Dec 2007 April

                                                    Total on ART    Children <14yrs



•        The number of health facilities accredited for providing ART increased
         from 212 by June 2006 to 306 health facilities by end of June 2007
         as shown in Table 3.13. Sites offering ART include two National
         referral hospitals, 11 regional referral hospitals, 97 HC IVs , 29 HC
         IIIs, 54 clinics and 106 hospitals (including both NGO and
         government hospitals).

Table 3.14: Number of Health Facilities accredited for providing
            ART in 2006 and 2007
                                                          Coverage by June       Coverage by June 2007
Health facility level                       Total
                                                              2006 (%)                    (%)
National referral                             2                2 (100%)                 2 (100%)
Regional referral                            11               11 (100%)                 11 (100%)
Other hospitals                              88                76 (86%)                 88 (100%)
Health centre IV                             165               66 (40%)                 97 (59%)
Health Center III                            905                   3                        29

Quality of Care

Quality Assurance
• Rolled out a countrywide Quality Improvement programme to ensure
  that health workers provide HIV care and treatment according to set
  standards. This has been done in collaboration with Quality
  Assurance Project (QAP). The programme activities which initially
  started in 57 health facilities have now been expanded to cover 87
  facilities in all the districts in the country.
• A steering committee, a core team and regional coordinators have
  been appointed to facilitate the smooth running of these activities.


                                                                                                76
    Ministry of Health formulated a set of Quality Improvement objectives
    and indicators for this programme.

Quality Improvement
• Successfully piloted the Continuous Quality Improvement (CQI)
  approach in 20 health facilities through coaching and mentoring
  clinical teams to build their capacity in quality management to
  provide improved quality of care. This was initiated through a
  partnership between the Ministry of Health and CDC.

Home Based Care
• Developed national HBC policy guidelines
• Support supervision of 2 districts to strengthen human capacity at
  district level to improve on quality of HBC services.
• Trained 60 HBC Trainers of trainers in HBC in 10 districts

HIV/AIDS/STI Surveillance,          Monitoring     and    Evaluation    and
Operations Research

•   Updated the protocol for conducting ANC and STD clinic based HIV
    surveillance.
•   Trained 47 sentinel surveillance site staff from the 25 sentinel sites in
    the updated protocol for conducting ANC and STD clinic based HIV
    surveillance.
•   Conducted the 2006 ANC and STD clinic based HIV surveillance in
    the 25 sentinel sites. The process of testing blood samples, data
    analysis and report writing is on going.
•   Continued to disseminate the 2004-05 National HIV Sero-Behavioral
    survey at regional levels.
•   Conducted the integrated support supervision in 45 districts
    considering all the components of the national response to
    HIV/AIDS/STD.
•   Provided on site support to strengthen district level M&E of health
    sector interventions in 16 districts.
•   Trained 50 M&E focal persons from 30 districts in Monitoring and
    Evaluation of HIV/AIDS activities in districts with M&E gaps.
•   Completed and disseminated the KABP survey report on
    STD/HIV/AIDS for fishing communities Wakiso district.

Challenges/Constraints

•   Weak district capacity in implementing the health sector response to
    HIV prevention, care and treatment leading to slow scale up of
    activities at all levels of service delivery:
        o Delay by Ministry of Public Service to establish counselors`
            cadre.
        o Inadequate number of staff at facilities compared to workload
            comprising the quality of services.
•   High attrition rate of trained skilled health care providers especially



                                                                          77
    doctors in comprehensive HIV care activities including ARV.
•   Weak supply chain management system leading to frequent stock
    outs of health commodities in health facilities particularly ARVs,
    Testing kits, laboratory consumables and Condoms. This has also led
    to expiry of some commodities at national and district level.
•   Coordination of partners involved in HIV prevention, care and
    treatment is becoming difficult as more sites get accredited for ART.
    The National Coordination Committee has not been functional due to
    lack of funds and the District Health Officers have not been able to
    coordinate HIV activities among partners.
•   Weak monitoring system for HIV activities resulting from poor
    documentation and reporting by facilities, lack of data from ANC
    surveillance sites and poor reporting to the ministry by partners (Both
    PPF and PNPF).
•   Inadequacies in diagnostic equipment especially CD4 machines at
    hospitals many of which have broke down.
•   Bad image of “Engabu” still lingers on after the quality issues of 2004.
    This necessitated the borrowing of “Lifeguard” name for one year. Re-
    branding process for a new public sector Condom is in progress.
•   Procurement of condoms has not been timely which leads to limited
    stock and procurement of condoms through Emergency arrangements
    with development partners.


3.3.2 Tuberculosis Control

The burden of Tuberculosis is still high. Globally, 1/3 of the World
population is infected with TB with 9 million new cases and 2 million
deaths annually. Nationally, a total of 80,000 new cases are expected
annually. In 2006, a total of 41,927 cases were notified. The mission of
the National Tuberculosis Control Programme therefore is to reach the
Global targets of Case Finding and Treatment success by 2010 and
Integrate Leprosy services at HC III level countrywide by 2010. The
intervention strategies of TB control are tailored along the Global STOP
TB Plan, the Expanded DOTS strategy, MDG Goals, Abuja Declaration,
Maputo Declaration, and Leprosy elimination strategy.

Achievements during F 2006/07

Table 3.15: Tuberculosis control key outputs - FY 2006/07
Indicator                              Baseline FY   Target FY
                                       2005/06       2006/07     Achieved    Comments
HSSP II indicators
Proportion of Tuberculosis cases notified  50.3%        65%        49.6%
compared to expected (CDE)
Proportion of Tuberculosis cases that are  70.4%        80%        73.2%
cured (successfully treated).
Central level programme performance indicators
Quarterly performance reports                1           4           2
Technical programme meetings                 2           12          6
Technical support supervision to districts   4           4           4



                                                                            78
CB-DOTS coverage per district                    100%                                    100%                 100%
District level (Service delivery level) indicators
Proportion of TB patients offered                 40%                                     60%                  75%
Counseling and testing per district
Proportion of deaths among newly                 6.2%                                     3.1%                6.6%
registered smear positives per quarter

    • Trends of Tuberculosis notification in Uganda:
The number of Tb cases notified is still high but seems to have stabilized
at around 42,000 cases as shown in Figure 3.6. This however is still a
low detection rate of 49.6% in 2006.

Figure 3.6: Number of TB cases notified
                Thous ands
         50

                         All cases
         40              AFB +
                         AFB-
                         EPTB
         30


         20


         10


          0
                74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 00 01 02 03 04 05 06
              19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 20 20 20 20 20 20 20

           Source: WHO update / Quarterly case finding reports, Uganda NTLP


Achievements during FY 2006/07

    •   Expanded Community Based TB care with Directly Observed
        Treatment with Short Course (DOTS) drugs to all districts in the
        country.
    •   Treatment success rate increased from 70.4% in 2005/06 to
        73.21% while Case detection stayed at 49.6%. Figure 3.7 shows
        the TB treatment outcome for the whole country of those
        registered in 2005.

Figure 3.7: TB treatment outcome




                                                                                                                     79
                                                                                                  Treatment Success
                                                                                                  Died
                                                                                                  Failed
                                                                                                  Defaulted
                                                                                        5         Transferred



      73.2

                                                                                               15.6



                                                                                         0.4
                                                                                      5.7




       Source: WHO update/Quarterly treatment outcome reports, Uganda NTLP (   Kampala City included )



•   Procured and distributed 300 motor-cycles to strengthen community
    supervision of TB and Leprosy interventions in the districts.
•   Procured and distributed ample fixed dose combination anti-TB
    medicines and laboratory reagents supplies countrywide.
•   Developed and operationalized countrywide a new Distribution and
    Tracking systems for medicines, reagents and supplies.
•   Produced a modular Training Manual and Job/Desk Aide to
    standardize training, practice and Care. Conducted various refresher
    training of in-service health care workers at national and district
    levels.
•   Established a national Coordination Committee for TB/HIV activities,
    drew a TB/HIV Policy, Communication strategy and Implementation
    Guidelines. A separate TB Communication strategy was also drawn
    during the year. The Policy and Communication documents were
    launched in 2006.
•   Implemented the Intensified Support and Action Countries (ISAC)
    Initiative by appointing 2 National Professional Officers (NPOs), 3
    Assistant Professional Officers (ANPOs) in WHO-Country office to
    boost CB-DOTS implementation. This has resulted in 100% coverage
    of all districts. A Logistics/Administrative Officer was posted to the
    Central Unit of NTLP.
•   Secured funding for physical rehabilitation and strengthening of
    External Quality Control (EQA) of the National Reference
    TB/Laboratory. All zones except Karamoja have been covered with
    improved performance of the laboratory network.
•   Conducted operational research on Integrating TB and HIV care in
    VCT services in Nsambya hospital. This approach facilitates
    comprehensive screening for both TB and HIV for easy access to
    DOTS, Isoniazid Preventive Therapy (IPT) and ARVS. The IPT has now
    been expanded to AIC centres in Kampala, Mbarara, Mbale and Jinja.




                                                                                                                      80
            World TB Day “TB Anywhere is TB Everywhere” Mpigi District
                                24th March 2007

    Challenges/constraints

•   Understaffing at Central Unit and in health units especially shortage
    of laboratory personnel limits the diagnostic capacity for TB.
•   The position of District TB and Leprosy Supervisors (DTLS) was
    removed during the Local Government restructuring exercise. The
    personnel working as DTLS are therefore not full time and this lowers
    the quality of support supervision to units.
•   Districts do not budget and allocation enough funds for TB and
    Leprosy control activities.
•   Flow of funds to and within districts is slow and this makes it hard
    for the DTLSs and Sub-County Health workers to complete their
    quarterly monitoring on time.
•   Inability of the health system to capture information of patients who
    go to purely private units.
•   Multiple Drug Resistance (MDR) Tuberculosis is on the increase. Data
    on culture and sensitivity testing from the National Reference
    Tuberculosis Laboratories over the period January – September 2007
    showed 15 cases of MDR out of 640 tested (2.3% among both new
    and re-treatment cases of tuberculosis) compared to 14 patients FY
    2005/06.


3.3.3 Prevention and Control of Malaria

Malaria remains one of the most dangerous diseases in Uganda with
respect to morbidity and mortality burden, as well as economic losses.



                                                                         81
Malaria contributes about 30 – 50% of outpatient burden and 35% of
hospital admissions. The goal of Malaria Control Programme therefore is
to control and prevent malaria morbidity and mortality, as well as to
minimize social effects and economic losses attributable to malaria. In
order to achieve this, the malaria control programme endeavours to go to
national scale with a package of effective and appropriate interventions,
attaining high coverages and promote positive behaviour change so as to
prevent and treat malaria in the country. The mainstay of intervention
strategies for malaria includes: Prompt and effective case management at
facility, community and household levels; Use of insecticide treated
mosquito nets; Indoor residual spraying with efficacious insecticides;
Environment management where feasible; Intermittent preventive
treatment in pregnant women; as well as Epidemic preparedness and
response.

Achievements during FY 2006/07

During FY 2006/07, key achievements were noted in IPT2 coverages,
promptness in treatment of children with a fever, ITN coverages and IRS
consolidation and expansion. Table 3.16 shows performance against key
indicators of health sector performance.

Table 3.16: Malaria Prevention and Control key outputs - FY
            2006/07
Indicator                              Baseline      Target
                                       FY 2005/06    FY 2006/07   Achieved        Comment
HSSP II indicators
Proportion of children under 5 years       60%           80%         71%          Data based on 4
with fever who receive malarial                                                   surveyed districts
treatment within 24 hrs from a                                                    (Rakai, Kumi,
community drug distributor                                                        Hoima & Apac)
% of fever/uncomplicated malaria
cases (all ages) correctly managed
at health facilities
Proportion of pregnant women               31%           60%         42%
receiving a complete dose of IPT2
                                             37%         50%        35%*          Incomplete data
Percentage of house holds with at                                                 figure based on
least one ITN                                                                     quarters 1,2&3.
Central level programme performance indicators
Quarterly performance reports                 1           4           1
Technical programme meetings                  2           12          4
Technical support supervision to              2           4           2
districts
Number of districts in epidemic               1
prone areas covered by IRS
District level (Service delivery level) indicators
Proportion of children under 5               15%
having slept under an ITN the
previous night




                                                                             82
Effective Case Management

This strategy is mainly through health facility and community based
channels.

Community channel
• Consolidation of the Home Based Management of Fever strategy
  (HBMF) in districts through retention of Community Medicines
  Distributors (CMDs) and treatment or referral of patients by CMDs as
  shown in Table 3.16. There was also piloting of ACTs at community
  level in 5 districts (Kitgum, Gulu, Pader, Amur and Kiboga).

Table 3.17: HBMF performance in 4 selected districts (FY 2006/07)

 Indicator                   Apac   Hoima     Kumi      Rakai   Average

 % CMDs still active         75%     72%      75%       76%       75%

 % patients treated by CMD
 who received Homapak        70%     70%      76%       63%       70%
 within 24 hrs
 % patients treated or
 referred by CMDs who        94%     91%      95%       96%       95%
 recovered


Health facility channel
• Rolled out use of ACTs in facility based malaria case management in
  the whole country through procurement, distribution, capacity
  building (84% training coverage), distribution of guidelines, as well as
  follow up support supervision.
• Trained private practitioners across the country.
• The programme has started registering a decline in malaria morbidity.
  Figure 3.8 shows the trend of outpatient malaria cases from 1999 to
  2006. There is a 39.3% reduction in the total outpatient cases (9.9
  million cases in 2006 compared to 16.3 million cases of the year
  2005). The reduction could be due to roll out of new malaria
  treatment policy change to ACTs (Coartem), the introduction of IRS in
  Kabale dstrict and the slight increase in ITN coverage.

Figure 3.8: Trends in Malaria morbidity – 1999 - 2006




                                                                          83
                                               Uganda;Trend of malaria OPD Cases over the years (HMIS DATA)

                   18,000,000


                   16,000,000


                   14,000,000


                   12,000,000
 Number of cases




                   10,000,000
                                                                                                                                    Series2
                    8,000,000                                                                              16,321,582



                    6,000,000                                                                 12,197,533
                                                                                 11,260,686
                                                                     9,791,014                                          9,901,882
                                                        8,966,564
                    4,000,000

                                5,247,359   5,470,361
                    2,000,000


                           0
                                  1999        2000        2001         2002         2003        2004          2005        2006
                                                                       YEARS (1999-2006)




Intermittent Preventive Treatment of Malaria in Pregnancy

This strategy aims at achieving a high coverage of intermittent preventive
treatment of pregnant women with at least 2 doses of sulfadoxine-
pyrimethamine (SP) in the 2nd and 3rd trimesters under direct
observation. The following was achieved:
• Reduction in stock outs of SP within health facilities;
• Increased facilitative supervision and peer mentoring in 24 districts;
• Rolled out standardized recording and monitoring of IPT data through
    pre-printed antenatal registers in 4 districts. The overall coverage of
    IPT2 increased from 31% in 2005/06 to 42% in 2006/07.




                                                                                                                          84
                      Africa Malaria Day “Free Africa from Malaria Now – Roll Back Malaria”
                                       Sembabule District 25th April 2007

ITN Promotion

•           There was a boost in distribution of nets from GFATM and PMI
            initiatives (1.8 million and 840,000 nets respectively) where 44%
            (427/971) sub counties benefited. All districts (80) benefited from
            GFATM nets, while 37 benefited from PMI nets. This resulted into
            approximately 42% ITN coverage among under-five children,
            compared to 32% coverage in 2005/06
•           Greater shift from distribution of untreated nets to long lasting nets
            (LLINs). It is estimated that 40% of nets in the country are long
            lasting nets. There was placement of ITNs at Antenatal, young child
            and HIV clinics to mop up the target groups.
•           Carried out the 3rd round of net re-treatment exercise in the same
            year, which realized an increased of 84.8% coverage as shown in
            Figure 3.9 below in the 19 targeted old districts (now 32 new
            districts).

Figure 3.9: Number of nets re-treated
                                                   Number of nets re-treated in 32 districts
                                                                                     net treated
            525,000


            520,000                                                                                     517,777

            515,000


            510,000


            505,000
    N ber




            500,000
     um




            495,000
                                                                    490,855
            490,000
                                  486,233
            485,000


            480,000


            475,000


            470,000
                             2004/05 (1st round)               2005/06 (2nd round)                 2006/07 (3rd Round)
                                                                     Period




Indoor Residual Spraying

The objective of strategy is to improve the quality and coverage of IRS in
epidemic prone and endemic districts as well as IDP camps. There was
consolidation and extension of IRS in districts of Kabale, Kanungu,
Kitgum, and Pader as shown in table 3.18 below




                                                                                                                         85
Table 3.18: IRS performance in selected districts
Key IRS indicators                                                    Kabale                Kanungu                  Kitgum                       Pader
                                                                      2nd Round             1st Round                1st Round
Total target houses found                                             78,020                44,799                   88,849                       141,754
Total structures sprayed                                              76,084                45,321                   84,007                       138,458

% of targeted houses partially and fully 97.5                                               100                      95                           97
sprayed
Total population protected               364,784                                            191,399                  371,846                      538,752

Number of children < 5yrs protected                                   60,698                36,222                   86,811                       138,605

Number of pregnant women protected                                    6,022                 5,580                    14,709                       30,339



All these resulted into rapid decline of malaria case admissions and
malaria parasitaemia as per blood smear tests as shown in Figure 3.10
below.

Figure 3.10:              Malaria-positive Blood Smears, Kihihi HC IV,
                          Kanungu District Aug 06-June 07

         2000                                                                19 6 2
                                                                                                             total blood smears
         18 0 0
                                                                                                             malaria-positive blood smears
         16 0 0


         14 0 0

                                                                                                          118 8
         12 0 0                                                                              1115
                                                           10 6 1
         10 0 0                              9 10                                     881
                                                                       844
                                78 7                                                                                     79 1
          800


          600     53 8                                                                                                               53 5
                                                                                                    436
                                                               3 76                                                                               4 17
          400                                                                325                              3 17

                                                                                        IRS-Icon
                                       241          2 13
                         19 2
          200                                                                                                                   82
                                                                                                                                            43           43
             0




                                             2006                                                                 2007




o   NEMA approved the use of DDT in IRS in December 2006. Policy and
    implementation guidelines for IRS using DDT have been finalized.

Malaria Operations Research

•   Carried out pilot Malaria Rapid diagnostic tests in 5 districts.
•   Evaluated the efficacy of Artemether - Lumefantrine and artemether-
    piperaquine Artemther Nephthaquine ACTs.



                                                                                                                                             86
Results show the high efficacy of the three drugs and the usefulness of
the new diagnostic tests (RDTs).

Challenges/constraints
• Delayed procurements of bicycles for Community Medicine
  Distributors
• Poor supply management of Coartem leading to artificial shortages in
  mainly rural health facilities
• Inadequate and ineffective Monitoring & Evaluation systems to
  measure the impact of scaled up interventions;
• Inadequate Infrastructure and supply management systems;
• Lack of proper disposal mechanisms of the expired HOMAPAK


3.3.4 Veterinary Public Health

The mandate of Veterinary Public Health is to reduce the burden of
zoonotic diseases and animal related food borne infections and ill-health
to a level that they are no longer of significant public health importance
in the country. This is important because a number of the newly
emerging and re-emerging human infections currently threatening global
public health are of animal origin (e.g. Avian influenza/ Bird flu, Rift
Valley fever, Severe Acute Respiratory Syndrome (SARS), Mad Cow
Disease /Bovine Spongiform Encephalopathy and Viral Hemorrhagic
fevers such as Ebola and Marburg ). In addition, long established
zoonotic diseases like rabies, bovine tuberculosis, brucellosis, anthrax,
meat borne parasitic diseases such as cysticercosis and hydatidosis are
still of major public health concern in the country.

Achievements during FY 2006/2007

Table 3.19:            Veterinary Public Health key outputs –FY 2006/07
                                       Baseline          Target for     Achieved       Comments
    Indicator                          FY 2005/06        FY 2006/07

    Central level programme performance indicators

    Quarterly performance reports            2               4              1
    Technical Programme meetings            N/A             N/A            N/A         VPH Unit has only
                                                                                       one technical officer
    Technical Support supervision to           6              6              4         Insufficient funds
    districts
    District level (service delivery level) indicators

    Number of suspected cases given        3,750            8,000         5,500        Increased cost of
    rabies post-exposure treatment                                                     rabies vaccine
    Reporting of suspected Avian &           0           80 districts   80 districts   Weekly IDSR
    pandemic influenza cases                                                           reporting

•     Developed guidelines on rabies Post Exposure Treatment (PET) and
      vaccine allocation criteria




                                                                                           87
•   Procured a total of 9,600 vials of human rabies vaccine for Post-
    Exposure Treatment (PET) of human rabies at a cost of UShs. 199
    million and supplied them to districts. A total of 5,500 people received
    post-exposure treatment against the disease.
•   The National Plan of Action on Avian influenza (NPA/AI) for promoting
    multi-sectoral collaboration and coordination with other sectors was
    finalized and approved by Cabinet in February 2007.
•   Procured 1,000 doses of Oseltamivir phosphate (Tamiflu) for use in
    Avian Influenza epidemics. Emergency stocks available at NMS with
    expiry date of 2010.
•   Developed capacity for laboratory diagnosis of influenza virus Type A
    H5 at UVRI, Entebbe
•   Established a National Influenza Centre at UVRI through Centers for
    Disease Control & Prevention USA/MoH collaboration which has
    enhanced epidemiological studies and operational research on
    influenza.
•   Sensitised 42 districts on National Plan of Action for Avian Influenza
•   Investigated over 200 suspected Avian Influenza/Bird flu outbreaks
    and /or rumours in birds and one in humans. All cases were found
    negative for influenza virus type A H5N1.
•   Trained a total of 96 hospital and district health teams staff from 12
    districts in Northern and North western Uganda on surveillance,
    monitoring and case management of Avian Influenza.
•   Printed and disseminated 3,000 copies of protocol and 6,000 folders
    with of Avian Influenza case definition and report forms.

Challenges / Constraints
• There is currently only one professional staff in the VPH Division, this
  should be improved through establishment and recruitment of more
  professional staff.
• Inadequate funding for the divisional activities
• Lack of reliable transport for field activities

3.3.5 Diseases targeted for elimination and/or eradication

Uganda is a signatory to international resolutions committed to the
elimination and eradication of particular diseases. The diseases targeted
for elimination include Leprosy, Guinea Worm, Onchocerciasis.
Substantial progress towards the elimination targets was registered
during HSSP I. HSSP II therefore continued to target these diseases and
support acceleration of their elimination and or eradication.

a)     Leprosy
Uganda achieved the WHO global target for elimination of leprosy as a
public health problem in 1994. HSSP II therefore aimed at maintaining
the required level of interest, skills, commitment and investment in
resources to sustain the elimination status. The burden of Leprosy was
423 (MB 293, PB 140) cases by December 2006 out of which 48 are
Children.


                                                                         88
Achievements during FY 2006/07
• Sustained the elimination rate of leprosy (prevalence rate of less than
  1/10,000 population) which was achieved in 1994 nationally.
• Detected and treated about 1900 new leprosy cases during the last 3
  years.
• Maintained a system for monitoring leprosy elimination at national
  and district levels.
• Maintained a regular supply of MDT (anti-leprosy treatment)
• Put in place a Programme for Social Economic Rehabilitation of
  people affected by leprosy (integrated with main stream rehabilitation
  services)
• Continued with rehabilitative services like foot wear, prostheses and
  Socio-Economic activities for persons affected by Leprosy in all the six
  national centres.
• Procured ample supplies of anti-Leprosy medicines and provided
  supplies for manufacture of rehabilitative materials by grants from
  the German Leprosy Relief Association – GLRA.

Challenges/Constraints:
• Implementation of leprosy control programme in a low endemic state
  is not cost effective (detection and management of a small continuing
  trickle of new cases is very expensive).
• Still experiencing stigma associated with leprosy in the community
• Low community awareness about leprosy in era of declining
  prevalence.
• Low awareness of health service providers on signs of leprosy and its
  management.

b).    Uganda Guinea Worm Eradication Programme
Uganda is still facing the challenge of re-infection with imported guinea
worm cases from the Sudan, which is still the most endemic country in
the world contributing about 60% of the current number of guinea worm
cases reported in the world. In view of this threat, the programme must
exist to ensure that guinea worm is not reintroduced in the country as
the certification process is on going. The objectives of the Guinea Worm
Eradication Programme are therefore to maintain zero transmission
status for indigenous guinea worm cases and contain 100% of any
guinea worm cases reported.Achievements during FY 2006/07

The targets for indicators of performance for Year two and the entire
HSSP II period for the programme have been fully achieved.

Table 3.20:      Guinea Worm key outputs - FY 2006/07
     Indicator            Baseline FY   Target FY       Achieved      Comments
                          2005/06       2006/07
     Central level programme performance indicators
     100% containment                   100% case       100% case     NCC in place
     of all imported      100% case     containment     containment   and preparing
     guinea worm cases    containment                                 the country for



                                                                       89
    No local           Zero           Zero transmission   Maintained     certification by
    transmission       transmission                       zero           ICCDE
                                                          transmission

Challenges/Constraints:
• Cross-border importation from the Sudan as a result of population
  movement across the common border. This challenge could delay
  early certification as guinea worm free country.
• Insecurity in Northern Uganda
• Inadequate funding in districts for surveillance, vehicle operations as
  well as maintenance of safe water sources due to misconception that
  guinea worm is already eradicated.

c)     Trachoma
HSSP II earmarked trachoma for elimination from the 18 affected
districts. This was to be achieved through implementation of the SAFE
strategy, both at national and district levels through mass community
distribution of Tetracycline and Azithromycin, training of Lid rotation
surgeons and provision of equipment, promotion of school facial hygiene
practices, family sensitisation and improved water supply through the
school health programme and capacity building in the communities and
schools to address the prevention and control of trachoma.

Achievements during FY 2006/07
• Conducted a survey on prevalence of trachoma in the districts of
  Kamuli, Kaliro, Namutumba and Iganga and disseminated the results
  to stakeholders.
• Developed the Training of Trainer’s Manuals for elimination of
  Trachoma, which is being implemented in several endemic districts.
• Developed IEC materials about prevention and control of trachoma
  and are already for printing and dissemination.

Challenges
  • Under staffing

d)     Human African Trypanosomiasis (Sleeping Sickness)
The programme on Human African TRypanosomiasis (HAT) provides
support to district health departments to carry out surveillance and case
management. There is done in close collaboration with the Veterinary
and Entomology sections of MAAIF through COCTU which is the
Secretariat for Uganda Trypanosomiasis Control Council established by
statute.

During FY 2006/07, the programme focus was directed at (a) providing
support to districts for surveillance and treatment (b) bringing on board
new outbreak districts (c) participating on efforts to halt the possible
merger and (d) providing support to ongoing clinical trials at Omugo HC
IV and Lwala Mission Hospital; and sample collection for the new
diagnostics study at Namungalwe HC III in Iganga District.



                                                                          90
Achievements during FY 2006/07:

•    Supplied drugs Suramin and MelB for T. b. rhodesiense and
     Pendamidine, MelB and DEMO for the gambiense infection to all
     treatment centres.
•    Sustained the surveillance on Sleeping sickness
•    Encouraged and supported districts to adopt the integration strategy
     with other programmes especially in obtaining reagents and supplies
     through the PHC fund.
•    Prepared and distributed guidelines on the management of T.b.
     rhodesiense infection to the South Eastern districts.
•    Provided support to new outbreak districts of Lira, Apac and
     Kalangala to establish treatment centres.

Challenges/Constraints
• The changing role of FITCA, from being a disease control project to
  more of an agriculture project, has implications for surveillance
  support to districts.
• Inadequate funding from government
• The recent re-allocation of Sleeping Sickness Assistants (SSAs) to
  other disease programmes is likely to have negative effects on HAT
  control in general.
• The slow take off of PATTEC is causing some concern to programme
  activities because it had been anticipated to bridge some gaps in HAT
  control.

e)      Schistosomiasis and soil transmitted helminths

The National Schistosomiasis and Worm Control Programme use the
strategy of mass annual antihelminthic treatment targeted at school aged
children and high risk communities using Praziquantel to treat
schistosomiasis and albendazole to treat intestinal worms in order to
control the morbidity due to the worms. Preventive measures focus on
raising awareness about Schistosomiasis and Soil Transmitted
Helminths and health education.

Achievements
• Treated over 1.2 million people annually for Schistosomiasis.
• De-wormed over 7 million people (mainly children) twice annually
   during Child Days Plus. As a result, morbidity due to Schistosomiasis
   and STH has been highly reduced.
• Awareness of the need for regular deworming has been raised in
   schools and in all endemic communities.

Challenges
• Under funding of Shistosomiasis and STH control from government.
  The programme continues to depend entirely (100%) on external
  donations, which raises issues of sustainability of the programme.




                                                                      91
f)     Onchocerciasis Control
Onchocerciasis (River Blindness) is a public health and socio-economic
problem in 28 districts of Uganda (Adjumani, Amuru, Arua, Bududa,
Buliisa, Bushenyi, Gulu, Hoima, Ibanda, Kabale, Kamwenge, Kanungu,
Kasese, Kibaale, Kisoro, Kyenjojo, Koboko, Manafwa, Maracha-Terego,
Masindi, Mbale, Moyo, Nebbi, Oyam, Sironko and Yumbe) where more
than two million people are at risk of acquiring the infection. The main
strategies being used to control the disease are community directed
treatment with ivermectin and vector elimination in isolated foci using
ground application of insecticide (Abate) in fast flowing rivers/streams
where the vector black fly breeds.

Achievements during FY 2006/07

Table 3.21:         Onchocerciasis Control key outputs - FY 2006/07
Indicator                          Baseline          Target FY
                                   FY 2005/06        2006/07        Achieved               Comment
Central level programme performance indicators
Quarterly performance reports               2             4                    1
Technical programme meetings                4             12                   6
Technical support supervision               4             4                    4
to districts
District level (Service delivery level) indicators
Maintain 100% geographical         100%              100%           100% geographical
coverage                           geographical      geographical   coverage maintained
                                   coverage          coverage
Maintain more than 75%             More than 75%     More than      More than 75%
therapeutic coverage               therapeutic       75%            therapeutic coverage
                                   coverage          therapeutic    maintained
                                   maintained        coverage
                                                     maintained

•   The vector black fly which was eliminated in Itwara focus covering the
    districts of Kyenjojo and Kabarole in 1997 has not been seen again in
    these districts.
•   The vector black fly which was eliminated in Mpamba-Nkusi focus in
    Kibale district since January 2007 has not been seen again.
•   More than 70% of Ugandans in affected communities have continued
    to receive an annual dose of ivermectin, with significant reduction in
    the prevalence of onchodermatitis, nodules and microfilariae carrier
    rates in some sentinel sites
•   Continued with the strategy of onchocerciasis elimination through
    semi-annual treatment with ivermectin in four foci namely: (1) Kigezi
    Bwindi focus covering Kabale, Kisoro and Kanungu districts; (2)
    Budongo focus covering Masindi, Hoima and Buliisa districts; (3) Mt.
    Elgon focus covering Mbale, Sironko, Bududa and Manafwa districts;
    (4) Kitomi-Kashoya focus covering Ibanda, Kamwenge and Bushenyi
    districts.

Major challenges



                                                                                   92
    •   Onchocerciasis control is heavily dependent on donor funding.
        There is an inadequate financial contribution from government to
        ensure sustainability.
    •   Inadequate health workers at all levels.


3.4         Prevention and Control of Non-communicable Diseases /
            Conditions

Uganda is experiencing dual epidemics of communicable and non-
communicable diseases. There is an increase in the incidence of
behavioral and physiological risk factors for non communicable diseases
in the population. The non-communicable diseases include the chronic
illnesses that are prolonged, do not resolve spontaneously, and are rarely
cured completely. The majority of NCDs are preventable through a broad
range of simple, cost-effective public health interventions that target NCD
risk factors. The priority health care interventions implemented in HSSP
II for addressing the non-communicable diseases include; Non-
communicable Diseases, Injuries, Disabilities and Rehabilitative Health,
Gender-Based Violence, Mental Health and Control of Substance Abuse
and Integrated Essential Clinical Care.


3.3.6 Non-communicable Diseases

The global incidence and prevalence of Non Communicable Diseases
(NCDs) is rapidly increasing. The most important NCDs include
cardiovascular diseases, stroke, diabetes and cancers (particularly
cancer of the cervix and of the Breast). The goal of Non-communicable
Disease therefore is to reduce the morbidity and mortality attributable to
Non Communicable Diseases through appropriate health interventions
that target the entire population.

Achievements during FY 2006/07
• The Ministry of Health established a Secretariat to spearhead the
  planning, implementation and coordination of NCD prevention and
  control efforts in the country, as a first step in response to the threat
  of an NCD epidemic

Table 3.22:        Non-Communicable Diseases key outputs - FY
                   2006/07
Indicator                            Baseline    Target FY
                                     FY          2006/07      Achieved    Comment
                                     2005/06
Central level programme performance indicators
Quarterly performance reports             2            4          1
Technical programme meetings                                              Understaffed
Technical support supervision to          2            4          3
districts
NCD risk factor survey
Proportion of districts implementing



                                                                         93
social mobilisation for NCDs
District level (Service delivery level) indicators
Percentage increase in OPD attendance
attributed to NCDs
Proportion of health facilities with
functional basic equipment for NCD
screening, detection in OPD (period
audit)

Challenges/Constraints
• Lack of awareness at all levels about the prevalence of NCDs and
  their risk factors leading to the apparent neglect of NCDs by policy
  makers, donors and researchers;
• Insufficient local data on NCDs and their risk factors;
• Absence of a clear policy framework, standards and guidelines for
  NCD prevention and control.


3.3.7 Injuries, Disabilities and Rehabilitative Health

The Disability Prevention and Rehabilitation programme was established
with the mandate of accessing all PWDs, older persons and their
caretakers with quality rehabilitative health care services to prevent
disability arising from injury, eye, ear disease and increasing access to
rehabilitative health care services within an integrated system.

Achievements during FY 2006/07

Table 3.23:             Disability, Injuries and Rehabilitative Health key
                        outputs - FY 2006/07
    Indicator                        Baseline          Target for FY
                                     FY 2005/06        2006/07         Achieved   Comments
    Central level programme performance indicators
    Proportion of districts                                                       Some ENT departments
    providing services for hearing         66%              78%           77%     are still under
    impairment                                                                    construction
    Quarterly performance                    2                4            1
    reports
    Technical programme                      12              12           12
    meetings
    Technical support supervision            1                4            2
    to districts
    District level (Service delivery level) indicators
    Proportion of people with                                                     Limited funding to
    disabilities provided with                -             20%           15%     orthopaedic workshops,
    Assistive devices                                                             they operate below
                                                                                  capacity
    Proportion of health facilities                                               Some districts like
    equipped with diagnostic             55%               65%            59%     Yumbe, Nebbi, Dokoro
    disability equipment                                                          have rehabilitation
                                                                                  units which are not
                                                                                  equipped at all

•      Finalised the Rehabilitative and Health Care Policy on Disability



                                                                                    94
•   Established the National Surveillance Network (Data-Base) for
    landmines and other PWDs. Tools for collecting data on landmine
    survivors and PWDs has been developed and pre-tested in 3 districts
•   Launched the Five Year Strategic Plan for Visual Impairment and
    Blindness (2006-2010) and is being implemented.
•   Advocated for the construction and equipment of several
    rehabilitation units at various levels of the districts. E.g. Gulu and
    Soroti Eye/ENT departments. Physiotherapy and orthopaedic
    workshops in Adjumani, Yumbe, and Nebbi.
•   Revised the curriculum for health workers, nurses, midwives and
    allied health professions to incorporate the disability component.
•   Sensitised Community Based Rehabilitation (CBR) workers on the
    medical rehabilitation component of CBR especially to Persons with
    Disabilities in Kayunga and Busia Districts.
•   Sensitised about one hundred teachers and Health assistants on
    handling children with disabilities and those with special needs. They
    also learnt safety promotion and injury control in schools to minimise
    injuries and First Aid in schools in 2 districts so far.

Challenges
• Lack of funding to directly support orthopaedic workshops to produce
  the assistive devices for persons with disabilities.
• Low priority accorded to disability at all levels
• Understaffing

3.3.8 Gender-based Violence

Gender is an important social determinant of health and development,
being male or female has a profound impact on an individual’s health
status as well as access to and utilization of health services. Gender
based violence is mainly based on social constructs of gender, gender
roles, behaviors, the resultant power relations and patriarchy within the
different societies and communities. Gender issues should therefore be
systematically considered and addressed in all health service delivery
throughout the planning process. The Gender Coordination desk in
Ministry of Health is responsible for promoting gender mainstreaming in
the health sector through strategic planning and developing monitoring
systems and procedures for integrating and addressing gender concerns.

Achievements during FY 2006/07
• Developed a gender mainstreaming guideline for the health sector for
  building capacity of health managers on gender mainstreaming
• Carried out a Baseline Survey on gender-based violence in Northern
  Uganda.
• Developed a training manual on clinical management of SGBV
  survivors for health workers
• Developed IEC materials for SGBV




                                                                       95
•     Carried out a training of trainers for health workers on the clinical
      management of GBV at National level and in 5 districts (Gulu, Lira,
      Pader, Kitgum, and Apac)
•     Produced a documentary film on SGBV
•     Sensitized district leadership and Village Health Teams on SGBV
      prevention and response in 5 districts
•     Carried out psychosocial training for IDP camp leaders, LCI
      secretaries for women affairs, religious leaders and local NGOs
      involved in handling SGBV survivors

Challenges /Constraints
• Limited conceptual understanding and appreciation of gender issues
  among policy and decision makers
• Lack of transport to facilitate fieldwork continues to hamper gender-
  mainstreaming activities.
• Inadequate financial resource continues to hamper the roll out of
  gender-mainstreaming capacity building for health workers to more
  districts.


3.3.9 Mental Health and Control of Substance Abuse

Mental health disorders account for about 12.5% of the global burden of
disease. In Uganda, mental health, substance abuse problems and
psychological disorders are responsible for a heavy disease burden. The
burden of substance abuse disorders especially crude, informally
distilled alcohol and adulterated liquor has increased tremendously and
resulted in a number of sudden deaths in the year under review. The
goal of Mental Health Programme therefore is to ensure access to services
for mental health, management of substance abuse prevention and
psychosocial disorders and neurological disorders such as epilepsy.

Major achievement during FY 2006/07

During FY 2006/07, the Mental Health programme focused on
developing and updating policies and interventions to address effects of
trauma and violence in Northern Uganda. The following were some of the
major achievements:

Table 3.24:          Mental Health key outputs - FY 2006/07
    Indicator                           Baseline   Target     Achieved   Comment
                                        FY 05/06   FY 06/07
    Central Level Programme
    Quarterly performance reports           2          4          1
    Technical programme meetings                                         I person unit
    Technical support supervision to        2          4          3
    districts
    Proportion of Regional referral       50%        50%         50%     3 mental units have
    Hospitals with Mental Units                                          psychiatrists
    Community access to mental health     20%        50%         40%     Recruited
    services                                                             Psychiatric Nurses



                                                                             96
                                                                       HC IVs
    District level (services delivery level) indicators
    Proportion of HC IV with Psychiatric       30%        70%    50%   Recruitment
    Nurse or other Professional                                        process in progress
    Proportion of HC IVs with Mental           80%        100%   90%   Mental Health
    Health Plans                                                       incorporated in
                                                                       AWPs
    Proportion of HC IVs with at least        10%         100%   40%   Increased demand
    one anti- psychotic, one anti-                                     for mental health
    depressant and one anti- epileptic                                 medicines but
                                                                       recurrent stock
                                                                       outs at NMS
                                                                       disrupt supply
•     Integration of mental health into
      general care and scaling up of mental
      health services with support of ADB
      funding. This has created high
      demand for mental health services.
      The number of patients with mental
      health, neurological disorders such as
      epilepsy    and     other  psychosocial
      disorders has increased by about 50%
      in most districts.
•     Ratification    of     the   Framework
      Convention on Tobacco Control
•     Equipped and staffed Regional Referral
      Mental Health Units to ensure
      appropriate functionality.
•     Recruitment      of     mental   health
      professionals at Hospital and Health
      Centre IVs by the Local Governments.
      This will strengthen the institutional
      capacity for mental health services
•     Conducted interventions to address
      effects of trauma and violence in
      conflict communities in Gulu, Kitgum,
      Amuru, Pader, Lira, Amolatar, Dokolo
      and Apac
•     Carried out community mobilisation in conflict areas for mental
      health services

Challenges
• Inadequate staffing at National and Regional Referral levels to address
  the mandates of the Programme
• Inadequate supply on the market and gross under funding of mental
  health medicines which are reported to be expensive.

3.3.10             Integrated Essential Clinical care

Integrated Clinical Care is one of the priority health care interventions of
the UNMHCP. The priority interventions within Integrated Clinical Care
are basic essential clinical care, including emergency care, and care of


                                                                           97
common illness. In addition oral health and palliative care were also
emphasized. Integrated clinical care services are provided through
hospitals. HSSP II therefore emphasized strengthening of hospitals
services in order to effectively delivery the Integrated Essential Clinical
Care. This section will therefore review the performance of hospital
services, oral health and palliative care during the FY 2006/07.

Hospital Services

Introduction

Hospitals continue to place a major role in the provision of preventive,
promotive, curative and rehabilitative health services and are therefore
central in the provision of the Essential Clinical Care. Hospitals are
classified into three categories; General Hospitals, Regional Referral
Hospitals and National Referral Hospitals. Hospitals are grouped as
public hospitals (government owned) and private hospitals.

The report on the performance of hospitals will therefore cover the three
categories of hospitals and will include both public and private hospitals.
Private Not For Profit (PNFP) hospitals owned by UCMB, UPMB and
UMMB constitute the majority of private hospitals and will therefore be
representative of the private sector.

Methodology

The methodology of standardizing outputs that is based on Standard Unit
of Output (SUO)17 which is a composite measure of outputs that can
allow fair comparison of volumes of output of hospitals that have varying
capacities in providing the different types of patient care services is used.
The analysis will lead to generation of Hospital League Charts and Tables
that will compare (without making rigid conclusions, given different
contexts of operation and sometimes doubtful accuracy of information)
performance of the hospitals as follows:
    • Performance of the core functions of hospitals (Higher level care
       e.g. inpatient services, major operations, referrals, diagnostic
       services, blood transfusion)
    • Quality of care – as can be measured through routinely available
       information and
    • Efficiency of resource use

In the analysis of hospital performance, efforts will be made to analyze
the outputs and relate these to inputs and to outcomes and quality

Incompleteness and late reporting has made full assessment of hospitals
difficult. For example 72 out of 87 General Hospitals submitted

17SUO stands for standard unit of output an output measure converting all outputs in to out patient
equivalents. SUO total = Σ(IP*15 + OP*1 + Del.*5 + Imm.*0.2 + ANC/MCH/FP*0.5) based on earlier
work of cost comparisons.



                                                                                               98
information with varying degrees of incompleteness and quality. Seven of
the 11 Regional Referral Hospitals submitted information while two of the
three National Referral Hospitals did submit. The same version of data
collection form as in the previous year was used. As much as possible
the information requested was what is routinely reported in the HMIS
forms in order to reinforce proper reporting and use of HMIS information
at hospital level.

The report attempts to use easily available information to develop a
measure of quality of care in hospitals by deriving a numerical index
from various quality dimensions. Hospitals will be compared for quality
differences and the derived score will be used to correct for quality
differences when interpreting some of the output and efficiency results.
The parameters chosen do not necessarily measure the whole spectrum
of quality. The Department of Clinical Services is developing a guideline
for comprehensive assessment of hospital performance that will include
indicators beyond these limited ones. The full quality dimensions
include: Technical competence and effectiveness of care, Presence of
qualified staff, Patient satisfaction, Access to and utilization of hospital
services, Continuity of care, and Safety of care and management
processes for quality improvement. In this years assessment the
underlined dimensions have been used.

The results of the analysis are discussed below for General, Regional
Referral and National Referral Hospitals, this includes PNFP hospitals. A
further general section on PNFP hospitals is also included.

i).   General Hospitals

Inputs to General Hospitals

      •   Finance

Sixty seven general hospitals provided financial information with varying
degrees of completeness but nonetheless useful in estimating the
financial resources used in these hospitals. General hospitals got an
income of Ugshs. 47,876,453,805 with an average income of Ugshs
714,573,937. Extrapolating this amount translates to an estimate of
Ugshs 62,167,932,553 for all the general hospitals in the country. The
absence of wage information in many public hospitals makes this an
underestimate. Figure 3.11 shows the breakdown of source of income for
General Hospitals, with Government Grants contributing the highest
proportion.




                                                                         99
    Figure 3.11:           Income for General Hospitals FY 2006/07




                      Donor funding
                          33%                                                      Government Grant
                                                                                         43%




                                       User fees
                                         24%




    Expenditure by general hospitals which is also an underestimate for the
    same reason mentioned above closely approximates to the income. The
    total expenditure reported is Ugshs 48,430,384,679 with an average
    expenditure of Ugshs 722,841,562 per hospital.

    More than 50% of the expenditure is employment cost, this is followed by
    expenditure on medical goods amounting to Ugshs 9.9bn with an average
    of Ugshs 148,058,880 per hospital.

            •   Human resource

    Presence of an appropriate number of qualified personnel is a critical
    factor in provision of hospital services. With the exception of support
    staff, there is universal shortage of staff especially the nursing staff in
    absolute numbers and the pharmacy staff in percentage terms. Overall,
    only 61% of the recommended staffing positions at hospital level are
    filled, leaving a shortage of 3,422 for the hospitals that submitted
    complete information. For all the general hospitals this translates to a
    shortage of 6,202 staff. Details for the various cadres are shown in the
    Table 3.25 below. Note that medical staff excludes administrative,
    support staff and nursing assistants/aides.

    Table 3.25:            Staff in general hospitals
                                                   Pharmacy




                                                                                   Admin +


                                                                                             Support




                                                                                                                    All Staff
                          Officers




                                                                Nursing
                          Medical




                                                                                                        Medical
                                                                          Health
                                       Dental




                                                                          Allied




                                                                                   Other


                                                                                             Staff



                                                                                                        Staff




Local Gov. Staffing
Norms                      7           4           3          116         28        14       13        143        185
Average in post            4           2           1           68         17         7       14         70        114
                                                                                             104
Average in post %         58%         52%       44%           59%         61%      52%        %        49%        61%
Total in post             194         100        63           3278        822      350       651       3362       5458




                                                                                                                  100
Total by
establishment           336             192       144      5568      1344     672            624          6864         8880
Gap                     -142            -92       -81      -2290     -522     -322           27           -3502        -3422
Extrapolated Gap for
all General Hosp        -257            -167     -147      -4151      -946    -584           49           -6347        -6202

            •     Medicines and health supplies

    Presence of medicines is an important indicator of quality of service
    delivered by hospitals. Medicines expenditure is the second highest item
    in hospital expenditure responsible for 24% of the total expenditure on
    average. The combined Credit Lines and Hospital Grants for EMHS for
    General Hospitals amounted to UShs 7,845,000,400. EMHS Grants
    constitute 54% of the overall available budgets for EMHS. Average
    expenditure on the Credit Lines according to NMS data was 115%. The
    General Hospitals spent 54% of their EMHS grants at NMS and/or JMS.
    The medicine stocks were good with only 7/72 hospitals reporting a
    stock out of one or more indicator medicines in one or more quarters of
    the year compared to 15/45 last year. This may however be related to
    rationing of medicines, a practice many hospitals use not to entirely run
    out essential medicines at any time of the year.

    Outputs from General Hospitals

    Hospitals continue to provide a large component of outpatient, inpatient,
    maternal and preventive services. The total outputs from the 72 general
    hospitals that submitted information is summarized in the Table 3.26
    below.

    Table 3.26:          Outputs from the General Hospitals FY 2006/07
                          In patients




                                                                                                                                 Immunizat
                                                                                                   operations
                                                                                Deliveries




                                                                                                                  Antenatal
                                               Inpatient




                                                               patients




                                                                                                     Major
                 Beds




                                                 days




                                                                                                                    FP/
                                                                 Out




                                                                                                                                    ion
 Total          9,931   567,982           2,948,237         2,901,108        99,219            27,730           344,488        740,136
 Average        142     8,232             44,670            42,663           1,503             603              5,142          11,047
 Count          70      69                66                68               66                46               67             67

    Given the variability of hospitals, the composite unit of activity, the
    Standard Unit of Out put (SUO) can be used to compare the volume of
    activity for hospitals, this unit adds up the 5 main outputs as if they
    were all outpatients based on their relative cost to the outpatient. For
    two consecutive years, Iganga Hospital has the highest output
    irrespective of quality – see Annex 3.1. Other detailed outputs are shown
    in Annex 3.2.




                                                                                                                       101
               Quality assessment

               Three quality dimensions have been used in assessing the quality of care.
               For each dimension one or more parameters have been chosen as
               outlined below.

               1. Technical competence and effectiveness of care – 3 parameters: –
                  Fresh still births rate (Fresh still birth/deliveries); maternal deaths
                  rate (Maternal death/maternal admissions). The rate of stock out of
                  medicines has been dropped because it was a very rare event.
               2. Qualified staff – 1 parameter of qualified medical staff per bed
                  (number of qualified medical staff staff/number of beds). Qualified
                  medical staff are the following – medical officers, dental staff,
                  pharmacy staff, nursing staff excluding nursing assistants and allied
                  health professionals for this analysis.
               3. Access to service – 5 parameters have been chosen looking at access
                  to hospital level of services. The understanding is that a hospital
                  should offer the following services: Major surgery, x-ray, ultrasound
                  scan, blood transfusion and laboratory. For each, a rate of use is
                  derived by dividing outputs with inpatients, all patients, inpatients,
                  all patients or all patients respectively.

               The rates derived are scored 1-10 and the final quality unit is the sum of
               these score. For 43 hospitals that gave complete information the results
               is as follows:

               Figure 3.12:                                                                        Overall Quality in General Hospitals FY 2006/07


                                                                                                                                                                               Total Quality Score

 60
Quality Score


 50



 40



 30



 20



 10



  0
                                  Tororo St.Anthony




                                                                                                                                                                                                                                                                                                                                                                             Maracha St. Joseph
      Kuluva

               Kisiizi

                         Kawolo



                                                      Nakaseke

                                                                 Kayunga

                                                                           Matany

                                                                                    Ngora

                                                                                            Kumi

                                                                                                   Masindi

                                                                                                             Naggalama

                                                                                                                         Nkokonjeru

                                                                                                                                      Bwera

                                                                                                                                              Moyo

                                                                                                                                                     Palisa

                                                                                                                                                              Angal

                                                                                                                                                                      Iganga

                                                                                                                                                                                Kisoro

                                                                                                                                                                                         Adjumani

                                                                                                                                                                                                    Average

                                                                                                                                                                                                              Kiboga

                                                                                                                                                                                                                       Mityana

                                                                                                                                                                                                                                 Bugiri

                                                                                                                                                                                                                                          Gombe

                                                                                                                                                                                                                                                  Bundibugyo

                                                                                                                                                                                                                                                               Kiryadongo

                                                                                                                                                                                                                                                                            Kapchorwa

                                                                                                                                                                                                                                                                                        Kambuga

                                                                                                                                                                                                                                                                                                  Kagadi

                                                                                                                                                                                                                                                                                                           Apac

                                                                                                                                                                                                                                                                                                                  Mubende

                                                                                                                                                                                                                                                                                                                            Lyantonde

                                                                                                                                                                                                                                                                                                                                        Atutur

                                                                                                                                                                                                                                                                                                                                                 Nyenga

                                                                                                                                                                                                                                                                                                                                                          Busolwe

                                                                                                                                                                                                                                                                                                                                                                    Bududa




                                                                                                                                                                                                                                                                                                                                                                                                           Nebbi

                                                                                                                                                                                                                                                                                                                                                                                                                   Kitgum Gov

                                                                                                                                                                                                                                                                                                                                                                                                                                Tororo

                                                                                                                                                                                                                                                                                                                                                                                                                                         Kaabong

                                                                                                                                                                                                                                                                                                                                                                                                                                                   Moroto
                                                                                                                                                                                                                                                                                                                                                                                                  Amudat




                                                                                                                                                                                                                                                                                                                                                                102
Efficiency
Efficiency has been expressed for the use of the following inputs: beds,
staff and funds. Unfortunately the financial information was incomplete
particularly lacking employment costs for public general hospitals. It
could not be possible to get efficiency for use of funds. Bed occupancy
rate, average length of stay and outputs attributed to each staff has been
used. Annex 3.3 shows the result of staff efficiency measured by the
standard units of outputs attributed to each staff (SUO/Staff) and other
bed utilization efficiency parameters – bed occupancy rate (BOR), average
length of stay (ALOS). There is high utilization of hospitals with average
bed occupancy rate at 85%. A staff on average is responsible for 1,571
units of out puts. Comparison for all hospitals is shown in the figure
below.

Overall performance of general hospitals –The General Hospital
league table

Forty three hospitals had complete information to allow overall rating of
hospital performance. This rating is an aggregate sum of scores in the 8
quality indicators plus bed occupancy and staff productivity. The
different parameters used in assessing the performance of the hospitals
were assigned weights reflecting the importance of the parameter. Annex
3.2 shows the ranking of overall general hospital performance and the
weights assigned to the different parameters for assessing hospital
performance.

ii)       Regional Referral Hospitals

The Regional Referral Hospitals have been analyzed together with 4 high
volume PNFP hospitals: Nsambya, Rubaga, Mengo and Lacor. Reports
were available from 14 hospitals with some level of completeness.

Inputs

      •   Finance

The 12 Regional Referral Hospitals provided financial information, and
had a combined income of UShs 43,073,293,517. The highest fraction
(43%) of the total income was from government grants; this was followed
by income from user fees (30%) mainly from the large PNFP hospitals and
the private wings of the regional referral hospitals. The large PNFP
hospitals did attract donor funding of about 9.5 billion most of it going to
only ------ Hospital.

The total expenditure from the 12 hospitals was UShs 40,896,652,561.
Figure 3.13 below shows the expenditure breakdown from Regional
Referral Hospitals with employment costs taking the biggest proportion of
51%.




                                                                        103
    Figure 3.13:                        Expenditures from Regional Referral Hospitals FY
                                        2006/07



                                         Capital
                                       dev'nt, 12%

                  Medicines,
                    15%                                                                                     Employ'nt,
                                                                                                              51%



           •      Human resource

    Overall the staffing situation in regional referral hospitals is better than
    in general hospitals which had 61% of the positions filled. The ten
    hospitals that submitted complete information on human resource had a
    total of 2,591 staff that is 75% of the recommended establishment. This
    leaves a shortage of 874 staff. In absolute numbers, the highest shortage
    is with support staff followed by doctors with a deficiency of 323 and 187
    respectively. For the doctors the deficiency is mostly with consultants
    and medical officer special grade where only 39% and 41% of the
    positions are filled respectively. Table 3.27 below summarizes the staffing
    positions filled and vacant in regional referral hospitals.

    Table 3.27:                         Staff in Referral Hospitals




                                                                                                                                                                Support Staff
                                                                                                                                  Allied Health
                                                      Principal MO
                                        Consultants
                         consultants




                                                                                                                                                    Admin and
                                                                             Senior MO




                                                                                                            Pharmacy
               Doctors
               Medical




                                                                                         Medical




                                                                                                                        Nursing
                                                                                         Officer


                                                                                                   Dental
                           Senior




                                                                     MOSG




                                                                                                                                                      Other




                                                                                                                                                                                 Total
 Total
Recom          365         41           109             3            113       1          98       77       64         1522       561                   201     675             3465
 Total
Filled         178         19           42              1            46        2          68       65       37         1412       431                   116     352             2591
                                                                                                                                                                 -
 Gap           -187      -22            -67            -2            -67      1          -30       -12      -27        -110       -130              -85         323             -874
% Filled       49%       46%            39%           33%            41%    200%         69%       84%      58%        93%        77%               58%         52%             75%



           •      Medicines and Health Supplies

    Medicines and health supplies constitute the second major expenditure
    item for Regional Referral and large PNFP hospitals; on average each
    hospital spent UShs. ???502,800,847 in the year. The combined Credit
    Lines and Hospital Grants for EMHS for Regional Referral Hospitals
    amounted to UShs 4,703,260,000. EMHS Grants constitute 62% of the


                                                                                                                                                  104
overall available budgets for EMHS. Average expenditure on the Credit
Lines according to NMS data was 103%. The Regional Referral Hospitals
spent 38% of their EMHS grants at NMS and/or JMS. Availability of
medicines was poorer than last year with 6 hospitals reporting a stock
out of at least one indicator item in one or more quarters of the year
compared to only 1 hospital reporting a stock out last year.

Outputs

The 10 Regional and the 4 large PNFP hospitals with scale and scope of
regional referral hospitals had 237,077 admissions, 1,694,534
outpatients and 62,939 deliveries in 2006/07 among other outputs. On
average each hospital had almost 16,934 admissions and 121,038
outpatients. Selected outputs for individual hospitals are shown in
Annex 3.1. The following outputs are shown, outpatients (Total OP),
inpatients (Total IP), deliveries (Total Del), cesarean section (c/section),
deaths (Total death), Antenatal, Major operations (major operns), x-ray,
total standard units of output (SUO). Figure 3.14 shows the SUO from
Regional Referral and large PNFP hospitals.

Figure 3.14:                     Volume of outputs (SUO) from Regional Referral and
                                 large PNFP


                                          e
                                     Volum of Output Large Hospitals

       700,000

       600,000

       500,000

 SUO   400,000

       300,000

       200,000

       100,000

           -
                 K ale



                         F rtp rta



                                     Lira



                                            G lu



                                                   H im



                                                          R ba



                                                                  S



                                                                           A



                                                                                             N my S


                                                                                                         J ja



                                                                                                                Ms k



                                                                                                                       A a



                                                                                                                             Mn



                                                                                                                                     Ma



                                                                                                                                             La r S M ry's
                                                                                                          in
                          o o l
                  ab




                                                                   oroti



                                                                            verag




                                                                                                                        ru
                                             u



                                                    o a



                                                           u ga




                                                                                              sa b a t




                                                                                                                 aaa




                                                                                                                              e go



                                                                                                                                      b le
                                                                                     F cis




                                                                                                                                               co t a
                                                                                      ran
                                                                                 e




Quality assessment

The same three quality dimensions have been used in assessing the
quality of care in referral hospitals. However because much information
was not provided, a much narrower set of quality parameters were used
to accommodate all the hospitals, these parameters were: fresh birth
rate, maternal death rate, qualified staff per bed and cesarean section



                                                                                                                                                             105
rate. The interpretation of quality therefore should be more of indicative
than absolute. The results are shown in the Figure 3.15 below.

Figure 3.15:                            Quality Score for Regional Referral Hospitals
                                                              os
                                                       Large H pitals Quality score


               45


               40


               35

               30
          cr
  u lity S o




               25
 Qa




               20


               15

               10


               5


               0
                    S ro




                            F rtp rta




                                        L




                                               Ma




                                                       G lu




                                                               H im




                                                                        K b le




                                                                                 A a




                                                                                       Jin




                                                                                               L co S M ry's




                                                                                                               M sa




                                                                                                                       Rb g




                                                                                                                              N m ya S F n
                                         ira




                                                                                                a r t a
                             o o l
                     o ti




                                                                o a




                                                                         aa




                                                                                  ru




                                                                                                                        uaa




                                                                                                                               sa b
                                                        u
                                                b le




                                                                                                                a ka
                                                                                          ja




                                                                                                                                      t ra cis
Efficiency

Efficiency of use of the following inputs: beds, staff and funds was
worked out in crude terms and adjusted for quality with the result shown
in Table 3.30 below. The quality adjustment was to derive efficiency if all
the hospitals produced the same median quality. The most efficient staff
use appears to be in Gulu Hospital. There is fairly high utilization of all
these hospitals with average bed occupancy rate at 75%. A staff on
average is responsible for 1,395 units of out puts interpreted as: if all
hospital outputs are transformed in to out patients, each staff will be
responsible for 1,395 out patients.

Overall performance – Regional Hospitals’ league table

The 10 regional referral and 4 large PNFP hospitals were rated on the quality
indicators and the efficiency indicators of bed occupancy rate and staff
productivity to derive a measure of overall hospital performance. The
different parameters used in assessing the performance of the hospitals were
assigned weights reflecting the importance of the parameter. Table 3.28
below shows the ranking of overall Regional Referral hospital performance
and the weights assigned to the different parameters for assessing hospital
performance.




                                                                                                                                                 106
                 Table 3.28:         Ranking of Regional Referral and Large PNFP
                                     Hospitals




                                                  SUO/Staff adj




                                                                                                                                                                                 Hosp.League
                                                                                                      Maternal DR


                                                                                                                    Matern DR
                                     BOR Score




                                                                  SUO/Staff




                                                                                         C/S Score




                                                                                                                                                          staff/Bed


                                                                                                                                                                      BedScore
                                                                              C/S Rate




                                                                                                                                Stillbirth


                                                                                                                                             Stillbirth


                                                                                                                                                          Qualified
             Hospital
Ranking




                                                                                                                                                                      Q.Staff/
                                                                    Score




                                                                                                                      Score




                                                                                                                                               Score




                                                                                                                                                                                    Score
                        Beds




                                                                                                                                  Rate
                               BOR
          Max                        10                              20                  10                            10                        10                       5          65
          Score
   1      Masaka        330    69%        3      2,369               20       20.9       10          2.52%               9      0.28                5      62%             2         49
                                                                                %                                               %
   2      Nsamby        303    68%        3      1,392                  8     20.6            9      1.22%             10       0.12             10         142            5         45
          a St                                                                  %                                               %                             %
          Francis
   3      Lacor St      476    127   10          1,364                  8      8.5            3      2.68%               8      0.33             10        70%             2         41
          Mary's                 %                                              %                                               %

   4      Rubaga        286    48%        1      1,774               12       14.2            6      2.18%               9      0.24                9      90%             3         40
                                                                                %                                               %
   5      Kabale        229    75%        4      1,917               14       19.2            9      2.46%               9      0.27                2      37%             1         39
                                                                                %                                               %
   6      Gulu          367    102        7      1,712               12        2.8            1      1.96%               9      0.22                8      33%             1         38
                                 %                                              %                                               %
   7      Arua          346    74%        3      1,590               10       14.3            6      3.37%               7      0.48                5      70%             2         33
                                                                                %                                               %
   8      Average                                                                                                                                                                    33
   9      Hoima         280    75%        4      1,549               10       11.4            5      3.04%               8      0.38                4      58%             1         32
                                                                                %                                               %
10        Jinja         410    78%        4      1,133                  5     10.2            4      2.36%               9      0.26                6      79%             2         30
                                                                                %                                               %
11        Mbale         400    68%        3      1,062                  4     11.8            5      6.85%               3      2.28                5      67%             2         22
                                                                                %                                               %
12        Lira          290    111        8        774                  1      8.5            3      4.84%               5      0.97                3      75%             2         22
                                 %                                              %                                               %
13        Soroti        290    84%        5      1,011                  3      7.7            3      3.90%               7      0.56                1      59%             1         20
                                                                                %                                               %
14        Fortport      351    56%        1        799                  1     13.2            6      7.67%               1      7.67                7      44%             2         18
          al                                                                    %                                               %



                 iii)   National Referral Hospitals

                 Reports were obtained from only two National Referral Hospitals of
                 Butabika and Mbarara. It was not possible therefore to get a
                 comprehensive picture. A short synthesis for each hospital is given here
                 below. There is urgent need to improve the completeness and
                 comprehensiveness of reports from National Referral Hospitals.

                 Butabika Hospital

                 Butabika hospital continues to provide specialized services for patients
                 with mental and psychological problems as the National Mental Health
                 Referral Hospital. It is also a teaching hospital for mental health students
                 of different cadres and is mandated to carry out mental health research.
                 For the immediate catchment area it provides general outpatient
                 services.


                                                                                                                                                                      107
Inputs
Funding for the hospital has always fallen short of desired ceiling. In the
year 2006/07 the hospital received the following grants:
       Wage UShs. 1,462,030,525
       Non-Wage UShs. 1,635,197,158
       Development UShs. 10,143,295,109
       Total Income UShs. 13,240,522,792

In 2006/07 the hospital had 75% of the staff positions filled, employing
301 staff out of the recommended 407 staff. The specific shortages were
as follows: Doctors 7, Pharmacy staff 3, Nursing staff 56, Allied health
staff 2, administrative staff 10 and support staff 29.

Butabika Hospital received a grant for EMHS of Ugshs 438,253,000 in FY
2006/07, of which only Ugshs 65,900 was spent at NMS while Ugshs
26,880,600 was spent at JMS (data from NMS and JMS). This means
that in theory 94% of the EMHS budget of Butabika Hospital was spent
in the private sector. EMHS procurement data were not available by the
time of report writing. Although the hospital spent Ugshs 1,195,644,954
on medicines and health supplies, it was not sufficient as evidenced by
the stock out of 1 or more indicator drugs in every quarter of the year.

Outputs
Although the hospital is meant to be a specialized mental health unit, it
continues to heavily provide general medical care especially in the
outpatient department. In outpatient service, only 1/3 of the 66,690
outpatients were mental outpatients. The hospital had 190,220
admissions. It was not possible to calculate the bed utilization efficiency
parameters owing to lack of information on patient days. The hospital
also provides the common diagnostic services with the following out puts:
X-rays 1,054; Ultrasound scan 596 and Laboratory 14,567 tests.

Mbarara Hospital

Newly reclassified as a National Referral Hospital, most of the activities
seen in Mbarara hospital have not changed much from those of a
regional referral hospital. Below is a summary of the report from the
hospital.

Inputs
Like all other hospitals Mbarara largely depends on government grants,
in the year 2006/07 the receipts were as shown below:
       Wage Ushs. 1,491,071,000
       Non-Wage Ushs. 1,516,401,000
       Non-Tax revenue Ushs. 8,131,000
       Total Income UShs. 3,167,179,979

Eighty percent of the 340 staffing positions in Mbarara Hospital are filled
leaving a shortage of 160 staff, broken down as follows – doctors 21,


                                                                       108
dental staff 8, allied health staff 20, administrative staff 27, support staff
20. Unusually there is an excess of 28 nurses.

The hospital used medicines and health supplies worth Ushs.
439,463,819 and experienced a stock out of only 1 indicator drug in one
quarter of the year.

Outputs
The hospital provides service in all the common medical and surgical
disciplines – Internal medicine, General surgery, Pediatrics, Gynecology,
ENT, Ophthalmology, Psychiatry and Occupational therapy. It also runs
specific disease clinics like hypertension clinic and diabetes clinic.

Table 3.29:              Outputs from Mbarara Hospital




                                                                                                           Out patients
                           Patient days
            Admissions




                                                      Occupancy




                                                                              Operations



                                                                                            Deliveries
                                          Length Of




                                                                                                                           Antenatal
                                           Average




                                                                   Deaths



                                                                                Major
  Beds




                                                        Rate
                                            Stay

                                                         Bed




                                                                            All 2,096
 302      18,983         102,872            5.4        93%        1,268        C/S         5,775         146,175          11,824
                                                                             1,391



1iv)     General comments on PNFP Hospitals

PNFP hospitals continue to play a major role in provision of hospital
services nationally. For three years running, there has been a trend
analysis of access and efficiency parameters of a set of 65 PNFP hospitals.
Previously the trends have been improving but for second year in a row
some trends are reversing. The charts below demonstrate some of these
trends. The summary messages from the data are as follows:

    •    The outpatient attendance has decreased by 2% from 2005/06
    •    The inpatient attendance has decreased by 10% from 2005/06
    •    Utilization of antenatal services has increased by 14%
    •    Immunization increased by 2%
    •    The overall volume of out puts measured by SUO has decreased by
         5%
    •    User fees have continued to go up after a consistent decrease since
         the year 2001/02.
    •    Staff productivity has started to decline
    •    Expenditure per unit of output has continued to rise, increasing by
         5% between 2005/06 and 2006/07.

The efficiency gains the PNFP hospitals gained as a result of
proportionate increase of subsidies under HSSP I is beginning to be
eroded as attempts by hospitals to remain in operation amidst escalating


                                                                                                          109
     cost of service delivery. The most important trend setter in cost
     escalation has been the employment cost. If the status quo continues,
     the PNFP hospitals may be taken to the pre-partnership state –
     underutilization, use of lowly qualified staff, loss of efficiency for staff and
     bed use.


     Figure 3.16:                                   Outputs from PNFP Hospitals 1997/98 – 2006/07

              Total OPD attendance (new and reattendants) cumulative in a sample of 65%                                                                                Total Admissions (cumulative) in a sample of 65% PNFP Hospitals
                                          PNFP Hospitals                                                                                     350,000
1,400,000

                                                                                                                                                                                                                                                   287,118   297,594
                                                                                               1,144,620                                     300,000
1,200,000
                                                                                                            1,093,661 1,075,241                                                                                                          255,635                       266,579
                                                                                                                                                                                                                               238,621
                                                                                  939,896                                                    250,000
1,000,000
                                                                 872,562
                                                    824,823                                                                                                                                                          199,464
                                                                                                                                             200,000
 800,000                                                                                                                                                                                                172,318
                                          729,519
                                685,891                                                                                                                                159,706         149,872
                                                                                                                                                       154,705
            577,744   597,707                                                                                                                150,000
 600,000



                                                                                                                                             100,000
 400,000



                                                                                                                                              50,000
 200,000




       0                                                                                                                                          0
             97 98     98 99     99 00     00 01     01 02            02 03        03 04         04 05        05 06      06 07                             97 98            98 99           99 00            00 01    01 02     02 03     03 04     04 05     05 06     06 07




                                                                                  Cumulative number of deliveries in a sample of 65% of PNFP Hospitals
                                                             50,000
                                                                                                                                                                                                    47,000
                                                                                                                                                                                    44,902
                                                             45,000
                                                                                                                                                                   42,738

                                                             40,000


                                                                                                                                                  34,064
                                                             35,000
                                                                                                                                    32,377
                                                                                                                           28,949
                                                                                                                28,403
                                                             30,000
                                                                                                   26,918
                                                                         23,709
                                                             25,000
                                                                                      22,618

                                                             20,000


                                                             15,000


                                                             10,000


                                                              5,000


                                                                 0
                                                                          97 98        98 99        99 00        00 01      01 02    02 03         03 04            04 05           05 06            06 07




                                                                                                                                                                                                                                                     110
Oral Health

Oral health encompasses the positive aspects of good oral health, all oral
conditions including dental caries, periodontal diseases and
derangement of oral-facial tissues. Although many oral diseases are not
always life-threatening, they too are important public health problems
because of their prevalence, public demand and their impact on
individuals and society in terms of pain, discomfort, social and functional
limitations and the effect on the quality of life. The goal of Oral Health
programme therefore is to ensure the availability of safe and appropriate
oral health services in the entire population.

Achievements during FY 2006/07

Table 3.30:            Oral Health key outputs - Year 2006/07
    Indicator                                 Baseline    Target     Achieved   Comment
                                              FY 05/06    FY 06/07
    Central Level Programme
    Quarterly performance reports                  2          4          2
    Technical programme meetings                  N/A        N/A        N/A     Understaffed
    Technical support supervision to               3          4          2
    districts
    Proportion of hospitals and HC IVs with       10%       15%         `2%     Phased
    equipped and functional dental units                                        equipping by
                                                                                JICA
    District level (services delivery level) indicators
    Proportion of population with access to
    primary oral health care                       47%      50%         47%
    Proportion of the population aware of
    the risk factors and prevention of oral
    diseases/conditions

•     Finalised the policy on oral health
•     Updated and sensitised a number of health workers on infection
      control measures and oral HIV lesions. Also trained oral health staff
      in the use of Atraumatic Restorative Technique.
•     Carried out support supervision to:
             monitor coordination of oral health activities and strengthen
             oral health promotion at 5 Regional Referral Hospitals and 10
             General Hospitals,
             carry out clinical audit of health units and issue guidelines on
             infection control at 3 Regional Referral Hospitals and 5 General
             Hospitals and to sensitize Primary Health Care workers in 40
             districts on community oral health care

Challenges/Constraints
• Inadequate/lack of equipment in most government hospitals and HC
  IVs
• Lack of dental infrastructure in many districts, especially the newly
  created ones


                                                                                111
•   Non or under utilization of many of the oral care workers in the
    district PHC programmes
•   Under funding of oral health programmes

Palliative Care

Palliative Care focuses on providing care to the terminally ill persons with
severe pain, especially those with HIV/AIDS and Cancer. The Objectives
of Palliative Care are therefore to increase the number of health workers
trained to provide palliative care and increase the number of ill persons
accessing palliative care.

Achievements during FY 2006/07
• Scaled up provision of palliative care to over 40 districts.
• Ministry of Health has continued to partner with Hospice Africa (U)
  and Mildmay Centre in the development of human resource and
  monitoring and supervision of palliative care.
• Sustained the provision of free oral morphine medicine for pain
  management in palliative care that is centrally reconstituted by
  Mulago Hospital.
• Use of oral morphine has been extended to other forms of illnesses
  associated with pain including sickle cell anemia, severe burns and in
  some cases of accidents.

Challenges

•   Limited appreciation of Palliative Care among some health facility
    managers.
•   Inadequate funding to meet the training needs, required medicines,
    scale-up and monitoring and support supervision.




                                                                        112
Chapter 4          Integrated Health Sector Support Systems ........................................... 115

4.1      Health Financing........................................................................................................ 115
4.2      Human Resources for Health................................................................................. 134
4.3      Health Infrastructure Development and Management.................................. 142
4.4      Management of Medicines and Health Supplies.............................................. 147
4.5      Diagnostics and Blood Transfusion Services.................................................... 166
4.6      Information for Decision Making .......................................................................... 171
4.7      Health Policy, Research and Development ........................................................ 177
4.8      Legal and Regulatory Framework ......................................................................... 179

Annex 4.1:             Budget Performance FY 2006/07......................................................... 201
Annex 4.2:             Poverty Action Fund Performance FY 2006/07 ............................... 202
Annex 4.3:             Health Sector1 Donor Project Funding on inputs
                       costed in the HSSP II; FY 2006/07...................................................... 203

Figures Chapter 4

Figure 4.1:    Trends in Budget Allocation by Level FY 2002/03-
    2006/07 117
Figure 4.2:    Expenditure by Item FY 2004/05 - 2006/07...............................................117
Figure 4.3:    Donor project expenditure in public and private sector FY
    2006/07 121
Figure 4.4:    Donor project expenditure by line item FY 2006/07.................................122
Figure 4.5:    Local Government Expenditure FY 2006/07 ...............................................125
Figure 4.6:    Trends in income for the PNFP health sector FY 1998-99
    to 2006-07 130
Figure 4.7:    Relative sources of income over time for PNFP Hospitals
               FY 1998/99 – 2006/07........................................................................................131
Figure 4.8:    Relative sources of income over time for PNFP LLUs FY
               1998/99 – 2006/07 ..............................................................................................132
Figure 4.9:    Productivity of health workers in 65% of PNFP hospitals
               (SUO / Staff) FY 1998/99 – 2006/07 .............................................................139
Figure 4.10:   Trend of attrition of key clinical cadres in PNFP hospitals
               2003/04 to 2006/07 ............................................................................................139
Figure 4.11:   Attrition of key clinical cadres in lower level PNFP health
               facilities in 2005/06 and 2006/07 ..................................................................140
Figure 4.12: Procurement Performance for various Programme inputs
    FY 2006/07 .............................................................................................................
Figure 4.13:     Variation in Medicines spending by districts at NMS &
                 JMS against the Indicative Budgets for FY 2006/07 ............................156
Figure 4.14:     Use of General Hospital Grants for EHMS (=40% of
                 PHC non wage grant) at JMS and NMS .....................................................158
Figure 4.15:     Use of Regional Referral Hospital Grants for EHMS
                 (=40% of PHC non wage grant) at JMS and NMS ...................................159



                                                                                                          113
Figure 4.16:                  Expenditure on EMHS by Mulago and Butabika
                              Hospitals at NMS and JMS ............................................................................159
Figure 4.17:                  EMNS Credit Line Utilization by Districts FY 2006/07........................160
Figure 4.18:                  National Medical Stores Credit Line Service Level FY
    2006/07                   162
Figure 4.19:                  Regional Blood collection FY 2005/06 – 2006/07 .................................169
Figure 4.20:                  HIV and Hepatitis test results FY 2005/06 – 2006/07 ........................170
Figure 4.21:                  Epicurve of Meningitis in Arua, Maracha-Terego
                              District, 1st April 2007 .....................................................................................175

Tables Chapter 4:

Table 4.1:     Health financing performance against indicators FY
    2006/07 115
Table 4.2:     Trends in health financing for HSSP I and II ...............................................116
Table 4.3:     Trends in Budget performance FY 2004/05 – 2006/07 ...........................118
Table 4.4:     Donor projects and Global Health initiatives FY 2006/07
    (‘000 Ugshs)...................................................................................................................................119
Table 4.5:     Trend in expenditure in public and private sub-sectors: .........................120
Table 4.6:   Trend in expenditure on the different line items FY 2004/05
             – 2006/07:....................................................................................................................122
Table 4.7:     Expenditure for Global health Initiatives (‘000 UgShs) FY
    2006/07 123
Table 4.8:     Local Government performance FY 2006/07 ...............................................123
Table 4.9:   Local Government Indicative Figures vs Revised Planning
             Figures 2006/07 ........................................................................................................127
Table 4.10: Construction and rehabilitation of health infrastructure in
             selected health facilities FY 2006/07 ..................................................................143
Table 4.11:    Achievements against targets FY 2006/07 (indicators) ............................147
Table 4.12: Health units without monthly stock-out of any HSSP
             indicator medicines. Zero tolerance indicator by level for FY
             2004/05 – FY 2006/07 ............................................................................................148
Table 4.13: Health units with monthly stock-outs, by individual HSSP
             indicator: Medicines FY 2004/05 – FY 2006/07 .............................................149
Table 4.14:    Per capita expenditure on procurements against planned
    FY 2006/07 ...................................................................................................................................150
Table 4.15a:      Realized procurements against planned for Category A.......................152
Table 4.15b:      Realized procurements against planned for Category B ......................154
Table 4.16: Allocations for EMHS compared with expenditures for
             EMHS at NMS & JMS FY 2006/07 ......................................................................155
Table 4.17: Utilization of indicative budgets for EMHS (GoU health
             units) FY 2004/05 – FY 2006/07 .........................................................................161
Table 4.18:    Joint Medical Stores Credit Line Sales FY 2006/07 ..................................163
Table 4.19:    Credit Line Utilisation comparison FY 2005/06 and FY
    2006/07 163
Table 4.20:    Utilization of the Laboratory Credit Line at JMS FY
    2006/07 164
Table 4.21:    Achievements in Health Information System FY 2006/07 ......................172
Table 4.22:    Achievements – Integrated Disease Surveillance FY
    2006/07 174


                                                                                                                        114
Table 4.23:            Major outbreaks responded to by ESD in FY 2006/07.............................175
Table 4.24:            Achievements for FY 2006/07...........................................................................178
Chapter 4           Integrated Health Sector Support Systems


4.1        Health Financing

           The goal of health financing for the sector is to raise sufficient
           financial resources to fund sector programs whilst ensuring equity
           and efficiency in resource mobilisation, allocation and utilisation.

           Indicators to assess progress towards attainment of these
           objectives were agreed on and are monitored annually as shown in
           Table 4.1. Targets against all indicators have not been met. Total
           public per capita expenditure has two estimations, one is derived
           using GoU funding donor project figures within MTEF and the
           figures in bracket is derived using GoU funding and donor project
           figures as per the MoH survey. Sources of variance include having
           donor projects outside the MTEF, expenditure above declared
           budget figures by some partners.

Table 4.1:          Health financing performance against indicators FY
                    2006/07
                                                              Baseline              Target                Achieved
                                                              FY2004/05             FY2006/07             FY2006/07
 HSSP II Indicators
 Percentage of GoU budget that is                                    9.7                 11.0%                 9.6%
 allocated to health.
 Total public per capita expenditure                             8.0 (10.51)              21.418             7.84 (19.67)
 on health in US$ (Includes GoU,
 donor projects and Global health
 initiatives)
 Proportion of disbursed PHC CG                                     93%19                  100%                 96%
 that is expended;

Public financing
Public financing is composed of GoU funding (which includes donor
budget support), donor project funding, funding from Global initiatives
and contributions from Local Governments. The government allocates
resources within the Medium Term Expenditure Framework including
GoU own generated resources, donor funds through budget support and
donor project funding. Majority of development partners continue to
channel their funding through budget support in addition to project
funding with the exception of the UN and US Government.

GoU funding:

18   Derived from the Health Financing Strategy.
19   Based on data from 26 out of 56 districts that submitted reports in FY 2004/05



                                                                                                       115
              Expenditure on health remains far below requirements as shown in Table
              4.2. Per capita expenditure on health that had registered minimal
              increases between FY 2000/01 to FY 2005/06 reduced by US$ 2
              between FY 2005/06 and FY 2006/07. Donor projects within MTEF that
              had played an increasingly significant role between FY 2000/01 to FY
              2005/06 reduced by 18 points between FY 2005/06 and FY 2006/07.
              Similarly, the overall resource envelope for the sector reduced by Ugshs
              116.38bn; equivalent to US$ 67.47m. Whereas there was a minimal
              increment in the GoU expenditure of Ugshs 12.27bn, donor funding
              reduced by Ugshs 129.15bn (48.1%) attributed to the reduction mainly
              from the Global Fund. Expenditure on Health as a percentage of total
              government expenditure has remained fairly constants for the previous
              5FYs far below the Abuja target of 15%. At the current level of funding,
              HSSP II is only 41% funded based on the best estimate scenario and 65%
              funded at the constrained resource envelope scenario.

              Table 4.2:           Trends in health financing for HSSP I and II
                                                 %
                                           contribution
                                             of donor                                         GoU
                                            projects to                                    expenditure
                                              sectors                                       on health                  Increase on
                                               public                                        as % of                       the
                                           expenditure       Per Capita     Per Capita        total                      previous
            GoU        Donor                  within        expenditure    expenditure     government       Budget     year in GoU
          funding     project20   Total        MTEF            in Shs         in US$       expenditure   performance   expenditure

2000/01   124.23       114.77      239          48%            10,349           6.0            7.5          82.8         31.0%

2001/02   169.79       144.07     313.86        46%            13,128           7.6            8.9          96.2          8.0%

2002/03   195.96       141.96     337.92        42%            13,654           7.9            9.4           96          13.0%

2003/04    207.8       175.27     383.07        46%            14,969           8.6            9.6          95.4         -5.0%

2004/05   219.56       146.74     365.5         40%            13,813           8.0            9.7          92.4          3.6%

2005/06   229.86       268.38     498.24        54%            18,213           9.98           8.9          95.7         -0.1%

2006/07   242.63       139.23     381.86        36%            13,518           7.84           9.6%         95.6


              As shown in Figure 4.1, increasingly more funding is being allocated at
              the district level where majority of the poor live, in line with the Poverty
              Eradication Action Plan objectives. Expenditure at the central level
              reduced significantly between FY 2003/04 and FY 2004/05 and has
              remained constant for the last 3 FYs. Funding for National and Regional
              Referral hospitals remains inadequate and has remained fairly constant
              for the last 7 FYs. This has greatly affected service delivery in these
              institutions (see Chapter 3).




              20   Donor project figures included in this table are figures within the MTEF.



                                                                                                              116
Figure 4.1: Trends in Budget Allocation by Level FY 2002/03-
            2006/07

       60%


       50%


       40%


       30%


       20%


       10%


        0%
              2000/01   2001/02      2002/03          2003/04      2004/05       2005/06       2006/07

             MoH Hqs.   National referral hospitals       Regional referral hospitals      District level

For the last 3 FYs, wages have taken the largest proportion of sector
expenditure followed by recurrent non-wage (Figure 4.2). Expenditure on
wages has been increasing for the last three years with very little, if any
towards non-wage recurrent and domestic development. Although this is
meant to address human resource shortage that exists in the health
sector, we should note that availability of inputs is essential to allow
optimal utilization of available human resource.

Figure 4.2: Expenditure by Item FY 2004/05 - 2006/07




                                                                                                            117
             120


             100


             80
  Bn UgShs




                                                                                Wage
             60                                                                 Non wage
                                                                                Develoment

             40


             20


              0
                   Approve Outturn       Approve Outturn      Approve Outturn
                   budget                budget               budget

                           2004/05               2005/06          2006/07



Overall budget performance has shown consistent improvement in the
last 3 FYs (Table 4.3). Although inadequate human resource is a
constraint to health service delivery, the Wage component continues to
under- perform.       Efforts put in place in the past have included
advertising district posts centrally. Despite these efforts, some districts
still face challenges in attracting and retaining trained health workers.

Table 4.3:            Trends in Budget performance FY 2004/05 – 2006/07
                                     2004/05        2005/06    2006/07

                   Wage               85%             92%         98%


                   Non wage           101%           100%         97%

                   Development        88%             97%         92%
                   Total              92%             96%         98%

Detailed budget performance for FY 2006/07 is presented in Annex 4.1.
Regional Referral hospitals and Mulago Hospital received a
supplementary funding during the course of the FY, hence a record of
more than 100%

Poverty Action Fund (PAF) performance
For FY 2006/07, the sector PAF releases amounted to Ugshs 199.35bn,
while actual expenditure amounted to Ugshs 198.87bn against an
approved budget of Ugshs 206.01bn. Releases to the sector performed at



                                                                                118
96% and actual expenditure performed at 96.5%. Actual expenditure as
a percentage of releases was 99.8%. It is also worthwhile noting that the
approved budget for PAF programmes was 85% of the entire sector
budget and actual releases and expenditure were 84% of the entire sector
releases and expenditure. The detailed performances of the different PAF
programmes are shown in Annex 4.2.

4.1.2 Donor Projects and Global Health Initiatives

Donor funding represent substantial contribution to the health sector
and it is important that it is prioritized within the HSSP II. Estimates of
donor project funding are supposed to be provided to the Health Sector
Budget Working Group at the time of compiling the Budget Framework
Paper to ensure proper prioritization, comprehensive planning and
alignment to sector priorities.

Data on donor projects was collected from eleven development partners,
namely; Belgium, DANIDA, DfID, European Union (EU), Italian
Cooperation, Japanese Government (JICA), Sweden (SIDA), UNFPA,
UNICEF, USAID and WHO, and two Global Health Initiatives: GFATM
and GAVI. In addition, expenditures for the humanitarian response
through the Consolidated Appeal Process (CAP) was included.         A
substantial portion of US Government support and the entire
humanitarian response through the Consolidated Appeal Process are
treated as off budget in the MTEF.

Analyses of expenditure data provided by the development partners
against the budgets they provided during the donor survey and the GoU
MTEF (2006/07) to assess budget performance were conducted. Overall
performance was found to be 210% but with great variations between
agencies as noted in Table 4.4. Per capita expenditure on health for
donor project amounted to US$11.08. The amount is almost the same as
that recorded in FY 2005/06 at US$ 10.

Table 4.4:         Donor projects and Global Health initiatives FY
                   2006/0721 (‘000 Ugshs)
                                                                              Budget
                                              Donor survey                 performance       MoFPED/MTEF
                                        Budget            Expenditure                            Budget
 SIDA                                                -         2,936,813                            1,794,000
 USAID                                     24,470,850        254,249,644           1039%
 WHO                                                 -        17,111,356                           10,170,600
 UNICEF                                      8,349,000         9,868,589            118%
 JICA                                      12,221,625         13,777,085            113%            3,478,290
 DANIDA                                     21,588,800        16,038,918             74%           13,248,000
 UNFPA                                       2,280,712         1,842,933             81%            1,380,000
 ITALIAN                                             -        24,094,963                            5,784,270


21   Exchange rate for FY 2006/07 Ugshs 1,725 to 1US$ (Bank of Uganda)



                                                                                           119
 EU                                               -        1,056,900
 DFID                                                     11,149,480
 Germany                                                                                           3,550,740
 Ireland                                                                                             84,525
 WFP                                                                                               9,311,205
 Netherlands                                                                                       2,198,168
 IDA HIV control
 BTC                                                         240,000
 ADB                                                                                               1,611,840
 Un specified aggregated funding                                                                   2,228,183
 Sub total                               68,910,987      352,366,680                  14          54,839,820
 Per capita UgShs                             2,440           12,474                                   1,941
 Per capita in YS$                             1.41             7.23                                    1.13
 GFATM                                  121,221,351      135,459,335               112%           71,126,518
 GAVI                                             -       21,477,231
 Sub total                              121,221,351      156,936,566                              71,126,518
 Per capita UgShs                             4,291            5,556                                   2,518
 Per capita US$                                2.49             3.22                                    1.46

 Consolidate Appeal (CAP) For
 humanitarian response                   66,944,575       30,818,203                46%
 Sub total                               66,944,575       30,818,203                                       -
 Per capita                                   2,370            1,091                                       -
 Per capita US$                                1.37             0.63                                       -
 Grand Total                            257,076,913      540,121,449               210%          125,966,338
 Per capita UgShs                             9,101           19,121                                   4,459
 Per capita US$                                 5.28            11.08                                   2.59
Source: Donor survey was from primary data collection and MoFPED budget data is from MoFPED;
Approve estimates of revenue and expenditure FY 2006/07.


A significant proportion of donor project funding remains off budget. The
criteria set by MoFPED, funding excludes expenditures for humanitarian
response (CAP) and those in the private sector are from the MTEF.
Excluding these funds, only 41% of donor project expenditure was
reflected in the MTEF. Issues of unpredictability continue to pose a
challenge to comprehensive planning within the sector and ensuring
harmonization and alignment of development assistance.

Overall, donor project expenditures remain predominantly in the private
sector at 74% compared to 26% spent in the public sector as shown in
Figure 4.5. Private For Profit sub sector represented 37% of total project
expenditure while PNFP facility based and Non-facility based were at
25%. USAID accounts for the biggest percentage of expenditure in the
private sector, spending 90% of its funding which represents 50% of total
project expenditure excluding CAP. The highest expenditure within the
private sector was in the Private For Profit sub-sector at 49%. No clear
pattern emerges over the 3 year period (Table 4.5).

Table 4.5:           Trend in expenditure in public and private sub-sectors:



                                                                                           120
                               2004/05                    2005/06                         2006/07
    Public                      39%                          98%                            26%

    Private                     61%                              2%                         74%

Expenditure figures for PNFP facility based and Non facility based were
19% of donor project expenditure within the private sector. The extent to
which the private sector specifically the PNFP non facility based and For
profit providers contribute to realization of sector objectives is yet to be
ascertained. Given that planning and prioritizing activities they
undertake is done without full involvement of the ministry of health.
Although these two sub sectors have potential to contribute significantly,
it calls for effective guidance, monitoring and regulatory mechanisms to
ensure value for money.




Figure 4.3: Donor project expenditure in public and private sector
            FY 2006/07

  100%

   90%

   80%

   70%

   60%

   50%

   40%

   30%

   20%

   10%

    0%
         WHO   UNICEF   JICA    DANIDA   EU     UNFPA Belgium     DFID   ITALIAN   SIDA   Over all USAID


                                              Public   Private



Non HSSP II inputs including Technical assistance (TA) and project
management costs continue to take a high percentage of donor project
funding at 31% (Figure 4.4). Although in some instances TA is at the
request of MoH, it is not one of the inputs costed in HSSP II. This may


                                                                                                           121
be reviewed after implementation of the recommendations of
rationalization of TA in the health sector. Non-infrastructure capital had
the lowest expenditure at only 1%. Details in Annex 4.3.

Figure 4.4: Donor project expenditure by line item FY 2006/07

    100%




      80%




      60%



      40%




      20%




       0%
                                              EF




                                                                                                                                                D
                                                                                         N




                                                                                                                           m
                                                                           A
                                                                   A
                       ID




                                                          A
                                      O




                                                                                                               EU
               A




                                                                                                                                                          ll
                                                                         FP




                                                                                                                                              FI


                                                                                                                                                        ra
                                                                 ID
                                                         C




                                                                                         IA
              D




                                     H




                                                                                                                        iu
                                            IC
                    SA




                                                       JI




                                                                                                                                             D


                                                                                                                                                      ve
                                    W
            SI




                                                                                                                      lg
                                                                                       AL
                                                               AN
                                           N




                                                                        N
                   U




                                                                                                                    Be




                                                                                                                                                    O
                                          U




                                                                       U


                                                                                    IT
                                                              D




  HR Ugandan                          Training                         Drugs and supplies                                              Other recurrent
  Capital non infrastructure          Infrastructure                   Non HSSP inputs



There is no clear pattern on the different inputs as shown in Table 4.6.
This may be a true finding but could also mean lack of a common
understanding on the different inputs for which data is requested. This
analysis uses self reported data which is not verified. In future efforts
will be made verify data and ensure common understanding on the data
collection tool.

Table 4.6:         Trend in expenditure on the different line items FY
                   2004/05 – 2006/07:
                                                                                              infrastructure



                                                                                                                      Infrastructure
                     HR Ugandan
                     Health staff




                                                                                               Capital non
                                                        Drugs and




                                                                        recurrent




                                                                                                                                                No HSSP
                                                         supplies
                                          Training




                                                         medical




                                                                                                                                                 inputs
                                                                          Other




     2004/05          4%                  0%             20%             7%                    4%                    9%                         56%
     2005/06          5%                  14%            58%             2%                    7%                    4%                         9%
     2006/07          7%                  24%            10%            20%                    1%                    5%                         31%




                                                                                                                                                               122
Budget performance for the GFATM was 112% showing an improvement
from the previous level of 50% in FY 2005/06. Ninety seven percent
(97%) of funding for Global Health Initiative (GHI) was on medicines and
medical supplies, within the private sector only 1.23%, and on non HSSP
II inputs only 0.03%. this is a much better picture of alignment
compared to donor project funding (Table 4.7). CAP expenditure for the
FY 2006/07 was Ugshs 30.8bn, 62% of which was channeled through
UN agencies while 38% was channeled through PNFP Non facility based.
Its effective utilization is yet to be evaluated.

Table 4.7:       Expenditure for Global health Initiatives (‘000 UgShs)
                 FY 2006/07
                                     GFATM                                      GAVI
                                                         %
                                                       spent
                                                        on
                        Budget       Expenditure      inputs    Budget        Expenditure     %
 HR Ugandan              1,107,457       1,148,481     0.85%
 Training                        -          83,823     0.06%
 Medicines and
 medical supplies      55,116,800     132,035,547    97.47%                    21,477,231    100%
 Other recurrent       17,709,518         482,608     0.36%
 Capital non
 infrastructure        15,467,316                -
 Infrastructure                 -                -
 Other inputs                   -           46,680     0.03%
 Civil Society         31,820,261        1,662,196     1.23%
 Total               121,221,351     135,459,335       100%                    21,477,231    100%

4.1.3 Analysis of health expenditure at Local Government levels

Local governments receive funds from the central government,
Development partners, Global health initiatives and locally raised
revenue to deliver health services. Analysis of funding received from all
sources was conducted for 80 districts which provided comprehensive
data.

GoU (PHC) funding:
During FY 2006/07, sector releases to Local Governments amounted to
Ugshs 129.15bn against an approved budget of Ugshs131.98bn resulting
in a release performance of 97.85% as shown in Table 4.8.

Table 4.8:       Local Government performance FY 2006/07
 Votes                            FY 2006/07             FY 2006/07       Performance
                                  Approved Budget        Releases
 District NGO Hospitals /PHC      17.74                  16.78            94.6%
 District Primary Health Care     103.63                 101.76           98.2%
 District Hospitals               10.61                  10.61            100.0%
 Total Transfers                  131.98                 129.15           97.85%
Source: Annual Budget Performance Report FY 2006/07. MoFPED, September 2007




                                                                                       123
Total district expenditure outturns for FY 2006/07 (non-wage recurrent
and domestic development), including donor expenditures and Local
Government contributions were computed as shown in Figure 4.5. It is
evident that, for the districts from which data was available, Government
of Uganda PHC conditional grant remittances to the districts are what
are financing, on average 80% of health services delivery. The remaining
20% of district expenditures is mainly funded by donors (16%) with LG
contributions constituting the least (4%). This has policy implications;
that in order to ensure improvements in health services delivery, the
issue of the level of funding of district PHC conditional grants needs to be
addressed.




                                                                        124
Figure 4.5: Local Government Expenditure FY 2006/07

              KUMI
  BUNDIBUGYO
      ADJUMANI
     KYEENJOJO
      RUKUNGIRI
              LIRA
          KAMULI
        MAYUGE
        MOROTO
            OYAM
        MASAKA
        PALLISA
    LYANTONDE
              ABIM
          KISORO
         WAKISO
            ARUA
      BUTALEJA
         KASESE
      KAYUNGA
       KANUNGU
  KAPCHORWA
           YUMBE
        BUDAKA
             NEBBI
          IBANDA
   NTUNGAAMO
     KABAROLE
 NAKASONGOL
         KIBOGA
            BUSIA
        LUWERO
        MITYANA
       MUBENDE
         IGANGA                                       GoU (PHC)
           KIBALE
             GULU
                                                      Local Government
            RAKAI                                     Donors
          National
            MOYO
         AMURIA
       BUSHENYI
   NAMUTUMBA
         MASINDI
        TORORO
           BULISA
      MANAFWA
            HOIMA
         KABALE
             MPIGI
      MBARARA
 KABERAMAIDO
            BUGIRI
     KAMWENGE
  NAKAPIRRIPIRI
       KAMPALA
           PADER
        MUKONO
       BUKEDEA
   KALANGALA
          SOROTI
    SEMBABULE
        SIRONKO
        ISINGIRO
        KOBOKO
      MARACHA
             APAC
             JINJA
           MBALE
     AMOLATAR
       KATAKWI
        BUDUDA

                 0%   20%   40%   60%   80%   100%




                                                               125
Fiscal Decentralisation Strategy (FDS)

The objective of FDS is to promote Local Government autonomy and
widening of participation in decision making, in order to enhance the
effectiveness in allocation of resources towards the achievement of PEAP
goals in line with local priorities, whilst strengthening the efficiency,
transparency and accountability of local government expenditures. FDS
was therefore initiated to give districts the option to reallocate funds
between and within sectors according to local priorities. Under FDS, LGs
are allowed up to 10% flexibility in the use of the sector recurrent
conditional grant non-wage to finance either un-funded or under-funded
activities within a sector or in another sector. FY 2006/07 was the first
year when the flexibility was applied on local governments’ grants
allocations.

In the health sector, the strategy is applicable to the PHC Recurrent Non-
Wage grant. Using figures compiled by the Local Government Finance
Commission (LGFC), which compare original Local Government
Indicative Planning Figures (IPFs) and revised IPFs after reallocation, the
following conclusions can be drawn;

For FY 2006/07, the total conditional grant allocation from MoH for PHC
non-wage is Ugshs 22.912bn. After using the flexibility, LGs allocation to
the health sector was Ugshs 22.867bn; i.e. Ugshs 45m or 0.2% was
allocated AWAY from the sector. This is a marked improvement from FY
2005/06 when Ugshs 393m or 1.5% was allocated away from the sector.

Most LGs left the PHC non-wage grant intact, but those that revised
tended to reallocate away from the sector. The reason why LGs allocate
away from health is that the health sector at district level receives or is
perceived to receive significant amounts of project and emergency aid
related to health from various off-budget donors.

The largest allocations away from health were by Wakiso (Ugshs 37.7m)
and Iganga (Ugshs 24.6m) and the largest allocations toward health were
Ntungamo (Ugshs 40m) and Bundibugyo (Ugshs 26.7m).

There is therefore still a lot of work to be done at Local Government level
in lobbying for increased prioritization and funding for the health sector.
As is shown in Table 4.9 below, the net gainers of the reallocations are
agricultural extension and natural resources at the expense of health
and education. It is counterproductive lobbying for increased district
PHC funding from the centre only for it to be reallocated away from at
district level. Further, more work has got to be done to help the LGs
internalise and understand the principles behind the use of the 10%
flexibility for non-wage recurrent conditional grants.




                                                                       126
Table 4.9:      Local Government Indicative Figures vs Revised
                Planning Figures 2006/07
Conditional Grant Account Title            Initial Indicative   Revised IPFs      Amount
                                           Planning Figures     after             (Revised IPFs -
                                           (IPFs)               Reallocation      Initial IPFs)
Primary Education                            33,488,531,170      32,826,558,005     -661,973,165
PHC- Non wage                                22,912,100,000      22,867,139,021      -44,960,979
Agriculture Extension                         2,771,225,185       3,060,654,387      289,429,202
Functional Adult Literacy                     1,597,760,000       1,597,187,322         -572,678
District Tender Boards, District Service                                                       0
Commissions, Public Accounts
Committees, Land Boards, etc.
Road Maintenance                             14,510,968,936      14,548,150,730       37,181,794
Community Development                           400,000,000         495,637,017       95,637,017
Natural Resources (Non Wage)                    252,500,000         537,758,809      285,258,809
Total                                       75,933,085,291      75,933,085,291                 0
Source: Local Government Finance Commission data base


Strengthening financial management and monitoring:

Improvement in financial management is key to efficiency in achieving
the set objectives of the sector.

Integrated Financial Management systems (IFMS): Over the last 4
years the effort of strengthening financial management through the IFMS
has demonstrated that there are sufficient controls and shown efficiency
gains in finance management and service delivery. The Ministry budget
has been posted to the IFMS and this has enabled better implementation
of the workplan. This has facilitated easy monitoring of the budget and
quick decision making on activity implementation. The IFMS system has
also enabled pilot districts to improve their performance and has been
appreciated in Kampala City Council Divisions, Mbale, Jinja, Mpigi,
Bushenyi, Mbarara, Lira, and Soroti. More districts are coming on board.

Some projects have been captured on the IFMS and others are yet to be
captured. To enable harmonization in Financial Management, this is
matter is to be discussed with HDPs and strengthen the system.
Regarding quarterly releases to districts, these have been timely in line
with release warrants.

Public Expenditure Review: This undertaking was commissioned by the
Ministry of Health due to the need for a comprehensive review of the
health expenditures and budgeting processes in order to generate
evidence that would inform strategic implementation of uganda’s health
program through improved planning, budgeting and management of
public funds, especially at a time of HSSP II implementation. A PER was
thus undertaken and key findings and recommendations made by the
consultants. A plan of action to implement recommendations of the PER
has been finalized.



                                                                                    127
Improving Budgeting & Planning for Donors: As a way of improving
budgeting & planning for donor funding, the MoH in the last FY started
holding budget consultations with individual donors. In addition, Long
Term Institutional Arrangements for the management of Global Funds
and other donor funds were instituted. Under the arrangement, the
health sector together with the Development partners (DPs) are supposed
to plan and budget jointly. DPs are thus requested to declare the
amounts of funding available for the sector in the medium term. The
ministry conducted a donor analysis exercise at the planning stage and a
report is available.

Auditor General’s Report FY 2005/06: During FY 2005/06, out of the
seventeen (17) accounts that had unqualified opinions, nine (53%) were
in the health sector. However for the Ministry of Health itself, a qualified
opinion was given. During the year, a foreign company was paid Ugshs
996,750,400 (US $538,784) and all supporting documents for the
payments were all photocopies and efforts to trace the originals were
fruitless. Further, the total interest component on the US$ 538,784 was
US$ 516,719 i.e. 96% of the actual payment made was interest. For this,
the Accounting Officer was advised to carry out a proper reconciliation of
all payments due and those made to the company under the contract to
clearly establish the extent of debt by Government and to ensure that all
efforts are taken to minimise nugatory expenditure of this nature.

During FY 2005/06, Ugshs 140, 386,742 was transferred from the
Ministry Treasury General Account to, the communicable disease
account.     The amount was purportedly transferred to cater for the
activities of the Nutrition and Early Childhood Development Project
(NECDP). This followed a reconciliation, which revealed that the monies
had earlier been spent on non-NECDP related activities during the year
ended June 2005. No explanation was however provided as to why
money had to first be paid to another project rather than effecting
payments directly from the Treasury General Account. The amount has
further not been accounted for. The AG could not therefore confirm that
the amount had been spent on NECDP activities.

The pay roll cleaning exercise undertaken in September, 2005 unearthed
a loss of Ugshs 38,575,654 resulting from various irregularities arising
from delays in effecting deletions from the payroll. The amount comprises
of Ugshs 10,580,213 relating to staff salaries which continued to be paid
for sometime after the staff had left the Ministry and Ugshs 28,575,654
which continued to be paid up to the time of the exercise. The cause of
this appears to be negligence of duty by the responsible officer and
weaknesses in the payroll management system. The Accounting Officer
stated that the list of the affected beneficiaries has been compiled for
appropriate action. The AG advised that monies earned wrongfully
should be refunded by the beneficiaries and existing weaknesses in the
payroll management system be addressed.




                                                                        128
During FY 2005/06, Ugshs 33,000,000 was paid out to a local airline to
cater for air travels for performance monitoring of District Health
Services in the north, mid western, and West Nile regions by the area
teams. However, the travels did not take place and the money was not
refunded by the airline. A search for the company further revealed that
the company had gone burst and wound up operations. It is therefore
evident that Government lost money as a result of the inability by the
firm to offer the service. The Accounting Officer promised to institute
recovery measures and advise the AG accordingly.

Lastly, Ugshs 45,726,000 was paid to Ms Uganda Community Based
Health Association (UCBHFA) to cater for its activities. However, funds
had not been accounted for by the time of writing this report contrary to
financial regulations. Efforts to trace the memorandum of understanding
between the association and the Ministry were also fruitless hence
limiting the scope of audit. Furthermore, according to the requisition
letter the activities, which were to be funded, were similar to those,
which were financed by the Ministry’s Department of Community Health
Services (Planning). This implied that there is unnecessary duplication of
activities, which results into wasteful expenditure. In his written reply,
the Accounting Officer explained that both the accountabilities and
Memorandum of Understanding were available but none was however
presented to the AG’s office for verification.

Rationalization of Development Assistance: The GoU led a division of
labor (DoL) exercise which process began in 2001 with the development
of the Uganda Partnership Principles. The Government and development
partners committed to a DoL exercise as part of ongoing efforts to make
interactions with, and assistance to, the Government more valuable.
Interest in the process was reiterated during the development of the
Uganda Joint Assistance Strategy (UJAS) in 2005. In January 2006 the
joint GoU/LDPG Harmonization Committee Meeting, chaired by the
MFPED, agreed to initiate the DoL exercise, which began in June 2006
with the design and implementation of the Aid Information Map (AIM).
The AIM provided a baseline for the Division of Labour exercise as a
whole and has two components: the Development Partner (DP)
Questionnaire and the Financial Data Tool (FDT). The DoL process built
on the aid effectiveness debates of the 1990s, which had produced the
Rome and Paris Declarations on Aid Effectiveness and Harmonisation
(2003 and 2005).

The objective of this exercise is to increase development and aid
effectiveness and efficiency in Uganda through an increase in transaction
benefits associated with aid balancing, and further streamlining of
financial support and policy dialogue in relation to the PEAP and GoU
budget systems.

Following a Government-led information workshop for sector working
groups in August 2006, the SWG process was set to begin in 2007, after
the delivery of the interim DoL report. While the DoL Exercise to date


                                                                      129
has involved mostly data collection and reporting, the SWG process will
mark the beginning of policy discussions on whether current patterns
and volumes of engagement across sectors are fit for purpose and how
improvements could be made. The SWG phase will determine whether
real DoL can be achieved and if development partners can change the
business-as-usual mode. All stakeholders will therefore need to ensure
that adequate staff time and political commitment accorded to this
crucial process.

The SWG discussions will be followed by an agreement between
Government and DPs on how to implement the DoL findings. The SWG
process will also mark the critical phase in the Government’s
involvement in the DoL process, and the time in which decisions will be
made between DPs and the Government on how to take DoL decisions
forward.


4.1.4 Financial Contribution from the Facility based Private Not for
Profit Sector (FB-PNFP)

The resources mobilized by the FB-PNFP sector amounted to Ugshs Bn
90 during FY 2006/07, a slight increase of 8% as compared with FY
2005/06 (Figure 4.6). Government contribution amounted to
approximately Ugshs Bn 20, hence the net contribution of the FB-PNFP
sector to the national health system continues to increase. The relative
contribution from Government has remained constant in absolute terms
around levels of FY 2003/04. In relative terms it has declined from a
peak of 36 % in FY 2003/04 to 22% in FY 2006/07. Inflows from user
fees have only slightly increased in absolute terms and have remained at
the same relative levels of last year (38%, with a speedy decrease since
FY 1998/99. There has been a net increment of inflows from donor funds
both in absolute and in relative terms. Donor funds for the last two years
are the largest source of income. About 30% of donor funds is spent
towards capital development and renovation of structures.

Figure 4.6: Trends in income for the PNFP health sector FY 1998-
            99 to 2006-07




                                                                      130
                                      PNFP Health Sector - Trends in income structure
       100,000,000,000


        90,000,000,000


        80,000,000,000


        70,000,000,000
                                                                                                              40%
                                                                                                   39%
        60,000,000,000                                                                   29%

        50,000,000,000                                                         26%
                                                                    20%
        40,000,000,000
                                                                                         42%       38%        38%
        30,000,000,000                24%       30%       22%                  43%
                                                                    45%
                            22%
        20,000,000,000
                                      58%       47%       45%
                            63%                                                          29%
        10,000,000,000
                                                                    36%        31%                 23%        22%
                                                22%       33%
                            15%       18%
                    -
                           1998-99   1999-00   2000-01   2001-02   2002-03    2003-04   2004-05   2005-06    2006-07

                   Govt. Subsidies (money and                                User                           Aid
Source: Bureax databases


The situation in the PNFP FB Hospitals in FY 2006/07 does not show
any change in trends. The user fees share continues to remain stable at
36% as in the previous years while the delegated funds contribute only to
20% of the total hospitals’ income (Figure 4.7). The income share from
aid in form of cash from outside the country, donation of goods,
equipment and drugs as well as project moneys is becoming more and
more significant. The income from external aid in form of projects and
vertical interventions comes with conditionalities posing a challenge to
implementation as well as administrative and accountability processes.

As observed for the past FYs the relatively stable share of the income
from patients (fees) shows the efforts of the FB-PNFP sector towards a
sustained user fees reduction policy, aiming at improving patients’
access to services, with a special focus on mothers and children (see
PNFP Hospital output section) documented by the increased number of
ANC contacts and Deliveries in the past FYs as well as the increased
number of Immunization doses given to children.

Figure 4.7: Relative sources of income over time for PNFP
            Hospitals FY 1998/99 – 2006/07




                                                                                                      131
                     Relative sources of incom e over tim e - PNFP Hospitals
  100%

   90%

            33%        36%      37%         35%       36%
   80%
                                                                  43%       40%       44%       44%
   70%

   60%

   50%
                                            38%       36%
   40%                          44%                               34%       36%
            56%        49%                                                            36%       36%
   30%

   20%

   10%
            11%        15%      19%         27%       28%         23%       24%       20%       20%
    0%
           1998-99   1999-00   2000-01     2001-02   2002-03     2003-04   2004-05   2005-06   2006-07

         Governm ent                     Users'                Aid (Other financial Sources and
Source: Bureax databases


With regards to the PNFP Lower Level Health Facilities (LLUs)
government subsidies represent a stable share of the total income as
compared to the past years, standing at 27%, while user fees share
slightly increased from 35% in FY 2005/06 to 37% in FY 2006/07
(Figure 4.8). The percentage of funds coming in form of aid has slightly
decreased to 35% after exceptional high level of 37% in the previous
financial year but still representing a sizeable share. Better
accountability as well as the high number of capillary initiatives taking
place in the various health centers may account for the high income
levels.

Figure 4.8:            Relative sources of income over time for PNFP LLUs
                       FY 1998/99 – 2006/07




                                                                                               132
                    Relative sources of income over time - PNFP LLUs
  100%

   90%
                                                             22%       24%
   80%                                                                           38%       36%
                    43%                  46%       41%
          53%
   70%                        60%

   60%
                                                             43%       43%
   50%
                                                                                 35%       37%
   40%
                                                   31%
                                         32%
                    44%
   30%
          36%                 26%
   20%

   10%
          11%       13%       14%        22%       28%       35%       33%       27%       27%
    0%
         1998-99   1999-00   2000-01    2001-02   2002-03   2003-04   2004-05   2005-06   2006-07

           Government                  Users'         Aid (Other Financial Sources and
Source: Bureax databases


Achievements – Health Planning Department:

Health Financing Database: In order to strengthen routine health
financing monitoring, a health financing database was put in place. The
database currently comprises of both public and private health
expenditures. Public funding (Government and donor projects) data has
been entered for FY 1997/98 – 2005/06. Comprehensive private
financing data has been entered for FY 1997/98; 1998/99 – 2000/01;
the years that had a National Health Accounts undertaken. The data
base will updated and data analyzed routinely to address pertinent policy
issues and strengthen the budget process.

Comprehensive 3–Year Sector Procurement Plan. This was supposed
to include procurements for all health related products utilized within
the sector from Regional Referral Hospitals to all national level
operations. A comprehensive proposal was developed by a team of
officials from the PDU, HPD and accounts sections of the ministry.
However, the budget allocated to this activity in the Partnership Fund
budget was insufficient that no progress has been made. The alternative
was for programs to develop their respective plans such as drugs and
supplies and the Health Infrastructure Division.

Project assessment undertaken (PRIA): This activity is on going and
funding for its operations has been committed from the Partnership
Fund. The appraisal tool has been adapted to the health sector taking
into account the Health Policy and HSSP II priorities.



                                                                                                    133
Preparation for the planned National Health Insurance scheme: A
draft bill has been sent to the Solicitor General for legislative drafting. A
Task Force that includes the private sector has been re-constituted
which is spearheading the scheme design process. Consultations with
various stakeholders have been undertaken by the MoH through
workshops and other fora. So far consultations with the private sector
mainly federation of Uganda employers, the National Workers Unions,
Community Based Health Insurance Scheme Managers, Permanent
Secretaries, Media Houses and radio journalists. Other institutions
consulted are the Sessional Committee of Parliament on Social Services,
National Social Security Fund, Health Maintenance Organizations, the
Armed Forces, Uganda Local Government Association and District
Councils. In the process of enriching the draft bill, the Task Force
established working committees to spearhead further technical analysis
of the Bill. These are in the areas of Economic Analysis, Accreditation
and Quality Assurance, Advocacy and Communication, Actuarial, Legal,
Financial Management, Organizational structure and IT and Information
Management.

Study tours to Thailand, Tanzania, Kenya, Rwanda, Ghana and Nigeria
have been undertaken and lessons learnt have been incorporated in the
draft Bill and the entire design process. The Ministry has negotiated for
assistance from World Health Organisation (WHO), the National Health
Insurance Fund of Tanzania, Nigeria, German Technical Assistance (GTZ)
and International Labour Organization (ILO) and the World Bank (WB)
for assistance in the design of the scheme.

Challenges
Inadequate financing remains the primary constraint inhibiting the
development of the health sector in Uganda. The different health
financing options for the sector and their potential to raise funds for
health services were elaborated in the Health Financing Strategy (HFS;
2002/03 – 2012/2013). The financing gap facing the health sector was
estimated and the strategy to close the gap by FY 2019/20 was
dependent on the health sector achieving 15 % of a GoU budget growing
at approximately 6% per year. Funding a basic package of services in
developing countries has been estimated at US$30 – $40 per capita22. On
the other hand, the Health Financing Strategy (HFS) made an estimate of
US$28 per capita, excluding ARVs and the pentavalent vaccine. The
current level of funding of US$7.84 per capita falls far below the
estimated requirements.

4.2   Human Resources for Health

The term Human Resources for Health embraces all persons, with or
without training, who contribute to the protection and improvement of
health. This includes all health workers whether they are employed in




                                                                         134
the Government Service, Non-Governmental Organizations or Private
Sector.

The health workforce is of strategic importance to the performance of
national health systems as well as of international disease control
initiatives. It is a scarce commodity and the most valuable asset within
the health system, which can ultimately influence the success or failure
of the health system. It therefore calls for emphasis on improving the
Human Resources for Health effectiveness and efficiency for good health
care and optimal productivity.

4.2.1 Human Resources for Health Development

The GoU is committed to avail highly competent, motivated and equitably
distributed Human Resources for Health effectively contributing to a
healthy and productive life of the people in Uganda.

As government continues to engage, maintain and develop an adequate
and competent health care workforce to avail people in this country an
equal access to quality essential health services in line with the
development goals of the country, there are challenges of resurgence of
the old diseases, emergency of the new ones hence changing the overall
picture of the disease partner. In addition the changing technologies in
health care delivery calls for continued re-profiling of the competencies of
the health workforce

In view of the above during FY 2006/7 financial year, the human
resources health development focused on;
   1. Providing and maintaining a policy and strategic framework to
      guide HRH processes
   2. Strengthening institutional capacity for the human resource
      policy, planning and management.
   3. Avail well trained HR to deliver the Uganda National Minimum
      Health Care Package (UNMHCP), and
   4. Upgrade and enhance skills of the Health Workers to deliver the
      UNMHCP.

Achievements:

1. Providing and maintaining a policy and strategic framework to
   guide HRH processes

The Human Resources for Health (HRH) Policy completed in FY 2005/06
has been widely disseminated and is now in use. The Human Resources
for Health strategic plan (2005 – 2020) has been completed and printed,
with electronic copies on CD also available. The plan translated the
policy into a national and district level strategy, by taking a long term
view of how health and health care needs will change and therefore how
the health services and the staff will need to change over the years to



                                                                        135
come. A core group of users of the strategic planning model have been
trained.

Rationalization study of health cadres: Human resources form the
major determinants of the quality, character and recurrent cost of the
health care. A study was done to find out how to optimize the size and
quality of health cadres for cost efficiency and effective delivery of
UNMHCP.

Retention Study: The sector and the government at large are committed
to implement health workforce policy reforms. This calls for availability of
real information. Among the agent information needs was why there
appears to be low retention for health workers. Therefore a study was
done to generate and document evidence for developing strategies to
improve health workforce job satisfaction and retention

2. Strengthening institutional capacity for the human resource
   policy, planning and management.

Human Resources for Health Action workshop for District Human
Resource Managers: A workshop for Human Resource Managers from
39 districts was held as a follow on action following an HRH Action inter-
country workshop was held to address HRH issues through sharing
experiences, best practices and finding solutions. More workshops, of
this kind, will be held in the coming year to complete all the districts.

Training in effective use of Human Resources for Health Data: A
workshop on effective use of data for policy and planning was conducted
for planners from MOH, MOES, HSC, PNFP to enable them make
evidence based decisions.

Evaluation of the Management Training for Health Sub- Districts: In
order to strengthen management at District and HSD levels, the above
training has been offered by MOH to HSD since 2004. Before committing
more funds, an evaluation was done in this financial year. It documents
the impact of the Management Training for Health Sub- District course,
the best practices and lessons learnt. Among the salient recommends of
the evaluation includes: need to involve district health managers to
facilitate in the training, to improve on the training materials and the
organization of the training programme to make it more effective. It
further points out the unmet management training needs for inclusion in
the curriculum. The report is now available for follow up on actions.

3. Upgrade and enhance skills of the Health Workers to deliver the
   Uganda National Minimum Health Care Package (UNMHCP).

Increasing access to and demand for Continuing Professional
Development (CPD): In-Service Training (IST) which is also referred to
as Continuing Professional Development (CPD) is a mechanism for



                                                                        136
addressing performance gaps of practicing service providers arising from
service demand and new technologies.

In an effort to increase access to and demand for Continuing Professional
Development, the Ministry of Health adopted the Regional CPD Focal
Centers concept. Initially four centers were opened (Lira, Arua, Mabarara
and Jinja) in addition to the Health Manpower Development Centre
Mbale, the national CPD coordinating center. The centers are functional.
They were equipped with office furniture, computers and internet
connectivity. These will enhance Distance Education and CPD/IST
delivery. They will, however, require strengthening with human resource.
Streamlining CPD delivery through Institutionalization in health facilities
within the framework of the National In-Service Training Strategy started
and is going on allover the country. The new districts and the districts in
war conflict zone were given priority during the period under review.

Establishment of Accreditation system for CPD: One of the measures
to increase demand and uptake of CPD by the health workers and
making it more meaningful and beneficial, the Ministry working with the
Health Professional Councils started on the process of establishing an
accreditation   system.    Guidelines    were    developed     awaiting
implementation.

Revitalization and strengthening of Health Manpower Development
Centre: Continuing Professional Development/In-Service Training
(CPD/IST) for health workers is critical for achieving and maintaining
relevance and adequate standards in health care. An evaluation of
Distance Education Programme (DEP) administered by Health Manpower
Development Centre (HMDC) was conducted. This was with the view of
evaluating Distance Education as a cost effective and time saving
strategy for IST/CPD.

A business plan for HMDC was developed aiming at creation of a national
level institutional capacity to promote and facilitate a learning culture.
The consultant recommended that in order for HMDC to fulfill its
intended functions as envisaged by the Ministry; it should be legalized by
an act of parliament.

4. Availing well-trained Human Resources to deliver the Uganda
   National Minimum Health Care Package (UNMHCP).

Postgraduate training/further formal training-
Government supported for 36 students for further training. The focus on
sub/specialities (e.g. Cardiology, Urology) and on disciplines which are
not attracting many health workers yet position in the establishment at
hospitals still exist. Examples include: Pathology, Anaesthesia, Ear Nose
and Throat (ENT) and Ophthalmology.

The training of critical health cadres instrumental in functionalising the
theatres at the HC IVs, the Theatre Assistants, continued during the


                                                                       137
period under review. One hundred and seven (107) completed the
syllabus and are waiting for the final examinations. When they pass out,
more than 203 will be available for recruitment for the service.

Pre-Service and Post Basic Training: The Ministry of Health continued
to work with the Ministry of Education and Sports in the training at Pre-
service and Post Basic levels. The activities included; support supervision
and development of standards for training. There was delay to start on
the construction works in the 15 selected nursing schools to expand
their capacities to increase on their admission of students. That was due
to the delays in the procurement processes in the European Union (EU)
headquarters. The five Years Development for Human Resources for
Health (DHRH) EU supported project, which is ending in September
2007, was instrumental during the implementation.

Preliminary arrangements for SHPS/DANIDA project Support to the
PNFP schools were completed. Construction and full implementation of
the project support will be fully done in the 2007/8 financial year.

The issue of the May and November 2006 groups of nurses that were not
registered by the Uganda Nurses and Midwives Council was addressed in
a series of meetings between the Ministry of Health and Ministry of
Education and Education Sports. Efforts to resolve the matter is in final
stages.

Challenges:

1. Low visibility for the Human Resources for Health.
2. Under funding for Postgraduate Training to meet the Sector’s training
   needs particularly for medical specialties.
3. Inadequate funding for Continuing Professional Development/In-
   Service Training.
4. Sustainability of the work done by DHRH – EU Project which is
   ending in September 2007 as now arrangements are in place.
5. Coordination of funding efforts by partners contributing to Human
   Resources for Health.

4.2.2 Human Resource for Health in the PNFP sub-sector

This section of the report covers PNFP health workers coordinated by the
three medical bureaus (UCMB, UPMB and UMMB). The total volume of
health workers in the three networks was 11,114 as by June 30th 2007.23
This is up by 10% from the 10,000 as of November 2004.24 It is a very
minimal rise in about three years and still much lower compared to
about 28% rise (from 20,000 in Nov. 2004 to 25,622 in 2007) in the
public sector. As in 2004, the workforce in PNFP still makes up 30% of
the combined public – PNFP workforce. Health workforce in PNFP has

23   Source: Data from UCMB, UPMB and UMMB.
24   HSSP II



                                                                       138
remained low largely due to low financial capacity of the sub-sector to
attract and retain staff. However staff productivity has increased steadily
although this is beginning to get affected by the increased scope and
volume of work for the relatively fewer staff due to the increasing attrition
(Figure 4.9).

Figure 4.9:      Productivity of health workers in 65% of PNFP
                 hospitals (SUO / Staff) FY 1998/99 – 2006/07




The PNFP has been dogged by high level of attrition especially over the
last two years. Available data indicate that over 60% of these attrition
cases join government services. Although they are replaced, the sub-
sector is depleted of experienced people as 30% of leavers have got over 3
years and 47% have got 1-3 years of experience. The PNFP networks have
therefore become like transit routes to civil service. Figure 4.10 and 4.11
below indicates the trend of attrition of key clinical cadres in 65% of the
PNFP hospitals.

Figure 4.10:     Trend of attrition of key clinical cadres in PNFP
                 hospitals 2003/04 to 2006/07




                                                                         139
                                  T r e n d o f a ttr ir io n o f k e y c lin ic a l s ta ffs in 6 5 % o f P N F P h o s p ita ls

 40%
                  38%
                                  36%
 35%                                                                                             34%


             30%
 30%                                                                                                                                                                             29%
       28%
                                                                                                                                     27%
                                        26%                  26%                                       26%
                                                                                                                                                                                   25%
 25%                                                               24%
                            22%
         21%                   21%
 20%
                                                      17%
                                                   16%
                                                                                   15%                                                 15%               15%
 15%                                                                                                                                              14%

                                                                                                                            11%                     11%
                                                                                         10%
 10%                                                                                                                   9%


                                                                                                                                             5%
  5%



  0%
             MO                   CO                        EN                                 EMW                            RMW                  RN                C o m b in e d E N +
                                                                                                                                                                           EMW

                                                                 2 0 0 3 /0 4     2 0 0 4 /0 5       2 0 0 5 /0 6     2 0 0 6 /0 7




It is important to note that enrolled nurses and enrolled midwives who
are critical for nursing care had high attrition rates at 46% in FY
2005/06 and still 40% in FY 2006/07 in lower level PNFP facilities. In
the hospitals they had rates of 29% in FY 2005/06 and 25% in FY
2006/07.     The lower level facilities are less attractive places of
deployment and yet they are rural and closer to the poor and vulnerable
societies.

Figure 4.11:                    Attrition of key clinical cadres in lower level PNFP
                                health facilities in 2005/06 and 2006/07
                                     T re n d o f A ttritio n o f k e y s ta ff in P N F P L o w e r L e v e l F a c ilitie s

 50%
                                                                                                                46%                                     46%
                                                      45%
 45%                                                                                                                           44%

                                                                                                                                                                    40%
 40%
                                                                    36%
                          35%
 35%

               30%
 30%


 25%


 20%


 15%


 10%


  5%


  0%
                     CO                                      EN                                                       EM W                          C o m b in e d E N + E M W

                                                                                2 0 0 5 /0 6     2 0 0 6 /0 7


The spike in attrition in FY 2005/06 coincided with beginning of massive
recruitment by government. The slight drop in FY 2006/07 is explained
by a less aggressive or less massive recruitment drive by government in
the period. The instability and loss of experienced staff caused in PNFP
by government recruitment is a phenomenon worth studying to
understand how many additional health workers are brought into the
system through these recruitments other than destabilizing a provider


                                                                                                                                                                             140
that significantly complements government effort in health service
delivery.


4.2.3 Health Services Commission

The Health Service Commission (HSC) is provided for under Article 169
of the Constitution of the Republic of Uganda to have jurisdiction over
the Health Service Human Resource. Its Mandate as contained in the
provisions of Articles 170 and 172 of the Constitution and also in Section
8 of the Health Service Commission Act 2001.

Broad Objectives

The broad objectives under which the Commission will achieve its
Mandate are:
     To ensure that all positions in the Health Service are expeditiously
     filled with qualified and competent health workers.
     To pay utmost attention to the special needs and problems which
     affect health workers in general in the entire health services; and
     To build the HSC into a strong institution, organizationally and
     professionally to enable it to fulfill its Mandate effectively.

Achievements:
• 476 health workers were appointed for various posts in the health
   sector
• Technical support provided to District Commissions of Kasese,
   Nakaseke, Busia, Kabarole, Kitgum and Ntungamo. 6 DSCs were
   supported against a target of 10
• Carried out outreach and support supervision visits to districts in
   Uganda to support compliance to recruitment guidelines. 6 DSCs
   were covered against a target of 10
• .Drafted the Health Service Commission regulations to guide its
   activities
• New Chairperson, Deputy and 4 other members appointed. A 3 days
   induction course was carried out
• One (1) new Double Cabin Pick-up vehicle procured for the Deputy
   Chairperson.
• Capacity building for staff of HSC. 3 secretarial staff were trained
• Carried out staff validation exercise for Uganda Blood Transfusion
   Services. Appointed 150, confirmed 75, re-designated 24, retained 14
   and retired 3 staff

Challenges

The Health Service Commission is still facing operational difficulties.
Due to the inadequate funding, the Commission is not able to effectively
carry out its field support visits and hence constrained in monitoring




                                                                      141
staffing levels at various Health Institutions.         In particular the
Commission is faced with the following challenges:

Lack of transport: The Commission fleet of vehicles stands at only ten
(10) vehicles to cater for entitled members of the Commission and the
senior staff. It should however be noted

Lack of office equipment: As a Recruiting Agency, the Commission
handles large volumes of paper work demanding application of
appropriate office equipments such as computers, photocopiers and fax
machines. Often times, at the peak of its activities, the Commission has
to outsource these services due to lack of facilities at a high cost.

ICT Development: The Commission needs to develop an appropriate
Human Resource ICT that will foster efficiency in monitoring staff gaps
among other functions. Due to budgetary constraints, the Commission is
not in position to allocate funds for this important need during Financial
Year 2007/2008.

Lack of Office space: It should be noted that the Commission is
currently being housed in rented premises at very exorbitant costs.
Besides, due to limited budget allocations, the office space allocated to it
is very much constrained leading to squeezing of members and staff in
small rooms, a situation not conducive to working environment.


4.3   Health Infrastructure Development and Management

A number of Health Infrastructure Development and Management
initiatives were carried out during FY 2006/07. The focus was
consolidating functionality of existing health facilities through
construction of additional physical infrastructure, renovation of
buildings, equipping of selected health facilities and maintenance of
medical equipment and plants.

Review of policies and guidelines on development and management
of health infrastructure

In order to improve planning and management of health infrastructure,
the following policy guidelines were formulated with the aim of improving
performance and effectiveness:

   The essential medical equipment credit line (EMECL) was formulated.
   The EMECL will be for procurement of a selected number of essential
   medical equipment and spares. Operationalization was initiated with
   Ugshs 3.0bn from GoU, DANIDA and UNFPA
   The National Advisory Committee on Medical Equipment (NACME)
   initiated the process to review the Equipment policy document to
   update equipment list for each level and technical specifications.



                                                                        142
     Medical equipment inventory was carried out in fifty four (54)
     hospitals and eighty two (82) health centres as strategy to put in
     place a system that links the equipment operational condition to
     procurement and maintenance planning.
     Problem oriented planning for medical equipment maintenance was
     initiated starting with the central region as the basic planning
     framework for the Regional Medical Equipment Maintenance
     Workshops.
     A proposal to transfer money directly to the regional medical
     equipment maintenance workshops was prepared in order to
     guarantee accessibility of allocated funds for routine medical
     equipment maintenance by the workshops. Proposal for a new
     funding mechanism is ready and awaits implementation in FY
     2007/08 in accordance with the last JRM recommendation.

Technical support supervision and coordination with projects in the
sector was strengthened in FY 2006/07 and this helped to avoid
duplication of efforts and wastage of resources. Coordination of
procurement planning was realised under the EMECL and funds from
DANIDA, UNFPA and GoU were pooled together to benefit from
economies of scale, ensure quality and standardization.

A number of projects were completed and should result in improved
working conditions for the staff and health services delivery to the local
communities. Insufficient funding for health infrastructure development
remains the major challenge and this affected start of planned activities
(e.g. Arua hospital general ward, rehabilitation of water supply and
sewerage in Moyo and Nebbi hospitals).

Table 4.10: Construction and rehabilitation of health infrastructure
            in selected health facilities FY 2006/07
Activity                                      Achievement
1. Rehabilitation of Fort Portal regional     • Rehabilitation and expansion of maternity ward was
    referral hospital                            completed
                                              • Walkway connecting wards constructed
2.   Rehabilitation of water supply and       •  Completed
     sewerage system of Abim general
     hospital
3.   Construction of new theatre, staff       •   Completed
     houses and repair of generator at
     Kaabong hospital
4.   Construction and equipping of Sigulu     •   Completed and commissioned. Scope included
     HC III                                           1. Remodeling and expansion of General
                                                         /maternity ward
                                                      2. Construction of 4 No. staff houses
                                                      3. Supply of essential equipment
                                                      4. Supply and installation of solar systems for
                                                         both medical buildings and staff houses
5.   Construction of Arua regional hospital   •   The Contract was signed and works start soon
     general ward
6.   Construction of incinerators in          •   Construction of two incinerators was completed and
     Mbarara and Masaka hospitals                 both incinerators are fully operational
7.   Rehabilitation and equipping of Mbale    •   Theatre constructed and equipped



                                                                                     143
     hospital under the Japanese Grant            •   New Maternity ward with obstetrics theatre
     Aid Project                                      constructed including delivery suites
                                                  •   X-ray department constructed and equipped with
                                                      Basic x-ray unit and Fluoroscopy unit
                                                  •   Generator house constructed and 50KVA generator
                                                      supplied and commissioned
                                                  •   Additional general equipment supplied and
                                                      commissioned.
8.   Rehabilitation and equipping of Tororo       •   New OPD block constructed and equipped including
     hospital under the Japanese Grant                Emergency unit, and various clinics
     Aid Project                                  •   Maternity ward rehabilitated and delivery suites
                                                      constructed.
                                                  •   Two wards constructed and equipped
                                                  •   Generator house constructed and 50KVA generator
                                                      supplied and commissioned
                                                  •   Several additional general equipment supplied and
                                                      commissioned
9.   Rehabilitation and equipping of              •   Construction works were flagged off by the Hon.
     Bududa and Upgrading of Masafu                   MOH and Japanese Ambassador to Uganda
     HCIV to 60 beds hospital under the           •   Construction works are ongoing25
     Japanese Grant Aid Project                   •   Equipment has been ordered and shipping has
                                                      started
10. Rehabilitation of Entebbe Hospital            •   Contract signed and works are ongoing for
                                                      construction of fully equipped casualty unit
                                                  •    Mortuary with body fridge constructed
11. Construction and rehabilitation of            •   Construction of Mayuge district Drug stores is
    health infrastructure by Districts                ongoing (under SHPS/DANIDA funding)
    under District transfers and direct           •   Construction of Maternity ward in Hoima hospital is
    funding by Donor Partners                         ongoing with support from AVSI.
                                                  •

Procurement, supply and installation of medical equipment and
plants26

ORET project for improvement of radiology and ultrasound services
• Seven (7) radiography X-ray machines procured and installation is
  ongoing in Kiryandongo, Nebbi, Arua, Abim, Moroto, Pallisa and
  Iganga hospitals.
• One (1) fluoroscopy x-ray unit procured for Arua hospital.
• Eighteen (18) ultrasound machines procured and installation is
  ongoing for 8 No. hospitals and 10 No. HCIVs
• Ten (10) HCIV supplied with theatre equipment, generator, solar
  lighting system and an autoclave in the maternity ward (i.e. Kityerera,



25 Masafu has following facilities: New OPD, Children’s ward, maternity unit, female ward generator,
covered walkways and generator house, and supply of various pieces of medical equipment.
Bududa has the following facilities: New OPD building, theatre, maternity unit with delivery suites,
generator and generator house, and supply of various medical equipment.
    26
a)     The Energy for Rural Transformation (ERT) Programme covers both the medical buildings
    and staff houses. Procurement started and its implementation should improve the working
    conditions in rural health centres including attracting qualified staff.
b) The ERT Project is ongoing but its speedy implementation in other districts will largely depend
    on the capacity of government to raise the required counterpart funding for phase 2 of this
    World Bank funded project.




                                                                                               144
       Busesa, Busia, Kibuku, Bugobero, Tokora, Nabilatuk, Aduku, Amach
       and Kotido)

Procurement of medical equipment for health facilities under the EMECL
• Procurement of basic medical equipment is under way for various
   hospitals and health centers for all districts totaling Ugshs 3.0bn
   Each district has placed an order for equipment for a selected
   number of health facilities within their allocated funds.
Procurement of the equipment from the EMECL has started

Procurement of tools and equipment for Regional workshops under JICA
funding
• Supplied tools and equipment to Arua, Hoima, Gulu, Soroti, Mbale,
   Wabigalo, Kabale and Fort Portal regional workshops.
• Procured eight (8) computers with printers for the regional
   workshops.
• Renovated Arua, Hoima, Gulu, Soroti, Mbale, Wabigalo, Kabale and
   Fort Portal workshops

Procurement and installation of solar energy system in selected HCs in
Katakwi, Kaberamaido and Yumbe districts under DANIDA funding
• Solar lighting systems were installed in Katakwi HCIV and Toroma
   HCIIII in Katakwi district; Abirara, Ocelakur and Murem HCIIs in
   Kaberamaido district; Kulikulinga HCIII and Matuma HCIII in Yumbe
   district

Procurement and installation of solar energy system in HCs in Arua,
Koboko, Nyadri, Yumbe and Nebbi districts under the ERT Project
• Contract was signed to install solar systems for lighting, operation of
   a microscope and radio/TV for 5 HCIV, 30 HCII and 37 HC

Procurement and installation of solar energy system in HCs in Kotido,
Abim, Kaabong, Pallisa, Budaka, Kumi and Bukedea districts under the
ERT Project
• Tender was advertised for supply and installation of solar systems for
   2 HCIV,37 HCIII and 42 HCII

Supply and installation of equipment in 32 selected health centres in 11
districts under SHSSPPI/ADB
• Delivery and installation of PHC equipment carried out27

Capacity building for better infrastructure management

Training of users of equipment and technical staff was carried out as
part of capacity building for better management of health infrastructure.
The following training was carried out:



27   Equipment delivery and installation was delayed and was only carried out in the last FY2006/07.



                                                                                                 145
      User training for thirty-eight health workers (38) was carried out on
      the use of Ultrasound scanners under the ORET Project.              The
      participants include midwives, clinical officers, nurses and doctors.
      Thirty six (36) more health workers for the ultrasound user-training
      programme were identified and training starts soon under the ORET
      project.
      A Basic x-ray maintenance training course was carried out for
      fourteen (14) technicians and engineers under the Project for
      improvement of health infrastructure management supported by
      JICA.
      Training of one hundred (100) equipment Users and technicians was
      carried out on operation and basic maintenance needs for solar
      powered radio call equipment.

Additionally, training was carried out on operation and basic
maintenance of equipment supplied under the Japanese Grant Aid. The
beneficiaries were health workers and hospital based technical staff in
Mbale and Tororo hospitals; and five (5) other technicians from Wabigalo
workshop supported by JICA.

Technical support to Districts and Projects

Support supervision was carried out as part of the Integrated Support
supervision (ISS) or planned technical monitoring and evaluation of
ongoing projects. Technical support and advice was provided to the
following specific Projects in addition to the routine district support
through the ISS:

HSPS/DANIDA:            reviewed the Bid evaluation report prepared by M/S
                        Crown Agents and supervised the installation of
                        solar systems procured.
SHSSPP:                 participated in supervision of pit latrine construction
                        and verified quality and performance of equipment
                        procured through NACME28
UNEPI                   provided technical advice and supervised design of
                        new UNEPI Headquarters.

Monitoring and Evaluation of the performance of Regional medical
equipment maintenance workshops (RW) was carried out. The findings
were:

•     Hospitals and HSDs are not remitting the funds for maintenance to
      the Regional Maintenance Workshops (RW) under the contributory
      funding mechanism currently in place.
•     Hoima, Fort Portal, Gulu and Central regional RWs received very little
      funds to carry out proper maintenance work (only about 20% of what
      was expected).


28   NACME      National Advisory Committee for Medical Equipment



                                                                           146
•     Only about 38% of available equipment in use is in good operational
      condition, and 38-50% of the available equipment needs repair or
      service.

It is therefore of paramount importance that the new funding mechanism
is put in place as recommended by the last Joint review mission (JRM) of
October 2006.

Constraints
  Inadequate funds hindered start of a number of capital development
  Projects like rehabilitation of water supply and sewerage in Nebbi and
  Moyo hospitals.
  The contributory funding mechanism for Regional Equipment
  Maintenance Workshops currently in place is not working resulting in
  poor performance by the workshops.
  Health Infrastructure Division and RW structures are inadequate.
  Some of the vacant posts in some cases need to be filled.
  Because of delay and slow release of funds, some activities were not
  carried out.


4.4      Management of Medicines and Health Supplies

The overall objective within the HSSP II is to ensure the availability of
adequate quantities of good quality essential medicines and health
supplies required for delivery of the UNMHCP at all levels of the health
care delivery system.

4.4.1 Essential Medicines Availability

The HSSP II indicator that quantifies medicines availability (as a proxy
for quality of care) measures the percentage of health units without any
stock-out of HSSP indicator medicines. It is a proxy measure for zero
tolerance for medicines stock-outs. As for the last four years a
standardized survey has been carried out to collect data for this
indicator.

Performance against HSSP II indicators was below target and central
level indicators have deteriorated slightly in comparison to FY 2005/06,
with only 58% of indicative cash budgets for medicines procurement
spent at NMS and JMS (based on information from NMS and JMS).
Improvements were nevertheless observed in medicines availability with
35% of sampled facilities having experienced no stock out of the indicator
medicines (27% last year) (Table 4.11)

Table 4.11: Achievements against targets FY 2006/07 (indicators)
                                             Achieved   Target                Baseline
                                             FY 06-07   FY 06-07   FY 05_06   FY 04-05
    HSSP II indicators
    Percentage of health   units   without      35%        55%       27%         35%



                                                                           147
 monthly stock out of any indicator
 medicines
 Central level indicators
 Percentage of the indicative cash budget
                                            58%         80%         60%          51%
 for medicines spent at NMS and JMS
 District level:
 Same as HSSP II indicator

Of the health units surveyed only 35% did not report any stock-out over
the 6 months period of the FY 2006/07 for which data were collected.
This is against the HSSP II year 2 target of 55%. This indicates a slight
improvement compared to the previous year, but still a marked under-
performance on this indicator, which is key determinant for quality of
care and patient utilization of health services. Issues similar to those
mentioned last year have contributed to this unsatisfactory performance
and include:
• the inadequate (and stagnant) funding for essential medicines and
   supplies;
• a lower than expected expenditure on medicines by the medicines
   budget holders (local governments and hospitals); and
• the challenges still evident at local government and central level in
   medicines procurement and logistics management, in part related to
   inadequate human resources and system inconsistencies in the
   required supervision in this subsector.

The availability of HSSP indicator medicines at facility level was assessed
using a retrospective survey conducted in six districts looking at six
months of FY 2006/07 (quarters 2 and 4). Overall, only 35% of sampled
health units had continuous availability of all the indicator medicines
during the month (zero tolerance for stock outs, (Table 4.12). In other
words, 65% of health units had a monthly store-room stock-out of one or
more HSSP indicator medicines. Overall, availability improved compared
to the previous FY when only 27% of the units surveyed did not have
stock out of any of the indicator medicines. Marked improvements were
observed at level III and IV and deterioration in availability at level II. It
has been suggested that failure to make proper medicines orders and
follow up as a result of heavy workload ultimately leads to the frequent
stock outs.

Table 4.12: Health units without monthly stock-out of any HSSP
            indicator medicines. Zero tolerance indicator by level
            for FY 2004/05 – FY 2006/07
                 FY 2006/07             FY 2005/06         FY 2004/05
              Num of                  Num of              Num of
                HU      % HU            HU     % HU         HU     % HU
 All levels     36       35%            28      27%         33      35%
 HC II          11       12%             9      25%         10      69%
 HC III         15       47%            13      32%         14      79%
 HC IV          10       47%             6      23%          9      52%




                                                                          148
On average, monthly stock-out of the 6 indicator medicines decreased to
20% in FY 2006/07 from 31% in FY 2005/06 (Table 4.13). Nevertheless,
monthly stock-outs of Cotrimoxazole and Coartem tablets were recorded
in 32% and 27% of the facilities surveyed respectively. The
extraordinarily high stock-out of Cotrimoxazole may be explained by the
increased use of the product for prophylaxis in HIV/AIDS, where demand
is high and steadily growing. This trend is indicative of the need for
increased focus at financing additional needs for Cotrimoxazole. Stock
out of Coartem was attributed primarily to failure by NMS to adhere to
published delivery schedules.

Table 4.13: Health units with monthly stock-outs, by individual
            HSSP indicator: Medicines FY 2004/05 – FY 2006/07
                                          FY 2006/07               FY 2005/06              FY 2004/05
                                        Stock                    Stock                   Stock
                                         card                     card                    card
                                        months                   months                  months
                                           *     % HU               *     % HU              *     % HU
        Any HSSP indicator drug**        216      65%             156      72%            189      65%
 1      Coartem Green***                 186      27%             156      13%            189      21%
 2      Sulfadoxine
        Pyrimethamine tab                 184          14%         141         24%         189         17%
 3      Cotrimoxazole 480mg tab           204          32%         159         44%         189         37%
 4      Oral Rehydration Salts
        (sachet)                          153          24%         109         46%         144         27%
 5      Medroxyprogesterone inj
        ("Depo")                          174          16%         93          36%         111         5%
 6      Measles vaccine                   158           7%         122         10%         171         5%
        Average of 6 HSSP
        indicator drugs                   177          20%         134         31%         166         19%
Notes
*        Maximum stock card-months is 216 (36 facilities x 6 months). A number of facilities did not
         have complete records for all the items and hence less than the maximum stock card
         months was reviewed
**       This refers to proportion of facilities reporting stock out of any indicator drug
***      Coartem Green was selected to replace chloroquine tabs as 1st line antimalarial medicine in
         the survey for the FY 2006_2007


The picture that emerges from the surveys and indicators is that targets
have so far not been achieved due to a combination of factors: poor
medicines management at the facility level, with poor records
management in particular, further decrease in the expenditure of the
cash budgets for medicines (district PHC and hospital delegated funds,
(see section 4.4.3), and inadequate stocks at the national level, at NMS in
particular. Analysis of expenditure data (see section 4.4.3) revealed
continued underperformance on the central level indicator: utilization of
the indicative medicines budget at NMS and JMS. Overall under-
spending on medicines by districts and hospitals exacerbate the
situation of frequent stock-outs at the service delivery level. Without
strong interventions it is unlikely to reach the set target of “80% of health
units without a stock-out of indicator medicines” by the end of HSSP II.
At least – as mentioned before - there is a critical need for a much closer
monitoring and evaluation of the utilization of decentralized funds for the
procurement of EMHS at districts and hospitals.


                                                                                               149
4.4.2 Financing and Procurement of medicines and health supplies
      in FY 2006/07

Planning and financing of Medicines and Health Supplies was the key
subject discussed at the 4th Technical Review Meeting 26-27 April 2007
in Kampala. Levels of routine funding of EMHS were unanimously
considered too low, with an estimated funding through service provider
or MoH budgets of US$ 0.72 for FY 2006/07 representing only a small
fraction of the HSSP II projected costing for EMHS including vaccines at
about US$ 5.30 per capita for the package in its 2nd year. An increasing
proportion of the financing comes through other mechanisms guided by
donors and global initiatives and these multiple funding sources create
predictability and planning problems highlighted in the last AHSPR FY
2005/06. The meeting identified an increasing need for harmonization
and alignment into existing functional financing mechanisms, such as
the Credit Lines. However, cash flow problems at NMS were the cause of
delays in the procurement of EMHS, leading to suboptimal stock levels
and inabilities to deliver the requirements of health facilities. FY 2006/07
has also been the first year of implementation of the newly developed 3-
year rolling plan for the financing and procurement of medicines and
health supplies. This year’s report examines the performance against the
Plan.

Evaluation of the FY 2006/07 Provision of Medicines and Health
Supplies

The 3-year Plan for provision of medicines and health supplies for the
UNMHCP (JRM October 2006 undertaking) showed budgeted inputs of
US$ 175 million in FY 2006/07, representing US$ 6.20 per capita.
Evaluation of the implementation of the Plan has provided preliminary
analyses of procurement performance and disbursement of funds, and
further work is planned to track resource flows through service providers
to the community level.

Realized procurements29 against planned procurements:
Both the procurements horizontally integrated into service provision at
district or sub-district levels (A), and for vertical, specialized or targeted
programmes including those that have received substantial earmarked
funding through global health initiatives to cover introduction or scaled-
up provision of high-cost technologies such as ACTs, ITNs, ARVs for
malaria and HIV (B), realized less than planned procurements. The per
capita spending is summarized in Table 4.14 below.

Table 4.14:             Per capita expenditure on procurements against
                        planned FY 2006/07


29   Value of procurements received by 30 June 2007.



                                                                          150
                                                                              USD per capita
                                                                         Planned                  Actual

                Horizontally integrated (A)                                2.24                    1.67
                 Vertical & specialised (B)                                3.95                    2.39

                               Total                                       6.19                   4.06

Product categories where receipts were substantially less than planned
include condoms for the public sector (US$ -3.6m), credit line items for
NMS own stock (US$ -3.5m), albendazole for lymphatic filariasis (US$ -
3.3m), HIV test kits (US$ -3m), ACT antimalarials (-14.8)30, ARV
medicines (US$ -10.7m), and ivermectin for onchocerciasis (US$ -14.7m).
Figure 4.12 shows the performance for each of the programme categories
in the Plan, comparing the value of supplies actually received at the
national level during FY 2006/07 with the budgeted inputs.

Figure 4.12:             Procurement Performance for various Programme
                         inputs FY 2006/07

             Provision of Medicines and Health Supplies against the FY 2006-07 Plan


                                                               Planned    Actual
      USD millions
            50.00
              45.00
              40.00
              35.00
              30.00
              25.00
              20.00
              15.00
              10.00
               5.00
               0.00
                                     4,5-   6-                                                       12-
                         1-    3-                 7-Med                    9-      10-                       14-
                                    Med&H Lab/Dia                8-BTS                   11-TB      Other
                       UNEPI ReproH               Equip                  Malaria HIV/STI                    Emerg
                                      S      g                                                       CD
             Planned   14.55   9.19    26.76   11.09    1.17      0.64   47.51     37.57   1.20     25.31   0.00
             Actual    15.80   5.78    20.28   4.23     1.08      0.00   30.26     25.69   2.10     7.30    2.21
                                                       Programme category




There are possible explanations for under-performance:
1) The unit value assigned for ivermectin by the manufacturer that
   donated the product may be inflated, exaggerating the deficit and
   giving a distorted impression of investment in the health sector; this
   may also apply for the programme’s cost estimate in the case of
   albendazole for LF.

30   Includes savings made from price reductions



                                                                                                            151
2) Missing data for some line items which may have been provided, e.g.
   HIV test kits and related laboratory supplies purchased by TASO, AIC
   and other PEPFAR implementing partners.
3) Delays in disbursement from the Global Fund related to the
   suspension, in part associated with changes in the responsible
   agencies for PSM affecting procurement of ARVs and HIV test kits and
   related lab supplies; and in part associated with fragmentation of
   planning and intrinsic programming challenges arising from the GF
   system of ‘rounds and phases’.
4) The underperformance of NMS in the procurement of ‘routine’
   medicines and health supplies, and difficulties in ‘keeping up with’
   the increasing volumes of Third Party supplies, which are known
   issues and discussed elsewhere.

In certain cases, budget performance may appear better than it actually
was since some programmed inputs were not specified in the original
Plan, but captured during the Evaluation; e.g. NMS non-credit line
medicines and health supplies, Northern Uganda CAP support.

Table 4.15a gives details of these performance indicators and the
procurement and supply arrangements for the main product categories
within each programme, sub-totaled for those horizontally integrated into
service provision at district or sub-district levels (A).


Table 4.15a:    Realized procurements against planned for Category
                A




                                                                     152
       Programme Product                                                  USD millions                       Procurement            Supply Mgt
        category       category                                         Planned        Actual % of Planned   Responsibility         Responsibility
       UNEPI          Vaccine, pentav.                                     9.450       10.827    115%        Unicef                 UNEPI
       UNEPI          Vaccines, other                                      4.331        4.209     97%        Unicef                 UNEPI
       UNEPI          Inj devices                                          0.770        0.766     99%        Unicef                 UNEPI
  1    UNEPI Total                                                          14.6         15.8    109%
       ReproH         Condoms for pub sector                               5.833        2.221     38%        GF Agent               NMS
       ReproH         Condoms for social marketing                         0.567        0.813    143%        USAID                  AFFORD/UHMG
       ReproH         Contraceptives for pub sector                        0.616        0.564     92%        USAID, UNFPA, NMS      NMS
       ReproH         Contraceptives for social marketing                  2.074        1.919     93%        USAID                  AFFORD/UHMG
       ReproH         Kits, equip for pub sector UNFPA, Danida             0.100        0.258    258%        UNFPA, NMS             NMS
  3    RH Total                                                               9.2          5.8    63%
       Med & HS       Credit line med & HS (NMS own)                       9.451        6.002     64%        NMS                  NMS
       Med & HS       Credit line med & HS (JMS own)                       5.960        6.184    104%        JMS
       Med & HS       Inj devices (Inj Safety Proj)                        1.579        0.738     47%        ?                    NMS
       Med & HS       Medicines for schisto control (SCI Proj)             1.421        0.608     43%        Agent-ImpCollegeLondoMoH-VCD
       Med & HS       Medicines for OI, malaria (GF)                       2.486        0.276     11%        GF Agent             NMS
       Med & HS       Medicines, cotrim/misc. for var. PEPFAR              1.060      missing                ?
       Med & HS       Non-CL med (NMS own)                         not specified        0.247                NMS                  NMS
       Med & HS       Non-CL HS (NMS own)                          not specified        1.080                NMS                  NMS
       Med & HS       Non-CL med (JMS own)                                 3.075        3.543    115%        JMS                  JMS
       Med & HS       Non-CL HS (JMS own)                                  1.723        1.599     93%        JMS                  JMS
 4-5   Med & HS Total                                                       26.8         20.3     76%
       Lab/Diag       Credit line lab supplies (JMS own and CDC)           0.389        0.401    103%        JMS                    JMS
       Lab/Diag       Credit line lab supplies (CDC proj at NMS)           1.102        0.964     87%        NMS                    NMS
       Lab/Diag       Non-CL lab supplies (JMS own)                        0.741        0.508     69%        JMS                    JMS
       Lab/Diag       Lab supplies misc PEPFAR UPHOLD-AIC                  0.464      missing                ?                      ?
       Lab/Diag       Lab supplies misc GF                                 0.334        0.510    153%        Third Party agent      NMS
       Lab/Diag       HIV test kits (JMS own)                              0.266        0.554    208%        JMS                    JMS
       Lab/Diag       HIV test kits for pub sector CDC-JMS                 0.390             ?               ?                      ?
       Lab/Diag       HIV test kits for pub sector CDC-NMS                 1.279        0.746     58%        NMS                    NMS
       Lab/Diag       HIV test kits for pub sector, GF                     1.000        0.188     19%        Third Party agent      NMS
       Lab/Diag       HIV test kits PEPFAR-AIC,TASO                        0.975      missing                ?                      ?
       Lab/Diag       HIV test kits for AIC, Unicef                        0.154             ?               ?Unicef                ?
       Lab/Diag       HIV test kits for ? Unicef                           1.000        0.361     36%        Unicef                 ?
       Lab/Diag       CD4 machines/related, GF                             3.000        0.000      0%        WHO-CPS                MoH-CPHL
  6    Lab/Diag Total                                                       11.1           4.2    38%
       Equip          Equip and instruments (JMS own)                      1.068        0.871     82%        JMS                    JMS
       Equip          Equip and instrum Danida-N.Ug                not specified        0.207                JMS                    JMS
       Equip          Safe water vessels PEPFAR                            0.100      missing                ?                      ?
  7    Equip Total                                                            1.2          1.1    92%
       BTS            Blood bags, lab tests GF-BTS                         0.640        0.000      0%        GF Agent               BTS
  8    BTS Total                                                            0.64           0.0     0%
       SubTotal A                                                         63.4          47.2     74%




Table 4.15b gives details for vertical, specialized or targeted programmes
including those that have received substantial earmarked funding
through global health initiatives to cover introduction or scaled-up
provision of high-cost technologies such as ACTs, ITNs, ARVs for malaria
and HIV (B), and the overall package.




                                                                                                                              153
Table 4.15b:                 Realized procurements against planned for Category
                             B
    Programme Product                                                 USD millions                       Procurement
    category       category                                        Planned         Actual % of Planned   Responsibility
    Malaria       HBMF antimalarials GF                               1.930         0.772                GF agent             NMS
    Malaria       ACT antimalarials GF                               27.310        14.505     53%        WHO-MMMS             NMS & JMS
    Malaria       ACT antimalarials PMI                               2.725         0.293     11%        WHO-MMMS             NMs
    Malaria       ACT antimalarials DfID                        not in plan         0.461                WHO-MMMS             NMS
    Malaria       Other antimalarials GF                        not in plan         0.107                GF agent             NMS
    Malaria       RDTs GF                                              0.04         0.000      0%        ?                    ?
    Malaria       ITN reTx DfID-UPHOLD                                 0.15       missing                ?                    UPHOLD
    Malaria       LLIN - GF                                           10.44        10.405    100%        WHO-CPS              MCP/AFFORD/MalCons
    Malaria       LLIN - JICA                                          0.18       missing                ?Unicef
    Malaria       LLIN - PMI                                          3.025         2.291     76%        Unicef (? AFFORD, Netmark)
    Malaria       LLIN - USAID/PPP Malaria No More                    0.210         0.540    257%        Unicef (? AFFORD, Netmark)
    Malaria       IRS DfID                                            1.000         0.422     42%        WHO-CPS              ?
    Malaria       IRS PMI                                             0.500         0.464     93%        RTI Int.             RTI Int./Districts
  9 Malaria Total                                                      47.5          30.3     64%
    HIV/STI       Fluconazole for OI, Pfizer                  not specified         0.316                ? Pfizer's agent
    HIV/STI       Nevirapine for PMTCT Unicef                         0.200         0.020     10%
    HIV/STI       ARVs GF                                            11.100         6.807     61%        Unicef               NMS
    HIV/STI       ARVs PEPFAR                                         9.400         8.622     92%        Medical Access       Medical Access
    HIV/STI       ARVs Out of Pocket/Misc funders               not in plan         1.536                Medical Access       Medical Access
    HIV/STI       ARVs PEPFAR JCRC                                    6.330         4.076     64%        JCRC                 JCRC
    HIV/STI       ARVs PEPFAR CRS AIDSRelief                          8.460         4.300     51%        Philips Nairobi      CRS/AidsRelief
    HIV/STI       HIV care PEPFAR                                     1.537       missing                ?                    ?
    HIV/STI       HIV home-based care                                 0.200       missing                ?                    ?
    HIV/STI       Infection control materials GF                      0.344         0.010      3%        GF Agent             NMS
 10 HIV/STI Total                                                      37.6          25.7     68%
    TB            Anti-TB drugs GF (+?)                               1.040         2.104    202%        GF Agent             NMS&MoH-NTBLP
    TB            TB lab/diagnostics GF                               0.160 see footnote                 GF Agent             NMS
 11 TB Total                                                             1.2           2.1   175%
    Other CD      Ivermectin for oncho/LF, MSD (See footnote)        22.000         7.300     33%        ? MSD's agent        MoH-VCD
    Other CD      Albendazole for LF                                  3.300         0.000      0%        ?                    MoH-VCD
    Other CD      anti-leprosy drugs, Novartis                        0.012       missing                ? Novartis agent     ?
 12 Other CD Total                                                     25.3            7.3    29%
    Emergencies Supplies for meningitis outbreak WHO            not in plan         0.500                WHO                  MoH/Districts
    Emergencies N.Ug emerg support CAP?                         not in plan         1.705                Unicef               Unicef/Districts
 14 Emergencies Total                                                    0.0           2.2
    SubTotal B                                                      111.6           67.6      61%


    Grand Total                                                     175.0         114.7       66%
    Notes:        Commodities for oncho/LF moved from Med&HS to Other CD; TB lab actual included in Lab misc.



This first Evaluation of the Plan suggests possible improvements in
procurement and supply management for consideration:
1) Limiting the number of different modalities and/or agents dealing
   with a programme or product category is likely to improve
   performance. A candidate product area for rationalization is the
   provision of HIV test kits and related lab supplies. This could be
   achieved by harmonization among partners and/or pooling of funds


                                                                                                                                 154
   (case in point: credit lines for medicines, and presently medical
   equipment), and/or integration using common arrangements for
   procurement and supply (case in point: UNICEF agency role in
   vaccines provision).
2) The demonstrated regular and continuous provision of ARVs to a
   number of implementing partners in the private/PNFP sector, funded
   by PEPFAR through CDC and using Medical Access Uganda Ltd as
   the procurement agent emerges as a positive model which deserves
   further study, in terms of efficiency and cost. Medical Access has
   demonstrated ‘just in time’ procurement and kept pace with
   increasing demand and volumes, utilizing warehousing facilities at
   JMS.
3) There    is    also   indication    that    funding      support   for
   albendazole/praziquantel      for    mass       anthelminthic     and
   antischistosomal treatment, or other ‘routine’ essential medicines/HS
   such as cotrimoxazole for prophylaxis in HIV, and autodisposable
   syringes would be better ‘re-integrated’ horizontally and channeled
   through service provider budgets, either with a degree of control or
   earmarking using the credit line model, or as direct grants to service
   providers. In the medium term, the same applies for high-cost ACTs
   for malaria and ARVs, with design of safeguards in the form of
   dedicated systems for resource management and tracking.

The full report of the Evaluation quantifies actual outputs in terms of
commodities and highlight shortfalls in relation to target service
provision or coverage indicators. Feedback from this and subsequent
Evaluations will hopefully contribute to iterative improvement of the
future Rolling 3-year Plans.


4.4.3 Utilization of service provider budgets for medicines (PHC and
      Credit Line)

Analysis of the information from the Logistics Information Systems and
Sales Statistics of NMS and JMS indicates that overall (Districts, General
and Regional Referral Hospitals) 53% of PHC indicative budget for EMHS
was spent at NMS and/or JMS in FY 2006/07 compared to 55% in FY
2005/06 (excluding National Referral Hospitals) (see Table 4.16 and
Figure 4.13). Out of the 53% PHC cash expenditure on EHMS, 69% was
spent in JMS while 31% was spent in NMS. The Regional Referral
Hospitals spent the least percentage at 38% of their indicative EHMS
budget at NMS and JMS (Table 4.13, Figure 4.14, 4. 15 and 4.16). The
low cash expenditure in NMS propagates the cycle of underperformance.
Although performance by NMS has been below expectations, these trends
do not necessarily coincide with available stock-out information from
NMS and JMS and therefore justifications for the trend have to be sought
outside the usual complaints about the performance of NMS.

Table 4.16:     Allocations for EMHS compared with expenditures
                for EMHS at NMS & JMS FY 2006/07


                                                                      155
                                                            Expenditure   at
Level + Type of funding                   EMHS Allocation                        %
                                                            NMS&JMS
National Referral Hospitals grant           5,438,253,000       641,263,528    11.8%
Credit Line
Regional Referral Hospitals Credit Line     1,800,000,000     1,863,174,286    103.5%
District General Hospitals Credit Line      3,600,000,000     4,135,415,880    114.9%
District PHC - DHOs Credit Line             7,206,084,959     7,459,051,925    103.5%
Sub Total - Credit Line                   12,606,084,959    13,457,642,091      107%
PHC Grant
Regional Referral Hospitals grant           2,903,260,000     1,112,157,939    38.3%
District General Hospitals grant            4,245,000,400     2,312,795,621    54.5%
District PHC - DHOs grant                  11,057,917,595     6,417,966,316    58.0%
Sub Total - Grant                         18,206,177,995      6,632,318,026    53%%
Overall Total                             36,250,515,954    23,941,825,495     65.3%

Districts on average spent 58% of their indicative EMHS budget at NMS
and/or JMS (see Figure 4.13). Seventeen districts used than 80% of their
PHC indicative budgets to purchase EMHS at NMS and/or JMS. Eleven
districts appeared to have mobilized additional funds for EMHS and
therefore registered expenditures of more than 100% of indicative
budgets; these districts include: Bukedea (155%), Kumi (145%), Gulu
(145%), Ibanda (140%), Amolatar (125%), Kaberamaido (119%), Katakwi
(111%), Mbarara (109%), Kiruhura, nebbi, and Pader (each 101%). The
figures indicate almost equivalent EMHS spending at NMS and/or JMS
compared to the previous year, although only five districts registered an
expenditure of over 120% compared to ten in FY 2005/06.

Only 55 districts recorded more than 40% utilization of their indicative
EMHS budgets at NMS and/or JMS; three districts recorded 0%, four
districts recorded 1 – 10%, 18 districts recorded 11 – 40%, 20 districts
recorded 41 – 60% and 18 districts recorded 61 – 80%. These figures
show only a slight deterioration compared to FY 2005/06.

Figure 4.13:           Variation in Medicines spending by districts at
                       NMS & JMS against the Indicative Budgets for FY
                       2006/07




                                                                               156
                               Use of PHC grants for EMHS at NMS & JMS

                 Average
                Bukedea
                     Kumi
                      Gulu
                   Ibanda
                Amolatar
            Kaberamaido
                 Katakwi
                 Mbarara
                 Kiruhura
                    Nebbi
                    Pader
                  Mityana
                  Koboko
                     Busia
                Bushenyi
                  Kabale
                     Apac
                     Moyo
                 Kyenjojo
                      Jinja
            Nakasongola
              Kapchorwa
                    Bugiri
                   Pallisa
                    Mbale
                Kayunga
                   Tororo
                  Kasese
                  Wakiso
                    Oyam
                      Arua                                      % Total PHC expenditure at NMS/JMS
                Rukungiri                                       %NMS
                    Hoima
                Adjumani                                        % JMS
                  Isingiro
                  Kitgum
                Kampala
Districts




               Nakaseke
                  Kibaale
             Nakapiripirit
                  Amuria
                 Masaka
                    Soroti
                 Mayuge
                    Kotido
                  Sironko
                Kaabong
                  Dokolo
                   Buliisa
                  Budaka
                 Mukono
             Bundibugyo
                Kabarole
               Kalangala
                     Mpigi
              Sembabule
             Namutumba
                  Masindi
                 Butaleja
                   Iganga
                  Kiboga
                  Luwero
                Mubende
                    Rakai
                       Lira
                Buduuda
               Ntungamo
                Manafwa
              Kamwenge
                  Yumbe
                     Abim
               Lyantonde
                  Moroto
                    Kisoro
                   Amuru
                Kanungu
                   Bukwa
                   Kamuli                     % of EMHS funds used
                    Kaliro
                    Nyadri

                          0%    20%   40%   60%   80%    100%     120%      140%       160%      180%




                                                                                          157
Figure 4.14:                              Use of General Hospital Grants for EHMS (=40% of
                                          PHC non wage grant) at JMS and NMS
                                                                                                       at JMS and NMS
                                  Average         14.3                         40.2

                       Lyantonde Hospital                                  59.4                                                      109.1

                          Kitagata Hospital0.0                                                                130.1

                            Atutur Hospital 2.4                                                 98.9

                            Bugiri Hospital 3.8                                              88.3

                            Nebbi Hospital0.0                                             91.8

                             Abim Hospital0.0                                            88.3

                           Kagadi Hospital 0.2                                           87.2

                         Adjumani Hospital                30.4                                         54.3

                           Bwera Hospital0.0                                            84.6

                         Kayunga Hospital                        41.8                                   35.8

                          Gombe Hospital              24.0                                      53.3

                          Kawolo Hospital                                  61.4                                9.2

                      Bundibugyo Hospital0.0                                 67.7

                           Kamuli Hospital            23.1                               41.2

                         Entebbe Hospital 2.4                               60.2

                       Kapchorwa Hospital0.0                               59.3

                             Apac Hospital0.0                           57.3
 District Hospitals




                         Busolwe Hospital0.0                            56.2

                         Mubende Hospital         13.3                         42.8

                      Kiryandongo Hospital               26.1                         29.3

                           Kiboga Hospital           21.1                         32.0

                          Masindi Hospital               28.2                       23.0

                         Kaabong Hospital      8.7                      39.4

                           Tororo Hospital            25.2                   15.5

                           Pallisa Hospital          20.1                  20.0

                              Itojo Hospital                31.8                  7.5

                          Kalisizo Hospital                     39.0                0.0

                        Nakaseke Hospital             24.2                  14.3

                            Rakai Hospital               28.6                8.9

                           Yumbe Hospital0.0             28.0

                          Mityana Hospital           19.3            8.4

                           Kitgum Hospital 1.8        20.6

                           Iganga Hospital 4.7           17.2

                           Anaka Hospital0.0         21.7
                                                                                                                                               % of EMHS grant at
                          Bududa Hospital         15.1         3.5
                                                                                                                                               NMS
                        Kambuga Hospital       7.6       9.0
                                                                                                                                               % of EMHS grant at
                           Kisoro Hospital     6.4 3.2                                                                                         JMS
                                           7.0
                            Moyo Hospital0.0

                                             0.0
                           Moroto Hospital 5.8


                                           0.0                 20.0                40.0                60.0           80.0   100.0     120.0      140.0   160.0     180.0
                                                                                                        Percentage of EMHS funds used




                                                                                                                                                           158
Figure 4.15:                                                                  Use of Regional Referral Hospital Grants for EHMS
                                                                              (=40% of PHC non wage grant) at JMS and NMS

                                                                       TOTALS / Average 6.7                 31.6

                               Mbarara Regional Referral Hosp
                                                          0.0                                                       69.3

                                                                   Soroti Referral Hospital
                                                                                         1.3                       60.1
 Regional Referral Hospitals




                                                                 Lira Reg. Referral Hospital8.0                     51.5

                                                                   Hoima Referral Hospital            32.1                 19.6

                                                                    Arua Regional Hospital
                                                                                         4.3                 42.2

                                                                                         2.2
                                                                            Jinja Hospital             34.2

                                                                         Masaka Hospital       14.7         14.7

                                                                  Mbale Regional Hospital 11.5        8.9

                                                                                       0.6
                                                                  Kabale Regional Hospital 14.7

                                                                                      6.0 8.0
                                                          Fort Portal Regional Hospital
                                                                                                                             % of EMHS grant at NMS
                                                                    Gulu Regional Hospital7.4
                                                                                       0.0                                   % of EMHS grant at JMS


                                                                                         0.0      10.0 20.0 30.0 40.0 50.0 60.0 70.0 80.0
                                                                                                       Percentage of EMHS funds used



Figure 4.16:                                                                  Expenditure on EMHS by Mulago and Butabika
                                                                              Hospitals at NMS and JMS
                                                                   6,000,000,000
                               Approved (and released) budgets




                                                                                                                                      Nat Ref Hosp EMHS grants
                                                                   5,000,000,000
                                                                                                                                      NMS sales to Hosp
                                                                                                                                      % of EMHS grant at NMS
                                                                   4,000,000,000                                                      JMS sales to Hosp



                                                                   3,000,000,000


                                                                   2,000,000,000


                                                                   1,000,000,000


                                                                                  0
                                                                                         Mulago University Hospital                    Butabika Hospital
                                                                                                                           Hospital


Analysis of the performance of the Districts/ DHOs utilization of Credit
Line resources availed during the year for the procurement of EMHS



                                                                                                                                                                 159
indicates that orders were placed well above the individual annual
allocations of the Credit Line (Figure 4.17). As with the General and
Regional Referral Hospitals this indicates an intention to utilize in full
the available credit line allocations at NMS regardless of whether or not
they need the supplied products. This masks the poor performance by
the NMS.

Figure 4.17:                                  EMNS Credit Line Utilization by Districts FY
                                              2006/07

                                                                     EMHS Credit Line Utilization by Districts/DHOs
300.0%
                                  Amount of CL utilized as % of CL allocation
                                  Amounts Ordered as % of CL allocation
                                  Linear (Amount of CL utilized as % of CL allocation)
                                  Linear (Amounts Ordered as % of CL allocation)

250.0%
         Utilization of Cl in %




200.0%




150.0%




100.0%




 50.0%
                  Moyo
               Mityana




             Manafwa
              Katakwi




              Mayuge
                  Mpigi




                 Nyadri




             Bushenyi
               Masindi
                Bukwa
            Lyantonde




          Bundibugyo


                 Mbale



              Masaka




               Luwero
             Kayunga
              Mbarara




             Mubende



              Kyenjojo




           Kapchorwa
              Mukono




                Moroto
              Average
                 Pader




                 Rakai




                 Nebbi
          Nakapiripirit




                 Bugiri




                 Soroti
             Rugungiri
                 Kisoro




              Butaleja


                  Kumi
           Kamwenge
               Kabale

               Budaka
             Bukedea

                   Jinja


                   Arua
            Nakaseke

               Dokolo
               Koboko
               Kiboga
             Amolatar




                Kamuli




             Kanungu
                Tororo
                Pallisa
             Kabarole
            Kalangala




                Ibanda
                 Kotido
             Kaabong
               Isingiro
         Nakasongola
               Kasese
                   Gulu



                    Lira

               Kibaale


               Sironko
                Iganga
               Bududa
                  Busia
                 Kaliro
              Kiruhura

                Buliisa
             Adjumani
                Amuru




             Kampala

                  Apac




               Yumbe


               Amuria
            Ntungamo




                 Hoima
         Kaberamaido




           Sembabule
                 Oyam
                  Abim




          Namutumba




               Kitgum
               Wakiso




                                                                                          Districts

For 50 districts that submitted data on EMHS budgets and expenditures
for FY 2006/07, the expenditures did not often correspond to the
indicated amounts in the guidelines for FY 2006/07 Districts Transfers
for Health Services. And district information on purchases from NMS and
JMS rarely corresponded to information received from NMS and JMS.
This casts serious doubts on the reliability of financial information
received from districts and hospitals.

Regarding the PHC expenditure on EHMS, crude analysis of the
presented reports indicates that of the cash funds (PHC) not spent at
NMS and/or JMS, about 40% may have been spent in the private sector
(a substantial increase from 23% in FY 2005/06). There is critical need
for a much closer monitoring and evaluation of the utilization of
decentralized funds for the procurement of EMHS at districts and
hospitals. Information signals a substantial underutilization of the cash



                                                                                                                      160
funding for EMHS and justifies increased ring fencing of EMHS budgets
in Credit Line structures.

Credit Line budgets have remained unchanged over the three years
despite population growth and inflation. Utilization of the Credit Lines
has been well over 100% for all levels with General Hospitals even
scoring 115%. Table 4.17 shows the utilization of indicative EMHS
budgets for GoU service providers by level.

In view of the consistently decreasing low service levels of Credit Line
items at NMS the Credit Line utilization is impressive. (The 29 CL Core
items scored only 45% service level by June 2007 while CL items for
Hospital and Level IV service providers only scored 9% service level by
June 2007. The service level is determined by the amount delivered
relative to the amount ordered (Figure 4.18). But the health units could
only achieve this by ordering on average 160% above their CL ceilings.
This adaptation regularly leads to accumulation of products with lower
priority and tying of funds in unnecessary oversupplies. The consistent
full utilization of the Credit Line therefore justifies the need to review the
quality of NMS (and JMS) deliveries in relation to the actual orders from
facilities.
Table 4.17:               Utilization of indicative budgets for EMHS (GoU
                          health units) FY 2004/05 – FY 2006/07

                                      PHC CASH for EMHS                                 CREDIT LINE
                            Medicines      Purchases      % Spent            Budget      Purchases      % Spent
                            Budget in     (NMS/JMS)       at JMS            (NMS) in      (NMS) in      at NMS
                             Ugshs          in Ugshs      and /or            Ugshs         Ugshs
                             billions        billions      NMS               billions      billions


               FY 06-07        11.4           6.4           58%                7.2           7.5          104%
   Districts




               FY 05-06        9.9            5.9           60%                7.2           7.1          99%
               FY 04-05        11.2           5.7           51%                7.2           6.4          89%
 Hospitals




               FY 06-07        4.2            2.3           55%                3.6           4.1          115%
 General




               FY 05-06        4.1            2.0           48%                3.6           4.0          111%
               FY 04-05        4.1            2.0           49%                3.6           2.9          79%
Hospitals




               FY 06-07        2.9            1.1           38%                1.8           1.9          104%
Regional
Referral




               FY 05-06        2.5            1.2           48%                1.8           1.7          93%
               FY 04-05        2.9            1.3           45%                1.8           1.7          94%
                            Source: NMS and JMS sales data.
                            The proportion of cash funds spent at JMS is increasing, while overall spending of cash
                            funds at NMS and/or JMS decreases at Districts and Regional Referral Hospitals.




4.4.4 Performance of National Medical Stores and Joint Medical
Stores


                                                                                                161
The HSSP II aims at achieving at least 90% availability of core credit line
and 80% availability of other items required for the delivery of the
UNMHCP at the national supply agencies.

National Medical Stores

The reported service level at NMS during FY 2006/07 was 62% on
average for the 29 core credit line, 23% for hospital and HC IV level items
and 71% for the credit line overall. As shown in Figure 4.18 credit line
service levels showed a continuing decline over the year. Despite the
decreasing service levels and the urgent need to actively build up
satisfactory customer (health provider) relationships and more reliable
services, NMS is still functioning as a vital link in the provision of EMHS
to public health providers. However for NMS to remain a vital link it
needs to substantially improve on its overall performance.

NMS has worked out a new fee scale and billing system for all the
activities it carries out for and n behalf of Third Parties (JRM October
2006 undertaking). It will become operational in next financial year.

Figure 4.18:                                National Medical Stores Credit Line Service Level FY
                                            2006/07

                   120%

                                                                                                                                       Core 29 items NMS
                                                                                                                                      stock Service level

                   100%


                                                                                                                                       Additional Items NMS
                                                                                                                                      stock Service level
                   80%
 % Service Level




                                                                                                                                      Hospital and Level 4
                   60%                                                                                                                items NMS stock Service
                                                                                                                                      level



                   40%                                                                                                                Contraceptives Service
                                                                                                                                      level



                   20%
                                                                                                                                      Coartem Service level



                    0%
                          Jul-06   Aug-06   Sep-06   Oct-06   Nov-06   Dec-06   Jan-07   Feb-07   Mar-07   Apr-07   May-07   Jun-07
                                                               Month of year (January missing)




In FY 2006/07, NMS distributed supplies valued at Ugshs 99bn
(compared to Ugshs 46bn in FY 2005/06) of which Ugshs 83bn (Ugshs
29bn in FY 2005/06) were Third Party items i.e. non-trading stock. Third
party supplies as part of NMS overall supplies therefore increased from
64% in FY 2005/06 to 84% in FY 2006/07. This increase is strongly
related to the high value of Coartem and ARVs. The involvement of NMS
and/or JMS in the planning for Third Party procurements remained
either minimal or non-existent, although NMS has been keen to take on



                                                                                                                                           162
some of the procurement activities. The challenges this created was
crowding at the NMS, the need for more storage space, parallel and
slowed order processing and severe strain on human resources and
logistics. This affected the entire supply chain, resulting in inefficiencies
in distribution of not only Third Party commodities, but also the routine
supplies to health facilities.

Joint Medical Stores

Credit Line allocations available in FY 2006/07 to NGO facilities totaled
Ugshs 3,440m (includes Ugshs 190m carried forward from previous
year). JMS recorded Credit Line sales of Ugshs 3,171m (Table 4.18)
indicating a Credit Line utilization of 92%. This is above the 90%
benchmark, particularly for UCMB and UPMB, who scored 95% and 97%
respectively.

Table 4.18:            Joint Medical Stores Credit Line Sales FY 2006/07
                        UCMB       UPMB          Others         Total
 Credit Line**           1,852      989           599          3,440
 Sales**                 1,756      955           460          3,171
 % Utilization            95         97           77             92
**Figures expressed in millions


There was a general improvement in comparison with the previous
financial year (FY05/06) in the Credit Line utilization for all categories
except for Uganda Catholic Medical Bureau that dropped by 1% as
shown in Table 4.19 below.

Table 4.19:            Credit Line Utilisation comparison FY 2005/06 and
                       FY 2006/07
       FY               UCMB       UPMB          Others        Total
    2005/06               96         86           74             90
    2006/07               95         97           77             92

Overall JMS sales from their own trading stocks amounted to Ugshs
31bn (about US$ 17m). This includes sales to GoU institutions from their
EMHS grants to the amount of Ugshs 7,260m (US$ 4.0m). The value of
Third Party items distributed in the whole FY was Ugshs 35bn (US$
19m). JMS charges 3.5% of the cost for handling Global Fund items, but
only delivers within Kampala Central region.

Increasing access to Laboratory Diagnostic Commodities

On April 30th 2007 JMS marked the end of the first year of
implementation for the laboratory project. As one of the partners of the
Ministry of Health, JMS is implementing the NMS/CDC laboratory
project under the PFNP sector. The project objective is to strengthen the
area of diagnosis in the fight against HIV/AIDS through improving the



                                                                         163
availability of laboratory commodities. The laboratory credit line
utilization trend for the first 12 months is highlighted below (Table 4.20).

Table 4.20: Utilization of the Laboratory Credit Line at JMS FY
            2006/07
                                                   May 06 - April 07
  No. of Units     Authority         Credit Line      Utilization    % Utilization        Balance
      128          UCMB             246,321,293      167,282,797          68           79,038,496
       76          UPMB             139,994,163       86,871,689          62           53,122,474
       22          UMMB              38,456,359       27,188,002          71           11,268,357
       27          I & LNGO          41,906,081       27,992,382          67           13,913,699
      253           Totals         466,677,896      309,334,870           66         157,343,026
Figures expressed in Uganda Shillings


The percentage utilization was low across the different authorities as was
expected for a new project. Initiatives taken to improve the trend
included publication of the project beneficiaries and funds allocated in
print media, sharing of information with the bureaus, sensitizing
customers through workshops organized by the bureaus and customer
days.

Increasing access to Reproductive Health Commodities

As a measure to reverse the high Maternal Mortality Ratio, Safe Delivery
Kits (Mama Kits) were made available to districts through NMS from FY
2005/06. During FY 2006/07 NMS distributed 30,793 Mama Kits. A
total of 69 districts received mama kits, out of which only 4 districts
received over 2,000 mama kits, 4 districts received between 1,000 and
2,000, 24 district received between 100 - 1,000 mama kits and 37
districts received less than 100 mama kits for the entire FY 2006/07.
15,070 Mama Kits were ordered from JMS for distribution to Northern
Uganda as part of the humanitarian response. Comparing the numbers
of kits distributed to the number of births in one year, it is clear that the
use of mama kits needs to be promoted more effectively.

Summary of Performance of the Pharmaceuticals and Health
Supplies Division

The most significant achievement of the year was the upgrade of the
pharmaceutical section to a division (partial fulfillment of JRM October
2006 undertaking). This serves as a foundation for the gradual
establishment of an effective pharmaceutical management structure in
the MoH headquarters. With an additional establishment of three new
posts yet to be advertised it is possible that the division will further
enhance its activities in improving medicines and supplies management
in the sector.

During the FY 2006/07, the Pharmaceutical Section continued to
coordinate, supervise and support the sub sector activities in the areas of
Essential Medicines and Health Supplies (EMHS) Management at all


                                                                                       164
levels of care. The major activities and achievements during the year
included:

 i.    Consolidation of the coordination, supervision and management of
       the Medicines Credit Line facility
 ii. Continued support to the NMS and JMS in improving their
       infrastructure and technical capacity with a view to improving the
       performance of the institutions
 iii. Secretariat to the Working Group on Medicines Procurement and
       Management
 iv. Completion of          the 3-year rolling integrated and harmonized
       procurement plan frame for Medicines and Health Supplies that
       includes the road map for its implementation (JRM October 2006
       undertaking)
 v. Coordination of the development process for the construction of
       infrastructure and technical and educational capacity at Makerere
       University to train Pharmacists and Pharmacy technicians
 vi. Provision of technical support to a number of (new) districts and
       general hospitals
 vii. Review of the Essential Medicines List of Uganda (EMLU), which is
       now ready for printing and dissemination
 viii. Continued support to the various MoH technical programmes
 ix. Initiation and construction of two district stores in Mayuge and
       Amuria districts
 x. Successful co-organization in partnership with the Health Planning
       Department of the 4th Health Sector Technical Review Meeting that
       focused on medicines and supplies
 xi. Detailed assessment of 60 ART sites in 34 districts and PNFP
       facilities in 16 districts.

Challenges and constraints
The challenges for medicines management and use, however, continue to
increase with the ongoing scale up of response to HIV/AIDS, malaria and
TB treatment and diagnostics and the increasing demand for resources
for Non Communicable Diseases (Cancer, Diabetes, Cardiovascular
conditions, etc). Within districts improvements in pharmaceutical
management capacity continues to be deferred, with a large proportion of
the existing posts for pharmaceutical cadres remaining unfilled. The
major concerns therefore remain:

  i.   Continued lack of Human Resources for the sub sector specific
       needs compromises efforts aimed at improving management of
       medicines
  ii. Underfunding for EMHS - particularly to Health Centres IV -
       disables distributive equity and country wide functionality of the
       theatres in these Health Centres, leading to slow progress in
       improving MMR indices.
  iii. Achieving the minimum desired levels of stock availability of
       supplies both at the NMS and in health facilities



                                                                     165
  iv.   Inadequate sector regulation and poor adherence to standards,
        leading to irrational use of medicines, poor compliance and
        wastage
  v. Inconsistencies and ambiguities in existing laws and regulations
        pertaining to EMHS
  vi. Low level of Pharmacovigilance practice (detection, assessment,
        understanding and prevention of Adverse Medicines Reactions)
        and reporting
  vii. Insufficient capacity to manage EMHS to the desired levels within
        the public health facilities
  viii. All the above leading to a continued inability to fulfill the
        expectations of the people of Uganda in providing the necessary
        care and services as specified in the UNMHCP.


4.5     Diagnostics and Blood Transfusion Services

4.5.1 Laboratory Services

The Central Public Health Laboratories (CPHL) is the technical focal point
for laboratory services in the Ministry of Health. It provides the required
laboratory support to all divisions and programs in the sector.

Mission:
To be a guiding organ in the prevention as well as control of disease and
the promotion of health through early detection of disease in Uganda in
order to achieve overall sustainable development.

Strategic objectives
   To develop a comprehensive health laboratory services policy
   To develop and manage a national laboratory quality assurance
   system
   To build capacity for effective laboratory support at all levels of the
   Health Care Delivery system
   To establish a sustainable laboratory supplies system
   To strengthen central capacity at the MoH to co-ordinate and provide
   effective stewardship for the national laboratory network

Achievements
   The development of a Health Laboratory Policy was initiated and an
   advanced draft is available

   A review of Laboratory Standard Operating Procedures was carried
   out. The revised SOPs are ready for printing and dissemination

   A Laboratory Safety Manual has been developed and is ready for
   printing and dissemination.

   Guidelines have been developed for a National External Quality
   Assurance Scheme and SOP’s for panel preparation are being


                                                                       166
   finalized. Reference laboratories that will prepare quality assurance
   panels have been identified and a national laboratory QA steering
   committee is being formed. It is expected that the scheme will take
   off in November 2007 in eight pilot districts with a total of 60
   participating laboratories.

   Capacity for supervision of laboratory services at the district level has
   been strengthened. Eighty (80) districts have received a motorcycle
   each for supervision of laboratory services. A standard supervision
   guideline and checklist was developed and disseminated. Each
   district was availed some funding to conduct supportive supervision
   of laboratory services.

   A massive roll out of training on rapid HIV testing was conducted
   with a total of 389 laboratory personnel and 178 non-laboratory
   health workers being trained. In addition to this, refresher training
   was given to 280 laboratory workers (HCIII, HCIV and district
   hospitals) in routine laboratory procedures; 180 clinicians and 160
   counselors in appropriates use of the laboratory; and 25 laboratory
   technologists from Regional Referral Hospital (2 each) in routine
   servicing and simple repair of CD4 equipment.

   Laboratory infrastructure in 32 Health Centre IVs were rehabilitated
   and remodeled to conform to national standards.

   A laboratory supplies credit line scheme was established and is being
   consolidated. From July 2006 to December 2006 supplies to all
   laboratory units were vertically distributed, and then from January to
   date the pull system was adopted. All laboratories in-charges, district
   laboratory focal persons and district storekeepers were trained in
   laboratory logistics management. The necessary logistics tools were
   developed, produced and disseminated.

   In order to strengthen Central Level capacity, the post of Principal
   Research Officer which was vacant was filled and the officer has
   already effectively assumed duties.

Major Challenges/Constraints

   Low status of the Central Public Health Laboratories
At a unit level, CPHL is not able to effectively advocate for laboratory
services which are vital for the success of many of the health programs.

   Poor staffing
There are only three established officer, Principal Research Officer, Chief
Technologist and Senior Technologist. This core staffs have been able to
realize the above achievements because of extra support in the form of
Technical Assistant (TA) from development partners and some staff hired
on the establishment for CPHL.



                                                                        167
   inadequate means of transport
There are only two functional vehicles. This made particularly technical
support supervision very difficult.

   Inadequate budgetary allocations.
CPHL was allocated only Ugshs 25m for the whole year under Program
09. This was insufficient for implementation of planned activities.

   Delayed release of funds
There are unnecessary delays in the release of funds for the
implementation of activities, which release may take up to 3-4 months to
be effected.


4.5.2 Blood Transfusion Services

The mission of Uganda Blood Transfusion Services is to achieve a safe,
efficient and sustainable national blood transfusion service based on
healthy volunteer donors and able to meet the needs of Uganda’s health
care system while promoting a good blood transfusion system.

The UBTS has an important task of meeting the increased demand for
blood transfusion especially at Health Centre IVs. Most of the blood is
used for transfusion of children and mothers; 50% of all blood collected
is for treating children with severe anemia largely due to malaria,
intestinal worm infestation and malnutrition; a further 25% the blood is
required to treat pregnant women with anaemia and complications of
child birth.As the accessibility of health services by the rural population
increases the need for more blood for transfusion will increase; this will
require more resources to meet the increased demand and efficiency in
utilizing such resources.

The UBTS currently operates 7 regional blood banks at Arua, Fort Portal,
Gulu, Kitovu, Mbale, Mbarara and Nakasero in Kampala, and blood
collection centres at Hoima, Kabale, Masaka, Soroti and Lira. During the
implementation period of HSSP II (2005/06 – 2009/10), a further 5
regional blood banks will be established alongside the remaining referral
hospital to support patient care in these areas of operation.

UBTS operations are aligned to the 4 specific objectives, with their
targets, as set out in the HSSP II i.e.,

1.1   To expand the blood transfusion infrastructure to operate
      adequately within a decentralized health care delivery system.
1.2   To increase the annual blood collection necessary to meet the blood
      requirements of all patients in the hospitals throughout the whole
      country.
1.3   To test all blood for transfusion transmissible infections (TTIs) and
      operate an effective, nationwide Quality Assurance Programme that
      ensures security of the entire blood transfusion process.


                                                                       168
1.4        To ensure continuous education and training in blood safety.

Achievements in FY 2006/07
• Construction of 2 modern regional blood banks at Mbale and Mbarara
  referral hospitals which had begun in April 2006 progressed
  satisfactorily. The building at Mbale is about 90% complete, whereas
  one at Mbarara is about 70% complete with funding from CDC
  (PEPFAR).
• In line with the health sector objectives, UBTS has its own specific
  vote status.     This has enabled more efficient operation of the
  institution.
• The UBTS Interim Board of Directors recommended an employment
  structure for the UBTS. The structure has been approved by the
  Ministry of Health and the Ministry of Public Service, and is in the
  process of being filled.
• During the FY 2006/07, another blood collection team was
  established at Masaka Regional Referral hospital. This is the 19th
  mobile team for the whole country.
• Using the resources provided in FY 2005/06, and with further
  assistance from the CDC (PEPFAR Programme), the UBTS was able to
  provide transport for recruitment of blood donors and collection of
  blood, reagents for testing of the blood and distribution of the safe
  blood to all hospitals in the country.
• During the Financial Year 2006/07, UBTS collected about 130,000
  units of blood, an increase of about 10% of over the previous year
  (Figure 4.19). All the blood donors, 99%, were voluntary non-
  remunerated blood donors.

Figure 4.19:            Regional Blood collection FY 2005/06 – 2006/07

           140,000


           120,000


           100,000

            80,000
  Litres




            60,000


            40,000


            20,000


               -
                     Kitovu   F/Portal   Mbale   Arua       Gulu   Central   Mbarara    Total
                                                   Region
                                     2005/06                         2006/07




                                                                                       169
•        All hospitals in the country received safe blood for transfusion from
         any of UBTS regional blood bank. Such blood is tested for HIV,
         hepatitis B and C and syphilis. HIV seroprevalence in the collected
         blood was 1.3%, which has declined from 1.7% (a decline of 23.5% in
         one year! Figure 4.20). The prevalence of Hepatitis B, however,
         decreased by 20% in FY 2006/07 compared to 2005/2006.
         Prevalence for Hepatitis C is 3% but that for syphilis is <0.5%.

Figure 4.20:                  HIV and Hepatitis test results FY 2005/06 –
                              2006/07

                 14.00

                 12.00

                 10.00
    Percentage




                  8.00

                  6.00

                  4.00

                  2.00

                   -
                         Kitovu   F/Portal   Mbale      Arua            Gulu   Central   Mbarara     Total
                                                               Region
                                  % HIV 2005/06                                % HIV 2006/07
                                  % Hepatitis 2005/06                          % Hepatitis 2006/07


•        During FY 2006/07, extensive training in blood transfusion for
         various cadres of health workers was implemented by UBTS. Cadres
         that attend training courses include doctors, senior technicians,
         nurses, clinical officers and final year clinical officers in their training
         schools.



Major Challenges/Constraints




•        Funding for construction of regional blood banks is available for two
         out of seven blood banks. All the others continue to operate in
         inadequate facilities, which compromise the standards of operation.
         More equipment for blood processing and storage is urgently needed




                                                                                                   170
•   Testing and storage of blood need constant electricity. Load shedding
    lasting up to 24 hours (Fort Portal) is a major challenge given the fact
    that UBTS cannot afford to buy standby generators for all blood
    banks and operate them for many hours daily.



•   There is inadequate transport for collection of blood in the field. Staff
    on mobile teams who spend long hours in the field do not have
    adequate facilitation.

•   The reference laboratory at Nakasero is too small to perform functions
    of blood processing and training of technical staff.




4.6    Information for Decision Making

4.6.1 Health Management Information System

Resource Centre Division is composed of the HMIS/Databank,
Documentation Centre/Library and the ICT sections. Health information
is both an input and output of a health system. It acts as an internal
combustion engine to propel and re-direct the clinical interventions in
the health system. With support from DANIDA, HMIS tools were reviewed
and revised. The revised forms however are inadequately distributed and
not effectively utilized. To improve analysis and interpretation of HMIS
data, guidelines and generic data analysis formats for all levels have been
developed and distributed. New quarterly performance assessment
formats for HSSP and program indicators for all levels were developed
and distributed to all districts.

Documentation Centre/Library deals with the storage and dissemination
of health and health related documents both electronically and in
hardcopy form while the ICT section is responsible for providing fast and
reliable communication both at the Centre and at the district levels
which has resulted to the establishment of a Local Area Network, Wide
Area Network and an Internet link for the Sector

The goal of the Resource Centre is to establish and maintain a
comprehensive source of routine health information for Planning,
Implementation and Evaluation (PIE) of the Health Sector.

Achievements

The Resource Centre continued to provide health related information for
Policy formulation, Planning, Monitoring and Evaluation of HSSP II.
During FY 2006/07, there was notable improvement in data



                                                                         171
management at service delivery points. Data utilization in Planning and
decision-making has also improved.

Table 4.21: Achievements in Health Information System FY
            2006/07
Indicator                  Baseline     Target for   Achieved   Comments
                           FY           FY
                           2005/06      2006/07
HSSP II indicators
Proportion of districts                     100%        95%     Decline due to factors like the
submitting complete HMIS                                        creation of new districts
reports
Proportion of districts                      90%        68%     Decline due to factors like the
submitting timely HMIS                                          creation of new districts
reports
Central level programme performance indicators
Availability of
data/information other than
HMIS in the databank
Updated MoH website                         100%                Departmental updates       not
                                                                readily available

HMIS/Databank
• The Out Patient & In Patient module for HMIS was developed and
  rolling out to district is going on
• Development of Health Infrastructure Information Systems is going
  on
• Discussions to have the Drug Logistics Information Systems
  developed is also in progress
• The development of the Human Resource Information System is on
  going
• HMIS feedback has been strengthened by Internet linkages.
• HMIS support supervision to lower levels increased
• 18 districts were trained in HMIS Data Management.
• HMIS data validation focusing on HIV/AIDS data was done in all the
  80 districts.
• Integrating Service Availability Mapping (SAM) in HMIS

Library
• Creation of a digital library /automation ongoing,
• Weeding out old publications,
• Biding of library news papers,
• Library user education,
• Reference/current awareness service.

ICT
• Maintenance and expansion of the Local Area Network (LAN)
• Backstopping for computing systems failure is accomplished on
   schedule
• Maintenance and continuous update of the website www.health.go.ug



                                                                           172
•   Dedicated and high capacity servers have been installed to
    accommodate the electronic mailing system to sustain the health
    sector electronic mailing needs for the Ministry of Health head
    quarters, Districts, Hospitals & Municipality.
•   Electronic knowledge Management Information System (e-library) has
    been developed, installed and configured to enable sharing of
    available paper based documentation in the sector.
•   The development of health Infrastructure (HI), Human Resource (HR)
    and Drug Logistics information systems (DL) is going on.
•   Provision of 1MB internet bandwidth for MOH to facilitate internet
    based research and communication.
•   A power storage infrastructure has been put in place to provide stable
    current to the server room, databank & library in case of power
    failure.
•   Hospitals, Municipalities and Districts have been assigned e-mail
    addresses to ease communication and dissemination of information.
•   The e-government fiber optic network has been installed,
    configuration and commissioning of terminals underway.
•   The centralized Anti-Virus guard (Mcaffee Orchestrator) is installed
    pending accomplishing configurations

Major Challenges/Constraints
  Shortages of staff especially at the Central level
  Training of Records Assistants;
  Inadequate supervision at all levels;
  Integration of data Management into other service delivery activities;
  Lack of feedback from district to lower level health units;
  Inability to capture data from Private Health Providers (PHP);
  Inadequate community health information;
  Declining trends in some indicators;
  Inadequate financial resources.
  Cultural adaptability (Technophobia)
  Poor & unstable Power availability
  Standardization of computing equipment for health facilities
  Legal / ethical issues related to information & ICT use.
  Lack of security framework for data management e.g. Pubic keys
  infrastructure.

4.6.2 Integrated Disease Surveillance and Response

Epidemiological Surveillance Division is mandated to coordinate and
ensure the early detection and prompt response to epidemics/ disease
outbreaks through the implementation of an Integrated Surveillance
System (IDSR) for priority diseases. The selected priority diseases for
Uganda are categorized as epidemic-prone (including emerging and re-
emerging) diseases, diseases targeted for eradication and elimination;
and selected diseases of public health importance.

The objectives of the division are



                                                                      173
       •    To strengthen outbreak/ epidemic detection, investigation and
            response
       •    To improve sharing of disease surveillance information through
            disease notification, regular dissemination and feedback
       •    To strengthen the capacity of health workers through training
            and support supervision
       •    To coordinate Disease Surveillance activities in Uganda
       •    To improve epidemiological data management, validity/ quality
            and utilization at all levels
       •    To coordinate the implementation on the International Health
            Regulation In Uganda

Table 4.22: Achievements – Integrated Disease Surveillance FY
2006/07




                                                   Achieved
                              2005/06




                                         2006/07
                              Baseline




                                         Target
           Indicator                                                           Comments
                              FY




                                         FY
Central level Programme Performance Indicators
% of suspected outbreaks   30.0%    80%      52.0%            Funding constraints delay the response.
responded to within 48hrs                                     Funds for emergency response were lacking
of notification                                               in the FY
% District Health Teams    50%      100%     73%              Some funding was obtained from WHO and
trained in IDSR                                               18 districts from the Northern Region were
                                                              trained on IDSR.
% of districts with Trained   55%        100%      73%        RRTs were trained in 12 districts in
Outbreak Rapid Response                                       preparedness for Avian Influenza
Teams (RRTs)
No. of Weekly                 52         52        52         Compilation     of  Weekly    epidemiological
Epidemiological Newsletter                                    Newsletter done but could not publish the
produced                                                      reports due to funding constraints
No. of Quarterly IDSR         2          4         1          Articles compiled but funding not available to
bulletin produced                                             print them. AFENET funded one publication
Conduct monthly IDSR          10         12        12         All the meeting were held with participation
coordination meetings                                         of MOH departments staff and other
                                                              stakeholders
District level (Service delivery)
% districts submitting         96%       100%      80.7%      Districts deteriorated in reporting. Absence of
Weekly Surveillance reports                                   feedback through the Newspaper was the
                                                              major cause
% districts submitting        62%        80%       58%        Absence of feedback through the Newspaper
timely Weekly Surveillance                                    was the major cause
Reports
% outbreaks notified to       65%        90%       72%
MoH within 24hrs of
detection
% districts with functional   65%        10%       76%        More EPR committee became in preparedness
Epidemic Preparedness and                                     for Avian Influenza and during the meningitis
Response (EPR) Committees                                     epidemic

Response to Outbreaks

The division received several reports of suspected from districts. With
funding mainly from development partners response teams were sent to


                                                                                       174
districts to help in outbreak investigations. Key partners in outbreak
investigation were WHO and Africa Field Epidemiology Network
(AFENET). In some cases response could not be effected within48 hours
of notification mainly because of funding constraints

Table 4.23: Major outbreaks responded to by ESD in FY 2006/07
Disease/Condition    District     Cases      Deaths       Case Fatality
                                                          Ratio (CFR)
Meningitis           *ARUA/       2025       62           4.7
                     MARACHA-
                     TEREGO
Meningitis           KOBOKO       468        22           5.9
Meningitis           YUMBE        545        32           4.9
Meningitis           ADJUMANI     326        16           5.0
Meningitis           MOYO         181        9            9.3
Meningitis           NEBBI        97         9            4.7
Meningitis           Kotido       151        10           6.6
Cholera              Ntungamo     284        12           4.2
Cholera              Kampala      1064       9            0.8
Cholera              Kitgum       883        12           1.4
Cholera              Arua         254        10           3.9
Cholera              Adjumani     171        4            2.3
Cholera              Koboko       159        4            2.5
Cholera              Kasese       139        0            0.0
Cholera              Bundibugyo   116        1            0.9
Plague               Masindi      22                      0.0
Methanol             Kampala      5          3            60.0
poisoning
Methanol poisoning   Mubende      28         9            32.1
Methanol poisoning   Mukono       26         23           88.5
Methanol poisoning   Wakiso       9          8            88.9

Figure 4.21:     Epicurve of Meningitis in Arua, Maracha-Terego
                 District, 1st April 2007




                                                                   175
                                    Epi-Curve of Meninigitis cases in Arua, Maracha-Terego Districts, 1st April-2007

                      120




                      100                                                                   98

                                                                                                  87 87
                                                                                             84
                                                                                                             82
                                                                                                   80       80
                          80
                                                                                        73    72                 73
 Number of Cases




                                                                                         7069
                                                                                  63                       64

                          60                                                          55
                                                                                     52                                 52
                                                                                                                   48
                                                                           44                                          44
                                                                                41                                    41
                          40                                                                          35
                                                                                                                                     31
                                                                                                                                      30
                                                                                                                            29          28
                                                                      27
                                                                             24                                                          24
                                                                        21                                                                       22
                                                                                                                                                      19 20
                          20                                    16 16                                                                         15       16
                                                    12        13 14                                                             13                 13
                                                               11                                                              10
                                                             9                                                               78              8                     9
                                                        55                                                                                               5 5           5      4
                                               33
                               1001 201 110 21                                                                                                                 0           100 20001122 11 000200 200 00
                          0
                                                                            07




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                                                                                                        Date of Admission



Training of Health workers

District health teams of Gulu, Amuru, Pader, Kitgum, Kotido, Moroto,
Nakapiripirit, Lira, Apac, Oyam, Amolator and Dokolo were trained in
Integrated Disease Surveillance and Response during the year. This was
to enable these districts considered to be conflict areas to monitor
epidemic potential diseases for timely detection of suspected outbreaks.

Training of Rapid Response Teams

Rapid Response Teams were trained in Arua, Nebbi, Koboko, Yumbe,
Moyo, Adjumani, Maracha-Terego, Lira, Amolator, Dokolo , Oyam, Gulu,
Amuru, Kitgum and Pader district. This was to enable districts to have
capacity for timely investigation of suspected outbreaks.

Production of Weekly and Quarterly Surveillance reports

In order to share the information generated through disease surveillance
systems, the division produces quarterly and Weekly surveillance reports
in forms of a bulletin and a newsletter respectively. The division managed
to produce all the 52 expected Weekly Epidemiological Surveillance
reports from surveillance reports submitted by the districts. However
these reports could not be published in the print media as was the case
in the previous year due to funding constraints. Completeness and
timelines of reports from the districts also dropped due to absence of



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timely feedback in the newspapers. Only one Quarterly bulletin was
printed due to funding limitations.

Notification of suspected outbreaks
Districts were timely in notifying the Ministry whenever an outbreak was
detected, however in some cases outbreaks were detected late at
community level. During the financial the Division piloted a Community
Based Disease Surveillance (CBDS) in five districts of Apac, Pallisa,
Nakapiripirit, Kabarole and Luwero. It is anticipated that CBDS will
improve outbreak detection at community level by involving community
members (Village Health Teams) in disease surveillance and suspected
outbreak notification.


4.7   Health Policy, Research and Development

Research is a critical tool for evidence based policy and decision-making.
It provides an informed basis for guiding and rationalizing
implementation of the health sector strategic plan. Health research is a
vital element for evolving rational approaches for solving specific health
problems many of which have multi-factorial causes embracing social,
behavioural and economic determinants. Evidence based management of
health sector reforms is essential to the improvement of healthcare
delivery.

4.7.1 Policy Analysis

The mandate of Policy analysis Unit is to spearhead the process of policy
and legislation development while ensuring conformity with overall
national policies.

Objectives:
1. To analyse, develop and formulate policies and ensure conformity
   with overall national policy
2. To review, analyse and evaluate research material for policy
   formulation
3. To review and develop relevant legal instruments
4. Liaise with other line ministries in order to develop crosscutting
   policies
5. Monitor and evaluate the implementation and effect of health policies

Importance and relevance to the health sector:
The steps towards achieving the targets of HSSP II and the aspirations of
the NHP cannot be achieved without the support of articulate policies,
and a legal and regulatory framework.

Achievements:
   • Two Bills for UNHRO and Pharmacy Practice and Profession were
      re-submitted to parliament



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      •    Facilitated development of several policies (oral health, school
           health, PEP, TCM etc)

Challenges/constraints
  • Delay and lengthy approval of policies for submission to cabinet
      affects the delivery of health services
  • The unit is grossly constrained by both human and financial
      resource to fully facilitate and participate in all policy development
      process.

4.7.2 Uganda National Chemotherapeutics Research Laboratories

The NCRL is a Scientific Research and Development centre that was
created in 1963 in the Ministry of Health. The NCRL is comprised of four
sections; Chemistry (analytical and Industrial), Botany (field surveys and
laboratory), Pharmacology and Administration. The mandate of NCRL is;
      •    To scientifically evaluate herbal products (plants, animal parts
           and minerals) for claims of safety and efficacy.
      •    To verify and register herbal products from stakeholders.
      •    To build capacity of stakeholders (herbalists, research students).
      •    To develop quality and safe natural products formulations and
           services by applying indigenous and modern technologies.
      •    To coordinate research and development of natural medicinal
           products
      •    To develop and implement the National Policy on Traditional
           medicine.

Table 4.24: Achievements for FY 2006/07
    Achievements                                    Outputs/Impact
    Scientifically verified the anti-HIV/AIDS       Protected over 3,000 patients/public from use of
    product claims e.g. the Ellahi case, due to     ineffective herbals.
    public demand
    Trained herbalists and herbal, research         Capacity for 20 scientific research and 50 herbalists
    students                                        increased.
    Developed anti-cough herbal syrup based         2 safe herbal remedies availed for observation study.
    on natural herbs
    Coordinate      medicinal      plants    and    Framework for the E. African medicinal plants and
    biodiversity network for E. African Region.     Biodiversity network operational.
    Developed      the    draft    TCM     policy   A draft guide for TCM practitioners availed.
    implementation guidelines

Major challenges/Constraints

•     Inadequate funding for laboratory research and monitoring and
      evaluation of evidence based research.
•     Delay in securing funding
•     Limited space for Pharmacology and Botany research
•     Uncompleted wider stakeholder consultation for TCM practitioners.




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4.8   Legal and Regulatory Framework

4.8.1 Pharmacy Council

The overall Goal is to regulate pharmacy profession and practice in both
the public and the private sectors, as well as control the conduct of
registered pharmacists.

Objectives
   • Set and enforce pharmacy practice standards
   • Regulate the conduct of & the discipline of pharmacists
   • Maintain a register of registered pharmacists
   • Ensure pharmacy training institutions conform to standards
   • Approve all pharmacy practice outlets both public & private
   • Conduct Continued Pharmacy Education
   • Empower the community to seek quality pharmaceutical services.

Achievements:

1. the council made technical visits to support the training of pharmacy
    students in Mbarara and Bushenyi Universities
2. 1300 copies of the Internship Manual printed and disseminated
3. 400 copies of the Pharmacy Profession and Pharmacy Practice Bill
    printed and distributed
4. designed a logo for the Council
5. initiated the process of drafting Continuous Professional Development
    and Accreditation guidelines
6. drafted the Pharmacy Council Strategic Plan 2007-20012
7. carried out standards enforcement visits in 5 districts
8. participated in the activities of the EAC Health Professional Councils/
    Boards and Association
9. carried out Council meetings as scheduled and Implemented council
    decisions.
10. Registered 24 newly qualified pharmacists

Constraints:
o Weak and fragmented regulatory framework
o Inadequate structure
o Inadequate finances


4.8.2 Uganda National Drug Authority

National Drug Authority (NDA) is a regulatory agency established under
the National Drug Policy and Authority (NDP/A) Act (Cap. 206). The
2006/7 performance and activities were in line with NDA’s mission of
ensuring that only good quality, safe and efficacious human and
veterinary medicines are available and are correctly handled in Uganda,



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and to contribute towards their accessibility, cost effectiveness and
appropriate use.
The departments carried out activities according to the Strategic Plan
(2007-2011) in line with the NDA Act and agreed objectives.

Major Achievements
During the FY 2006/07 the following were achieved under various
departments;

Drug Assessment & Registration Department
• A total of 539 new applications were received (Human – 517 and
   Veterinary – 22); 460 human and 06 veterinary applications were
   approved and registered.
• 60 Dietary supplement applications were received and 50 were
   evaluated.
• 520 applications to amend products on the register were handled.
• Guidelines for foreign traditional medicines published and in place.
• Guidelines on notification and subsequently registration of household
   chemicals and acaricides were approved by the Board and
   notification on going.
• Guidelines/checklist for evaluation and auditing for food fortificants
   / premix manufacturers available.

Inspectorate Department
•   360 pharmacies were inspected to ensure that drug-handling
    operations were supervised by authorized persons and that they
    complied with statutory requirements. 3,720 drug shops were
    inspected to ensure that all premises and practices of drug outlets
    complied with the licensing provisions.
•   Regulated drug distribution outlets. The following drug outlets were
    approved;
    o Pharmacies; 353
               Wholesale Pharmacies 72 (Human & Veterinary)
               Retail Pharmacies 136 (Human & Veterinary)
               Wholesale/Retail 145 (Human & Veterinary)
    o Drug shops – 3245
    o Small Scale Manufacturers – 8
    o Large Scale Manufacturers - 4
•   Carried out support supervision in 60 districts
•   Amended the guidelines on sampling of drugs, condoms, syringes,
    gloves and LLINs at entry ports.
•   Controlled importation of medicines through issuance of verification
    certificates; 5,179 verification certificates were issued.
•   4,069 consignments were inspected; 3,595 approved, 450 queried
    and 24 rejected. Consignments were inspected at the ports of entry
    (designated ports of entry are: Nakawa inland port, Entebbe Airport,
    Busia/Malaba, Mutukula and Katuna) to ensure that all imported
    drugs complied with import requirements.




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•   3,860 drug outlets; 3,500 drug shops and 360 pharmacies were
    monitored to ensure proper record keeping.
•   1,986 samples were analysed; Nakawa – 777 (1.16% failed), Entebbe
    – 864 (0% failed) and others - 345 (picked from the market) – (3.48%
    failed).
•   Guidelines for Food Fortificants, Medical Devices and Public Health
    Chemicals were developed.

National Drug Quality Control Laboratory (NDQCL)
• 1,806 samples were received and tested of which 18 failed.
• 374 batches of various brands of condoms were received and tested; 7
  batches of these failed the tests.
• 82 batches of PermaNet (containing Permethrin 2% (w/w) as active
  ingredient) Long Lasting Insecticidal Nets (LLINs) procured by WHO for
  the MoH were tested.
• Received HPLC Agilent 1200 procured by USP DQI with funds from the
  Presidential Malaria Initiative (PMI) Project. This was installed and
  commissioned in September, 2006.
• Received a Gas Chromatography (GC) procured by USP DQI with
  funds from the Presidential Malaria Initiative (PMI) Project.
  Installation, commissioning and training of staff was in December,
  2006.
• Received an Automatic Titrimeter procured with funds from HSPS.
  This was installed and commissioned in September, 2006. All
  technical staff members were trained on how to operate the
  equipment.
• Developed Terms of Reference for a consultancy for ISO 9001 & ISO
  17025.
• Started testing antibiotics (Amoxycillin and Ciprofloxacin were selected
  for a start).

Drug information
• Regulated drug promotion and advertising activities;
      o 182 advertisements and drug promotional materials were
          vetted; 174 were approved, 2 rejected, 8 defaulted, fined and
          cautioned.
      o 32 Herbalists announcements were vetted; 28 authorized, 2
          rejected.
      o 5 applications for exhibitions handled and approved.
• Distributed 3,610 ADR forms and collected 66 ADR report forms.
• Sensitized 1307 health workers on matters relating to rational
  medicines use, pharmacovigilance and effective drug regulation.

Finance and Administration
• A number of staff were recruited namely; Head, Drug Assessment and
  Registration, Head Finance, One Drug Analyst, two Inspectors, one
  Secretary and one Driver
• Human Resources Manual was finalized and approved by the
  Authority.


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• All NDA staff were moved from permanent to 4-year employment
  contracts.
• 17 employees were confirmed in their appointments.
• 5-year Strategic Plan was considered and approved by the Authority
• Board Manual was considered and approved by the Authority.
• Monthly procurement plans were sent to NDA.
• 2 Motorcycles were purchased.
• 6 Generators purchased by HSPS were received
• Audit for FY 2005/06 was concluded
• Audit Committee was put in place.

Constraints
• Inadequate funding. As a result a number of planned activities could
  not be implemented. Key activities that were affected include:
      o Operation of 18 Zonal Offices to carry out support supervision
         and setting up 18 Zonal offices (vehicles and office equipment).
      o Support to effectively operationalise Regional Offices in order to
         improve licensing and market surveillance.
      o ISO 9001 & 17025 accreditation of NDA and the Laboratory
         respectively.
      o Inadequate office, laboratory and storage space.
      o Recruitment of staff. Inadequate number of staff in
         departments has led to heavy workloads and limited coverage
         of regulatory activities as planned for.
      o Conducting pharmacovigilance in 69 old districts.
      o Training of staff to acquire world class skills in drug regulatory
         activities (this includes attachment to other DRAs, conferences
         and workshops and formal training.
      o Construction of office block for NDA Head office.
      o Extension of the National Quality Control Laboratory.
• Inadequate legal provisions and/or loopholes in the current law has
  frustrated prosecution of offenders leading to loss of law suits and
  encouraging a number of offenders to challenge NDA’s authority or to
  break the law with increased boldness
• Overlap of roles and inadequate coordination with other regulatory
  and professional Councils. As a result, multiple private clinics and
  “dispensaries” licensed or authorized by other councils without
  adequate inspection and supervision are mishandling drugs leading
  to public criticism of NDA.
• Liberalization and inadequate regulation of the media industry has
  led to abuse by herbalists.
• Non-payment of verification fees by National Medical Stores (Global
  Fund items) and Ministry of Health. By the end of the financial year
  the two Institutions owed NDA Ugshs 1.3bn. This has greatly affected
  NDA’s cashflow position and negated the revenue performance that
  was registered during the financial year.




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                   Chapter 5:     Monitoring Implementation of the HSSP II

                   The framework for HSSP II implementation was agreed with health sector
                   stakeholders. This Chapter of the AHSPR 2006/07 documents progress
                   of HSSP II implementation in the following areas:
                   • Provision of health services in conflict and post-conflict areas;
                   • Progress on Scaling up the provision of an improved package of
                       services at the Health centre IV;
                   • Monitoring of the HSSP II with particular focus on:
                          o Update on Supervision, Monitoring & Mentoring for the HSSP
                              II;
                          o Progress on SWAp Implementation;
                          o Issues in Monitoring the HSSP II;


                   5.1 Health Services and Health Status in Conflict and Post Conflict
                   Situations

                   The wider North region including West Nile, Acholi, Lango, Teso and
                   Karamoja sub-regions has been affected by conflict of varying intensity
                   and duration over the last 3 decades, which has led to challenges for
                   human development including population health. The Uganda National
                   Household Survey of 2005/06 showed that the proportion of poor people
                   is highest in the North at 70%, with the poverty gap between the North
                   and the national average increasing from 17% in 1992 to 30% in
                   20005/06. The analysis in this report is focusing on the Acholi and
                   Lango sub-regions, and to a less extent Karamoja and Teso.

                   5.1.1 Health Outcomes and Outputs in Post-Conflict Areas of Uganda

                   The UDHS 2006 provides us with health output and outcome data at
                   several levels: national level; regional level - West Nile, North (including
                   Acholi, Lango and Karamoja), Eastern (including Teso, Bugisu, Sebei,
                   Bukedi); and specifically for the Internally Displaced Persons (IDPs) and
                   Karamoja sub-region given special sampling that was built into the 2006
                   UDHS methodology.

                   Table 5.1. Selected UDHS 2006 Health Indicators by Region

DHS Region         Neonatal    Infant      Under5      Total       Contraceptive   Health     Stunting   Received    H/holds
                   Mortality   Mortality   Mortality   Fertility   Prevalence      facility   in         all basic   with
                   /1000 lb    /1000 lb    /1000 lb    Rate        Rate %          delivery   Children   vaccines    Mosquito
                                                                                   %          %          %           net %
West Nile          25          98          185         7.2         13.7            33.5       37.7       46.4        28.8
Eastern            19          70          116         7.7         20.6            39.5       36.2       46.8        44.1
North              33          106         177         7.5         10.9            29.9       40.0       46.5        41.5
        IDPs       38          123         200         8.6         11.6            34.6       37.4       53.6        53.1
        Karamoja   26          105         174         7.2         0.6             15.4       53.6       48.2        13.5
Best Performing    24          54          94          3.7         47.6            89.6       22.2       51.0        65.6
Worst Performing   54          109         185         7.7         10.9            29.8       49.6       41.4        20.0
National           29          75          137         6.7         23.7            41.1       38.1       46.2        34.3



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Table 5.1 shows performance on some of the key health output and
outcome indicators in these populations, compared with: national
averages; the best; and the worst performing regions on each indicator.
The West Nile and North regions have poorer performance than the
national averages for Infant Mortality Rate (IMR), Under 5Mortality Rate
U5MR), Contraceptive Prevalence Rate (CPR) and Health Facilities
deliveries. However on all these indicators they are not necessarily the
worst performing region as shown in the table. The performance against
these indicators tends to be worst for IDPs and the Karamoja sub-region.
On a number of output indicators including immunization, coverage of
households with mosquito nets, and the nutritional indicator of stunting,
the indicators are more comparable to the national averages and in some
cases better. This is most probably illustrative of the recent efforts by
government and partners to provide appropriate services in the region.

Over the recent past and especially over the FY 2006/07 there has been
marked improvement in the security situation in the region. The
improved security situation coupled with increased resources for health
services delivery has led to an increased number of interventions, and
increased coverage of interventions across the region. In addition to the
routine government funding for health services, Section 4.1 of this
report indicates that up to 32 billion Ug. Shs was spent by health sector
partners in the region under the Consolidated Appeal Process (CAP), and
other programmes like the Northern Uganda Social Action Fund (NUSAF)
have provided funds to the health sector in the region. This has markedly
improved services delivery in the region as shown by the UDHS output
indicators above, and the performance of the districts on the different
indicators as shown in Chapter 2. Gulu and Pader districts appear in
the top 15 districts of the District League Table; and Gulu district has
specifically registered a marked increase in the proportion of mothers
delivering in health facilities – see Section 2.2 and 3.2 for more
information on this. These interventions are being carried out under the
wider national Peace, Recovery and Development Plan (PRDP) . However
this scale up is associated with a number of challenges, especially as
indicated before (AHSPR 20004/05, 2005/06) in the area of coordination.

5.1.2 Coordination of Post-conflict health services delivery

The District Health Offices of the North were asked to provide detailed
information on efforts on coordination including progress so far made.
Annex 5.1 provides details and specific information by district. Detailed
responses were received from Amuru, Gulu, Katakwi, Kitgum, Kotido,
Lira, Moroto, Oyam and Pader. A few highlights are indicated here below.
The situation in Karamoja was generally found to differ from Acholi,
Lango and Teso sub-regions most probably because of the more insidious
conflict situation, and the involvement of much fewer partners.




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Most districts have a Coordination Forum for the health sector
including the local government representatives, the UN agencies and the
NGOs and CBOs operating in the health sector in the district. The forum
is usually monthly, and chaired most commonly by the District Health
Officer (DHO), but in some cases this responsibility is shared with UN
agencies and NGOs. The districts indicated that they have found the
forum useful, usually discussing issues of emergency preparedness and
response; planning; receiving reports, and mapping of partners activities
in the district. The linkages between the different stakeholders within the
coordination forum and between the forum and other institutions, helps
in implementation and follow up of issues. Pader district has used this
forum to address the issue of frequent and uncoordinated training
workshops that leave health facilities without health workers. District
health officials though indicated that the coordination fora need to adapt
to the situation of improving local government systems, and recovery and
resettlement.

Most of the districts reported the existence of signed Memoranda of
understanding (MOUs) with funding and/or implementing partners,
though they were not readily available for verification except for Katakwi
district which provided some copies. The MoUs are usually signed by the
CAO and implementing agency and in some cases the UN agency and
DHO too. In some of the districts though some implanting NGOs/CBOs
do not have MOUs with the local government. In most districts the
NGOs are assumed to be duly registered with the NGO Board and other
institutions of government as required; this is usually not verified. The
professional status of health workers (both local and expatriate) is often
taken for granted. Some of the districts have attempted to verify
professional status of NGO health workers but have been discouraged
because of the very high turn-over of staff.

The coordination fora mentioned before has been a useful framework for
planning and reporting on health service delivery. The UN agencies
WHO and UNICEF were specifically commended for improved sharing of
information. However a number of challenges still do occur and the most
frequently quoted were: different planning periods e.g. for the CAP and
the Ugandan Fiscal Year, which the local governments follow for the
preparations of the integrated work-plans leading to information on
resource levels being available after the district councils have approved
work-plans; and inappropriate representatives at meetings that are not
in position to provide information on resource availability and
prioritisation. Most districts are able to include outputs by the different
partners in the normal reporting systems like the HMIS, monthly and
annual reports. However some of the partners have been noted to use
separate tools and personnel to manage data – the supervision teams
including Area Teams have noted separate medicines stock-cards,
outpatient and in-patient registers and even immunisation cards at
health facilities in Amuru, Gulu and Kitgum.




                                                                        185
A number of the partners are implementing partners – i.e. they are
involved directly is providing services to the population. The District
Health Offices and MoH supervising teams have noted that some of the
NGOs/CBOs are not following the standard MOH guidelines and
protocols – specific examples noted are: different first line anti- malaria
treatment; different packaging for anti-TB treatment; refusal to
implement DOTs; and different HIV/AIDs testing protocol. In particular
the international NGO Medicins Sans Frontiers (MSF Spain & Holland)
has been implicated on this in a number of districts. Such practices have
often led to conflicting messages being given to the communities by
health workers in one locality and in some cases attending the same
health facility, which has led to clashes with health managers and
political leaders.

5.1.3 Return, Recovery and Resettlement (3Rs)

Every month more of the population is leaving the IDPs camps to go back
to their villages. The North is truly in the Recovery and Resettlement
phase. However there are a number of challenges that the District Health
Offices are faced with in this region. These include:

Human Resources for Health – although a number of efforts have been
made in the recent past to improve the situation in this region, including
government recruitment; support with hard-to-reach areas incentives for
public and PNFP health workers; and short term recruitment of key
cadres by implementing partners, a number of problems persist.
Shortage of health workers, especially medical officers, mid wives and
laboratory technicians remains a big problem. The proportion of staff
positions at the DHO and Health Centres filled in the districts of
Kaabong, Abim, Amuria, Gulu, Kaabong, Kitgum and Moroto were noted
to be below the national average of 38% in this report. However it has
also been noted that there are high instances of staff absenteeism and
other forms of indiscipline by both district and MoH supervisors. The
high levels of staff absenteeism from stations have been noted to be
partly due to frequent training workshops organized by different
stakeholders including MoH, districts, UN agencies and NGOs.

The shift from the IDP camps to homesteads in rural villages is likely
to be a challenge for health service delivery, with different needs for
service delivery (opening new health centers, reopening old ones), in
terms of management, human resources, infrastructure and even
community and local government involvement in health. Capacity and
resources are required at the DHO, HSD and health facilities for this
transition, together with the comprehensive outlook e.g. the role of the
Sub- county authorities.

The broader challenges of transport, safe water, communication,
lighting and buildings make it more challenging to provide health
services to the returnees. The fact that people in these regions have to
move longer distances to find points where services are delivered may


                                                                           186
result into lower utilization of health services. Supervision and
monitoring of the lower level units will most definitely be more
demanding as there will be longer distances to cover. In addition the
population will have different priorities – food and shelter – recent
supervision has shown that building of latrines for example is low down
on the priority list.

5.1.4 Recommendations
A number of initiatives have been implemented to improve the situation
in Northern Uganda. However as noted by the Northern Uganda Public
Expenditure Review (NUPER) 31, “...the overall effectiveness of
humanitarian intervention can be compromised by multiplicity of actors;
earmarking of funds; short funding cycles; mistrust and opacity..”. Efforts
need to be continued both to mobilise resources and also to improve
coordination and effective utilisation of available resources. The following
are some recommendations for improvement:

Efforts in coordination like the Coordination Forum should continue
and be strengthened, including more formal recognition of these fora and
making sure their Terms of Reference (TORs)are clear to all stakeholders.
In particular continuous mapping and allocation of funding and
implementing partners across the region and across districts should take
place to ensure equitable and efficient use of resources. Sanctions to deal
with non-compliant partners should be agreed. NGOs and their staff
should register with appropriate authorities as a minimum, and districts
should enforce this requirement, whereas MoUs cannot be signed with
NGOs unless properly registered.

Planning and Reporting on Implementation – stakeholders should
ensure provision of information for planning and reporting purposes.
Information on funding should be provided in good time for the
development of District Annual Work-plans. The integrated HMIS and
other systems for health sector and district reporting should be used by
all partners.

The efforts to make improvements in the numbers and qualifications of
Health Workers should be monitored especially following recruitment
and the provision of incentives. This will help ascertain the new levels of
staffing and the next steps required for appropriate staffing of health
facilities in the region. Planning for human resources – recruitment,
salary levels and short and long term training should be done in close
consultation with all partners and especially the District Health Office.

 The post-conflict phase is well under way with the different
 requirements in resources and approaches. This should be appreciated
 by all stakeholders. There is need for more involvement of all
 stakeholders in the PRDP especially the District Health Offices, the

31Northern Uganda Public Expenditure Review January 2007. Carried out by Regional Forecasts for
the Uganda Multi-Donor Group.


                                                                                            187
 MoH, UN Agencies, NGOs and CBOs. It is especially important to have
 clear activities and a monitoring and financing framework. These should
 clearly reflect some of the issues discussed above.

 The Karamoja region still bears a much higher burden than the rest of
 the North and the country. This is illustrated by human development
 including health outcome indicators and on the District League Table. It
 is high time sector stakeholders came up with affirmative action for this
 region and people.


5.2 Functionality of Health Centre IVs

The Health sub-district (HSD) and the Health Centre IV (HC IV) are an
innovation of the National Health Policy and Health Sector Strategic Plan
(HSSP I). The implementation of these innovations is continuing in the
HSSP II. The key feature of the HSD Strategy was that each HSD of
approximately 100,000 people would have a Hospital or a Health Centre
IV with the capacity to provide basic promotive, preventive and curative
services, including Emergency Surgical and Obstetric Services. This was
in a bid to address the poor health indicators especially Infant Mortality
Rate and Maternal Mortality Ratio. Countries with comparable economic
development levels like Cuba, Sri Lanka have been able to improve these
indicators ot levels of much wealthier countries32. Being a key strategy of
the HSSP I and II the functionality of Health Centre IVs, and in particular
the key objective of providing special components of the UNMHCP make
it necessary to carry out regular reviews of progress as has been done in
the last 2 AHSPRs.

5.2.1 Methodology
The District Annual Reports included information on HC IVs, at input,
management, output and even outcome levels. 161 HC IVs (99%) from 49
districts provided information of varying degrees of completeness. Data
from 102 HC IVs (63%) with an acceptable level of completeness were
analysed. HC IVs that did not report OPD attendances were excluded
from the analysis.
Functionality was determined by outputs from selected key components
of the minimum service standards i.e. Maternity (deliveries), Inpatient
Blood Transfusion, Theatre (caesarean section, Major and Minor
surgery), HCT, PMTCT, ART, Long Term Contraception and Outpatient
services. This is similar to the analysis done in FY 2004/05 and
2005/06.

5.2.2 Level of Functionality




32   See the Health Financing Strategy 2003 for more detailed discussion of this.


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               PHC Service Outputs at HC IVs
               Only Nyahuka HC IV in Bundibugyo district had outputs in all the 12
               sections considered while Kamukira HC IV in Kabale district only had
               outputs from the Outpatient Department. Lyantonde which was shown
               eo have all the key services is now a Hospital and has been assessed with
               other hospitals. The median number of services available was 7.
               Outpatient services were the only services available in all the HC IVs
               considered, while Blood Transfusion (14%) and caesarean section (19%)
               were the least available. 6 HC IVs providing major surgery were not
               providing caesarean sections. This is not in line with the objectives of the
               HSD and HCIV strategy, as provision of EmoC is the first priority at this
               level. Detailed information of services provided each HC IV is provided in
               Annex 5.2.

               Table 5.2: Provision of Selected Services by HC IVs




                                                                                                                                      Major Surgery




                                                                                                                                                                       Transfusion
                                                                                                                                                           Caesarean
                                  Deliveries




                                                                                                                Surgery




                                                                                                                                                            Section
                                                                PMTCT


                                                                             Dental




                                                                                                                 Minor




                                                                                                                                                                          Blood
                                                                                                                          LTFP
                                                     HCT
                      OPD




                                                                                                     ART
                                                                                           IP

Number of HC IVs            103                 98         92           85            74        68         63       47           44                   23        20           14
Offering Service
 As % of respondent         100                 95         89           83            71        66         61       46           43                   22        19           14
       HC IVs
  Average Outputs       28,227          1,530          737         533           537        3106       286        122       151                       65        21              5
    FY 2006/07
  Average Outputs       31,728          1,184               -      634                 -    1,803      116          46           37                   17          7          10
    FY 2005/06
Gross Change 05/06      -3,501                 346               -101                       1303      170           76      114                       48        14           -5
     to 06/07




                                                                                                                                      189
190
                                               H       e
                                                ealth C nres

                    N




                                                                              OPD
                      ya
                         hu
                             ka




                                   0
                                       2
                                           4
                                                6
                                                        8
                                                               10
                                                                    12
                                                                         14
                    K
                       at
                          a
                   P kw
                     ak        i


                                                                              Dental
                         w
                            ac
                    M          h
                  S uko
                   em n
                                                                              ART
                       ba o
                          bu
                              le
                      B
                         ul
                                                                              HCT




                    K iisa
                      al
                        ag
                            al
                    M         a
                      ul
                         an
                             da
                    K
                 K iy
                  an un
                                                                              Inpatient




                    gu ga
                        lu
                          m
                   K         ira
                     ity
                         er
                            er
                              a
                                                                              Deliveries




                     K
                       ik
                         uu
                    B       b
                     uw e
                          en
                   B
                    uk ge
                                                                              PMTCT




                        om
                           er
                              o
                      To
                          ko
                             ra
                       N
                         tu
                           u
                     W si
                                                                              ceaserian




                         ak
                           is
                              o
      Services
                       N
                         de
                            jje
                        B
                          u
                                                                                                                                 Figure 5.1: Services Availability at HC IVs – this chart needs to be updated


                                                                                                  Services Available At HC IVs




                    B sia
                      ud
                          on
                            do
                                                                              Major operation




                   N
                 N yim
                  am b
                    ay wa
                       um
                          ba
                      K
                   R iky
                                                                              Minor operation




                    w o
                      ek
                        ub
                   N        o
                     tw
                       et
                         w
                    S       e
                      em
                         ut
                           o

                      K
                       ob
                         ok
                                                                              Blood Transfusion




                      B    o
191




                       uk
                         as
                           a
                                                                              LTFP
The HC IVs under review accounted for about 10% (2,907,417 attendances) of total
annual outpatient attendance in Uganda. Individual performance varied widely though
ranging from 158 in Rwampara HC IV to 300,000 in Amuria HC IV with a median of
20532. A total 223,637 inpatients were seen, 48,923 deliveries conducted and 6,965
ART clients attended to in FY 2006/07.

There was improvement in utilization of key HC IV services (e.g. Inpatients, HCT, ART,
Deliveries and Long Term Family Planning provision). Though still low, functionality of
operating theatres (minor, major and caesarean operations) increased. However, there
seems to be a reduction in utilization of OPD, and Blood Transfusion at the HC IVs.

Since the main objective of
setting up HC IVs was to
provide         Comprehensive
Emergency Obstetric Care
CEmoC – that is being able to
provide intervention in case of
complications during delivery,
which includes the ability to
provide a Caesarean Section
and Blood Transfusion, HC
IVs    have      been   judged
“functional” if they have been
able to carry out at least one
Caesarean Section in the FY
2006/07.        Using      this
nomenclature, 19% of the HC
IVs were functional – this is
down from 22% in the FY
2005/06.

Figure     5.1    shows     the
proportion of HC IVs by
district that are functional.
The districts of Katakwi, Moyo
and Nebbi have 1 HC IV each
and they were functional in
FY 2006/07 thus a full score
of 100%. Mukono has 4 HC
IVs of which 3 were functional
and a score of 75%. Busia has
3 with 2 of them functional;
and Amuria, Apac, Bugiri,
Kabarole,     Kiboga,    Mbale,
Mpigi, and Sembabule have 2
HC     IVs   apiece    with    1
functional.       Bundibugyo,
Luwero and Tororo have 3 HC
IVs each with 1 reported functional. Kibaale has 4 HC IVs with 1 reported functional.
All the remaining reporting districts had no functional HC IVs. Of particular note are
Wakiso with 5, Jinja and Kabale with 6 each and Masaka with 8, none of them
functional. Iganga, Isingiro, Kasese, Kitgum, Mbarara, Ntungamo, Sironko, and Soroti

                                                                                   192
have 3 HC IVs each, all not functional. The rest of the reporting districts have 1 or 2
HC IVs each. The following districts did not report on the HC IVs or provided very
scanty information: Amuru, Budaka, Bukedea, Bukwo, Bushenyi, Dokolo, Ibanda,
Gulu, Kaberamaido, Kaliro, Kamuli, Kampala, Kiruhura, Kisoro, Kumi, Kyenjojo, Lira,
Manafwa and Terego-Maracha. The analysis of HC IV functionality in these districts is
therefore not included in this analysis.

5.2.2 Factors affecting HC IV Functionality

Just like the previous 2 years, there are a number of key issues that are associated
with HC IV functionality. These include: presence of appropriate infrastructure and
equipment; presence of qualified health workers especially medical officers; and local
government management capacity and interest in HC IV functionality.

Infrastructure and Equipment
Seventy three (70%) of the theatres were complete and equipped. This is nominally
more than the theatres completed and equipped by the end of FY 2005/06. Other
notable infrastructure gaps were mainly the lack of a general ward and a functional
energy or/and water source for some Health Centres while none of the Health Centres
had adequate accommodation for staff.

Human Resources
95 HC IVs had a total staffing of 1,493. The average number of staff was 15 members
of staff per HC IV which translates into 30% of the staffing requirements. Only 45% of
the available staff was housed by the Health Centres. 70% of the HC IVs had at least
one (1) medical officer, 57% had an anaesthetic assistant and 75% had a qualified
laboratory staff. The staffing strength has not changed much from last year, and
critical staffing gaps still exist for Medical Officers, Anaesthetic Assistants and
Laboratory Technician.

Table 5.4: Human Resources for Health Status at the HC IVs
                   Anaesthetic




                                                                    Technician
                                                                    Laboratory




                                                                                 Laboratory
                                                       Registered




                                                                                              Attendant
                   Assistant




                                                                                 Assistant
                                            Enrolled

                                            Midwife




                                                       Midwife




                                                                                              Theatre
         Medical




                                 Clinical




                                            Nurse/




                                                       Nurse/
         Officer




                                 Officer




Mode         1           1           2            2           3          1              1         0
Mean        <1          <1         2-3          2-3         5-6         <1              1       1-2
Norm         2           1           2           12           6          1              2         2

Local Government Management

There seems to be other factors that determine HC IV functionality beyond mere
presence of appropriate Human Resources (especially a medical officer) and
Infrastructure (specifically a complete and equipped theatre). The combination of these
2 also matters - It has been noted that twenty two (21%) of the theatres were equipped
but had no Medical Officer. An attempt to analyse any role that funding and
availability of medicines and supplies was not successful as information provided on
these aspects was generally very poor. It has been noted though that the theatres are


                                                                                                          193
more likely to be functional where local governments make particular efforts to attract
and retain medical officers and supervises them to make sure the units are functional.

It was noted that 38 HC IVs (37%) were equipped, and had a medical officer but were
not offering Caesarean Section. These include: Kikuube (Hoima); Kiyunga & Busesa
(Iganga); Nyamuyanja & Kabuyanda (Isingiro); Jinja (Buwenge); Nyarurambi, Kamwezi,
Hamurwa (Kabale); Kalangala (Kalangala); Ntara, Rukunyu (Kamwenge); Kaproron
(Kapchorwa); Rwesande (Kasese); Bbale (Kayunga); Koboko (Koboko); Nyimbwa
(Luwero); Kyanamukaka, Kiwangala, Kiyumba (Masaka); Bwijanga (Masindi); Bufumbo
(Mbale); Mwera, Kyantungo (Mityana); Nabilatuk (Nakapiripirit); Pajule (Pader);
Kakuuto (Rakai); Ntuusi (Sembabule); Atiriri, Apapai, Serere (Soroti); Mulanda (Tororo);
Wakiso, Kasangati, Buwambo, Namayumba (Wakiso). A few of these may have
remodelling works or minor construction still taking place like at Pajule HC IV, but for
the majority there is no clear reason why the facility especially the theatre is not
functional.

5.2.3 Quality of Care

Only 21 HC IVs (20%) had a Yellow Star (quality) assessment carried out on a quarterly
basis as recommended. While the indicators used are basic and HC IV should have a
perfect score only Bufumbo HC IV had scored above 90% in the 4 quarters in FY
06/07. 7 HC IVs (Oli, Luwero, Bufumbo, Ndejje, Busesa, Kashari and Namayumba)
were regularly assessed and showed an improving trend. The highest score was 94%
for Nyimbwa HC IV in the 3rd quarter while the lowest was 15% for Karugutu HC IV in
the 1st quarter.
With total bed capacity of 2,760, the HC IVs had a total of 149,693 admissions and
6,830 deaths, giving a crude facility death rate of 4.6% and a patient turnover of 54.
The average length of stay for HC IVs was 2.7 days and the bed occupancy rate was
15%. A total of 35 maternal deaths and 202 peri-natal deaths (4%) were reported.


5.2.4 Conclusions and Recommendations


The Health Centre IVs continue to be the most feasible way of ensuring universal
access to some key components of the UMHCP that directly impact on health outcomes
without escalating costs. Currently 19% can be considered ‘functional’ and are
significantly contributing to the key national outputs intended, but with improved
management capacity and commitment especially at Local Government level
functionality can be increased to over 40%. The sector needs to devise mechanisms for
ensuring that adequate resources and improvements in management capacity are
directed towards HC IVs if we are to achieve the maternal & child health MDGs. A
number of steps need to be taken by the different stakeholders including:
•   Increased Monitoring of HC IV Functionality: to ensure better tracking of HC IV
    functionality both the inpatient and outpatient monthly reports should be
    submitted regularly to DHOs who should in turn submit a summary of HC IV
    outputs to MoH.

•   To improve the existing level of functionality of HC IVs, existing gaps should be
    addressed including:


                                                                                    194
         Infrastructure: Focus allocation of PHC Development Grant for FY 07/08 and
         08/09 on improving and completing HC IVs structures including staff houses
         and other key structures like wards where they are lacking.
         Human resource: In addition to providing funding for wage accommodation
         should also be addressed as it may be a bottleneck and mechanisms should be
         put in place to ensure that key staff at HC IVs especially Medical Officers,
         midwives, and Anaesthetic Assistants when available deliver the expected
         outputs. Refresher training and frequent and regular supervision and mentoring
         visits for medical officers at HC IVs in surgical skills should be carried out
         systematically across the country.
         Financing: The need for accurate financial reporting should emphasized to all
         HC IVs; The funding gap for recurrent and infrastructure requirements at HC
         IVs should be accurately estimated and resources mobilized to have this need
         addressed.
         Medicines and supplies: Accurate reporting should be emphasized.

•     Quality of Care - An audit of the reported maternal deaths needs to be carried out
      to inform the sector of the key health system bottlenecks that directly lead to
      maternal deaths within Health Facilities. In addition Yellow Star assessment should
      be regularly carried out in all HCs.


5.3     Monitoring of the HSSP II

5.3.1 Update on Supervision, Monitoring and Mentoring under the HSSP II
The HSSP II objective for Supervision, Monitoring and Mentoring is to provide regular
and appropriate supervision of different entities of the health sector as a means of
ensuring efficient and equitable delivery of health services. The HSSP II also provides a
framework for annual review of performance for Supervision, Monitoring and
Mentoring.


Supervision of Central Programs
The MoH Top Management Committee (TMC) and the Senior Management Committee
(SMC) have responsibility for supervision of central level programmes. The TMC and
SMC have continued to meet regularly to consider reports achievements and
constraints at the various level;s. One review meeting was held for central MoH
programmes and the autonomous institutions to review performance. More effort has
been made to align implementation and performance review with the HSSP II and the
MoH Annual Work-plan.


Supervision from National to Regional and District Levels

   a. Integrated Supervision and Monitoring to local governments
The Area Teams (ATs) formed during the HSSP I continued to support the local
governments with visits both for Supervision and Monitoring and for support for
planning. 3 out of 4 planned activities were carried out – 2 for Supervision and
Monitoring – in February/March for monitoring Quarter 1 and 2 of FY 2006/07, and in
August/September for monitoring Quarter 3 and 4 of FY 2006/07. In January 2007
regional meetings were held to prepare districts to plan for the FY 2007/08.


                                                                                      195
The ATs provide on-site support though briefing and de-briefing meetings at the
district and HSD level and at the health facilities. Individual district reports are
prepared by the ATs and a national summary is prepared and discussed at SMC,
HPAC and TMC. This provides appreciation of key issues at the implementation level
by the various managers at the MoH and different follow-up actions are initiated by the
different programmes as appropriate.

Challenges and constraints for the ATs are logistical – inadequate funding, late release
of funds; varying skills and capacity across the teams; and difficulties in composing
appropriate teams given competing demands at the MoH. Follow-up of issues identified
during visits could improve.

   b. Specialists Outreach Services
The Clinical Specialists Outreach Services from the Ministry of Health is aimed at
providing technical support supervision. Several activities have been carried out with
support from different partners and agencies and include:

•   Support supervision from the national hospitals to regional hospitals and from
    regional hospitals to general hospitals and Health Centre IVs. All the regional
    hospitals carried out specialists outreach to the general hospitals and health centre
    IVs.
•   Flying Doctors’ Services to hard-to-reach areas were sponsored by AMREF carried
    out four rounds of outreaches to 17 hospitals in Eastern, Northern and Western
    regions of the country. These were in the months of July 2006, October 2006,
    February 2007 and May 2007.
•   UNFPA and EngenderHealth funded a number of VVF repair camps in Kitovu,
    Kagando, Lacor, Arua, Kitgum, Kumi, Nebbi and Matany hospital. During the
    camps hands-on training is provided to gynecologists, nurses and anaesthetists.
•   Ministry of Health together with the Association of Surgeons of Uganda organised a
    surgical camp in the Mbale region in July, 2006. This covered health facilities in
    the districts of Mbale, Tororo, Pallisa, Kapchorwa, Sironko, Budaka and Bududa. A
    total of 433 operations were done.
•   ORBIS Flying Eye Hospital in partnership with Ministry of Health organised a two
    week hands-on training for ophthalmologists, ophthalmic clinical officers, nurses,
    anaesthetologists and biomedical engineers. The hands-on trainings were done at
    the Flying Eye Hospital stationed at Entebbe International Airport, Mulago National
    Hospital and Mengo Hospital.
•   Uganda Sustainable Clubfoot Care project (USCCP) has been treating clubfoot in
    children using the Ponsetti method. With the coordination centre at the department
    of Orthopaedic, Mulago National Hospital, support supervision were carried out to
    the clubfoot clinics in several hospitals.

District Supervision
There has been no comprehensive analysis of district supervision of lower local
governments and health facilities. However anecdotal evidence indicates that this is on
the decline, with districts and HSDs indicating that financial resources under the PHC
CG are very inadequate for this role. The District Annual Reports also indicate that
very few districts are carrying out Yellow Star accreditation.




                                                                                     196
5.3.2 Monitoring the Sector-Wide Approaches implementation


The Health Sector Strategic Plan II is being implemented through a Sector-Wide
Approaches (SWAps) which was jointly agreed between Government of Uganda and the
Development Partners. A number of tools and structures were put in place to monitor
and facilitate the implementation of SWAps. Among the key tools and structures used
by government and partners to monitor the implementation of SWAps in Uganda is:
the Memorandum of Understanding, the National Health Assembly and the Joint
Review Mission. This section of the report highlights the performance of the health
sector against these tools and structures.

5.3.2.1   Memorandum of Understanding

A Memorandum of Understanding (MoU) for guiding the implementation of the second
Health Sector Strategic Plan under the Sector-Wide Approaches was signed between
the Government of Uganda and the health sector Development Partners. The MoU spelt
out the obligations and expectations of government and partners in the SWAps
partnership.

One of the key guiding principles of the SWAp partnership is that government should
provide overall leadership in planning, administration, implementation and monitoring
of the HSSP II. Government tried to uphold this principle and continued to provide
leadership in the implementation of HSSP II. During the year however there were a
number of challenges experienced in the leadership of the Ministry of Health. As the
new political leadership was settling in, there were changes in the senior
administrative and technical leadership of the Ministry of Health which undermined
the health sector’s institutional memory of the SWAps partnership.

Another key principle in the SWAp partnership is the financing obligations of both the
government and development partners. Government had undertaken to ensure that all
resources for the HSSP II are reflected in the resource envelope and the Medium Term
Expenditure Framework. Government also obliged to ensure that the proportion of
overall Government budgetary allocation to the health sector increases annually in real
terms over the five year period of the HSSP II. The financial obligations of government
have not been met. Proportionate increases in the budget allocations to the health
sector did not occur. The obligations of development partners were to provide
comprehensive information regarding resources provided to third parties to support
the health sector in Uganda and that these resources support the HSSP II. Partners
were also to ensure that the support provided should as much as possible avoid
distorting the existing government systems and strategies. Development partners have
also not met this obligation. Information on resources for the health sector from a
number of partners was not readily available during the planning process for FY
2006/07. The move towards alignment and harmonization was seriously undermined
by more donor projects and Global Initiatives coming on board during the year with
increasing but rather unpredictable and earmarked resources.

Government and partners were obliged to ensure an effective reporting and monitoring
system to provide financial and health management information data on time.
Government did not provide periodic (quarterly) reports on health sector performance
both on service delivery outputs and financial management information on time.

                                                                                   197
Information required for the Annual Health Sector Performance was not readily
available in time. Reports which were supposed to be prepared and submitted to
stakeholders did not come in time and some never came at all.

The structures established for open and transparent dialogue and consultation
between government and partners in the implementation of the HSSP II - the Health
Policy Advisory Committee (HPAC), the Joint Review Mission and National Health
Assembly and the Technical Review Meeting were in general functional. As part of the
move to rationalize the SWAps structures with a view to improving the efficiency and
effectiveness in the implementation of HSSP II and MoU, the HPAC Working Groups
were restructured. The restructured HPAC Working Groups have been given new terms
of reference and membership, but are however yet to be fully functional. The HPAC has
also been expanded to subsume to role of Country Coordinating Mechanisms as part of
the Long Term Institutional Arrangements for Global Fund to fight AIDS, TB and
Malaria and its Chairmanship changed.

Overall, both parties did not fully uphold the obligations agreed in the MoU during the
second year of HSSP II. Government and partners need to fully uphold the principles
and obligations agreed in the MoU in order to effectively implement the remaining
years of HSSP II.


5.3.2.2   Resolutions of the 4th National Health Assembly

The 4th National Health Assembly for all health sector stakeholders was held on 28th –
29th October 2006 in Kampala. The main objectives of the National Health Assembly
was to provide a forum for wider participation of all the major health sector
stakeholders and in particular with Local Government representation to review the
performance of the health sector and discuss the priorities for the upcoming year. The
2006 NHA received and discussed the Annual Health Sector Performance Report for FY
2005/06 and the priorities for FY 2007/08. At the end of the NHA, stakeholders agreed
on a number of resolutions for implementation in order to improve health service
delivery and contribute to improvements in health status of the people of Uganda.
Health sector stakeholders implemented the 2006 NHA resolutions as part of their
annual work-plan process. A number of achievements were attained and challenges
experienced by stakeholders at different levels during the implementation of the 2006
NHA resolutions. Annex 5.4 provides a summary report on the progress of
implementation of the 2006 NHA resolutions.


5.3.2.3   Undertakings of the 2006 Health Sector Joint Review Mission

The 12th Health Sector Joint Review Mission was held on 25th - 27th October 2007 in
Kampala. The objectives of the Joint Review Mission was to review the progress on
implementation of the second Health Sector Strategic Plan and to agree on the
priorities and budgets for the upcoming Financial Year (FY 2007/08). At the end of the
Joint Review Mission, health sector stakeholders agreed on a number of Undertakings
to be implemented by the different stakeholders and a report on the progress of
implementation presented and discussed at the October 2007 JRM. Health sector
stakeholders implemented the Undertakings of the 2006 JRM as part of their annual
work-plan process. Out of ten Undertakings, four were fully achieved, two were
partially achieved and four were not achieved at all. Table 5.5 provides a summary

                                                                                    198
report on the progress of implementation of the Undertakings of the 2006 Health
Sector Joint Review Mission.


5.3.3 Monitoring of the HSSP II


The HSSP II provided a monitoring framework for the sector, including 25 main
indicators, with targets for the FY 2009/10 and most of them with annual targets
against which to determine annual sector performance. The FY 2006/07 performance
has been reviewed using the HSSP II indicators and targets. Performance against this
framework has been provided in Chapter 2: Overview of Sector Performance. In
addition Programme level indicators have been used throughout the report especially
under Chapter 3: Implementation of the UNMHCP, and Chapter 4: Integrated Health
Support System.

A number of challenges have been noted in Monitoring of the HSSP II, and have been
highlighted already under Chapter 2. The key challenges include: Availability of data –
a number of key indicators do not have values against them, 2 years in a row; and
Data Quality.

The work around the Mid-Term Review (MTR) should include an assessment of these
constraints and determine a Way Forward.




                                                                                   199
200
Annex 4.1: Budget Performance FY 2006/07


                                              SECTOR BUDGET PERFORMNCE FOR FY 2006-07

                                         Wage                               Non Wage Recurrent                     Domestic Development




                                           Release




                                                                       Release




                                                                                                  Release




                                                                                                                              Release
                                                                                        Arrears
                                Budget




                                                             Budget




                                                                                                                    Budget
                                                              MTEF
                                                      %




                                                                                  %




                                                                                                             %




                                                                                                                                          %
Ministry of Health             3.50      2.88         82%   25.65     22.62       88%   2.85      2.82       99%   13.11     12.10        92%
Butabika Hospital              1.57      1.46         93%   1.59      1.59       100%   0.04      0.04      100%   7.32      6.77        92.4%
Mulago Hospital Complex        13.58     12.46        92%   11.79     13.44      114%   0.74      0.74      100%   1.39      1.94       139.9%
Health Service Commission      0.42      0.32         75%   1.23      0.99        80%   0.02      0.02      100%   0.05      0.05       100.0%
Uganda Aids Commission         0.69      0.69        100%   0.83      0.63        76%     -         -              1.51      1.42        94.0%

District NGO Hospitals/PHC       -         -                17.74     16.54      93%      -         -                -         -
District Primary Health Care   74.62     74.82       100%   22.91     21.42      93%      -         -              6.10      6.095      100%

District hospitals               -         -                10.61     10.61      100%     -         -                 -         -
Regional Referral Hospitals    17.53     15.87       91%    7.26      8.91       123%   1.59      1.61      101%      -         -
UBTS                           1.10      0.81        73%    0.73      0.72        98%     -         -                 -         -
TOTAL                          111.9     109.29      98%    100.34    97.46      97%    5.24      5.23      100%   29.48     27.13       96%




                                                                                                                                        201
Annex 4.2: Poverty Action Fund Performance FY 2006/07
PAF programmes            FY           FY       FY 2006/07     FY 2006/07       FY 2006/07
                       2006/07      2006/07       Actual          Actual           Actual
                       Approved     Releases    Expenditure    Performance     Performance
                        budget                                                against releases
District RRH (wage)      17.53        15.82        15.82          90.2%           100.0%
District RRH (drugs)     2.33         2.27          2.27          97.3%           100.0%
Mulago Hosp.             5.00         5.00          5.00          100.0%          100.0%
complex
PHC ministerial Devt     13.05        12.43        12.44           95.4%          100.1%
budget
National PHC service     22.19        21.39        21.36           96.3%           99.9%
delivery programmes
PHC CG (wage)            74.62        74.24        74.24          99.5%           100.0%
PHC CG (non-wage)        22.87        21.42        21.42          93.7%           100.0%
PHC CG                   6.10         6.10          6.10          100.0%          100.0%
(development)
PHC – NGO                17.74        16.78        16.78          94.6%           100.0%
District Hospitals       10.61        10.61        10.61          100.0%          100.0%
UBTS                     1.53         1.54          1.07          70.0%            69.6%
Uganda AIDS              2.83         2.66          2.66          94.0%           100.0%
Commission
Support to AIDS           1.86        1.85          1.85           99.3%          100.0%
Orphans and
Children’s
Rehabilitation
Butabika Hosp.            0.44        0.44          0.44          100.0%          100.3%
(drugs)
Butabika Hosp.            7.32        6.81          6.81           93.1%          100.0%
(development)
Total PHC (excl          206.01      199.35       198.87           96.5%          99.8%
arrears)
Source: Annual Budget Performance Report FY 2006/07. MoFPED, September 2007




                                                                                                 202
    Annex 4.3: Health Sector1 Donor Project Funding on inputs costed in the HSSP II; FY 2006/07


                                                                Medicines
                                                                and other                         Capital
                              HR                                medical         Other             non infra-     Infra-            Non HSSP
                              Ugandan2          Training**      supplies        recurrent3        structure4     structure         inputs5           TOTAL                %
Public Sector                            -               -                -               -               -                  -                -                 -
Central level                    2,341,169       3,934,154       27,080,652       5,331,159       1,054,286         15,080,632        8,754,935        63,544,043         18%
District level                     215,097       7,369,326        6,227,034       8,574,796         693,193            594,263        2,732,911        26,406,619          7%
Sub-total public sector          2,556,266      11,303,480      33,307,685       13,905,955       1,747,478        15,674,895        11,487,846       89,950,662          26%

Private Sector
PNFP (facility based)             4,595,576      37,807,400         565,110        9,487,787         282,900            89,492         9,199,523       66,195,938         19%
PNFP (non-facility based)         4,595,576      20,706,599         269,100       18,863,048         616,688           807,300        14,218,480       67,537,015         19%
For Profit Providers             13,786,728      13,786,787               -       27,573,435               -                 -        73,536,115      128,683,065         37%
Sub-total private sector        22,977,880      72,300,785          834,210      55,924,270          899,588           896,792       96,954,119      262,416,017          74%

TOTAL                           25,534,146      83,604,265      34,141,895       69,830,225       2,647,066        16,571,687      108,441,965       352,366,680
Percentage                                7%            24%              10%              20%              1%                5%              31%             100%         100%

    Notes:
    Complete separate forms for donor funding and counterpart funding requirements and for different financial years
    1. The Health Sector as defined in the HSSP i.e. preventive and curative health care services. Do not include non health activities in other sector e.g. education,
       social services, nutrition, sanitation infrastructure, population services
    ** Include both short and long-term training
    2. Salaries and allowances for staff employed by GoU or Private Sector health providers - not project staff
    3. E.g. office running costs, fuel, maintenance of vehicles and premises. For HSSP services not project management
    4. E.g. vehicles and equipment. For HSSP services not project management
    5. Includes all inputs not directly costed in the health financing strategy including: technical assistance and project management costs




                                                                                                                                                                  203
Annex 5.1:     Coordination of Health Services in Northern Uganda


District     Coordination          Stakeholder Mandate            Planning &                Implementation Of             Return, Recovery        Comments
             Forum                 and MOUs Status                Information Sharing       Minimum Health Care           & Resettlement
                                                                                            Package                       (3Rs)
Gulu         Two coordination      Majority of NGOs have          Planning Information      Some NGOs not                 District has            Supervision
             fora exist both are   signed MOUs, a few             largely shared but        adherent to MOH               recovery and            by DHO
             chaired by DHO;       implementing agencies          financial information     guidelines e.g. HIV           resettlement plan       improves
             Health and            have no MOUs. NGO              usually not available.    testing protocols and TB      available. Staff        compliance
             Nutrition co-         registration status and        WHO and UNICEF            treatment in the case of      accommodation           with MOH
             chaired by WHO,       verification of their staff    share information         MSF (Swiss) who have          and maternity           guidelines
             HIV/AIDS co-          assumed to be done at          more easily than          since had disagreements       units are among
             chaired by            central level. Initial staff   others. Originally top    with the district and left.   the priorities in the
             UNICEF, each          verified but subsequent        down planning but         Uncoordinated training        return, recovery
             cluster meets         staffs are not.                with the current          by partners and MOH           and resettlement
             monthly and                                          return, recovery and      partly responsible for        plan.
             jointly determine                                    resettlement;             extensive staff
             the agenda. These                                    approach is more          absenteeism from the
             fora have been                                       participatory.            health units.
             found useful                                         Sometimes donors
             especially on                                        have different
             follow-up given the                                  planning cycles and
             weekly progress                                      reporting
             reports made.                                        requirements
                                                                  resulting into parallel
                                                                  efforts.
Kitgum       Forum meets           Majority of NGOs have          Planning Information      Most NGOs compliant           Gaps/intervention       Peace,
             monthly chaired       signed MOUs, CAO,              shared except             save for                      s have been             Recovery and
             by DHO. Agenda        DHO, LCV and the               financial information     MSF(Holland)which is          identified and          development
             Jointly               NGOs partners verify           not readily shared by     not adherent to the           linked to CAP and       plan is not
             determined.           content and sign.              partners                  national TB treatment         PRDP.                   explicit about
             List of NGOs                                                                   guidelines                                            health.
             operating in the
             district known and
             provided.


Pader        Forum meets           MOUs are signed; NGOs          Planning Information      Most NGOs compliant           Interventions for       Lack of full




                                                                                                                                                        204
District   Coordination          Stakeholder Mandate         Planning &                Implementation Of            Return, Recovery      Comments
           Forum                 and MOUs Status             Information Sharing       Minimum Health Care          & Resettlement
                                                                                       Package                      (3Rs)
           monthly, chaired      legal status assumed to     shared; Financial         with MOH treatment           recovery and          participation
           by DHO and            be ok but no verification   information not easily    guidelines and HIV           resettlement have     by the district
           agenda formulated     done. NGO Staff             accessible. WHO and       testing protocols, MSF       been identified and   in the
           by DHO and then       registration status not     UNICEF easily shares      (Holland) were non-          will be jointly       formulation of
           discussed with        always verified.            information.              compliant while they still   implemented by        the PRDP
           partners. Have                                                              operated in the district.    partners.
           been useful by
           helping focus and
           track outputs.
           Forum meets           Most NGOs/CBOs have         General planning          Some NGOs not                District has          DHT didn’t
Amuru      monthly chaired       signed MOUs.                information shared        compliant with MOH           recovery and          participate in
           by DHO and co-                                    but financial             protocols and guidelines     resettlement plan,    making PRDP.
           chaired by WHO.                                   information not easily    for example HIV testing      being implemented     Agencies still
           Agenda jointly                                    accessed.                 protocols and TB             jointly with          carrying out
           determined.                                                                 treatment                    partners.             activities
                                                                                                                                          outside the
                                                                                                                                          DDP and
                                                                                                                                          AWP.
Oyam       Forum meets           Majority of partners        Planning information      All the NGOs/CBOs are        Gaps and priority     District has
           List of NGOs          have signed MOUs but        always provided late,     compliant with GOU           interventions         been part of
           operating in the      some have not,              are poorly represented    treatment guidelines and     identified and        CAP and
           district known and    registration status of      at planning meetings      testing protocols            costed                PRDP
           provided.             NGOs/CBOs not known         often sending junior
                                 including their staff       staff who cannot make
                                                             decisions.
Lira       Forum meets           Signed MOUs available,      Information for           Most NGOs compliant          Return,               Ministry of
           monthly, chaired      content jointly             planning shared and       with MOH guidelines          resettlement and      Health should
           by DHO and            determined. Verification    been useful in            except MSF (Holland) but     recovery plan         strengthen
           reports to DDMC       of legal status of NGOs     determining priorities    it has since closed          complete.             stewardship
           (meets monthly        and Staff not routinely     and closing funding       operations.                  Implementation of     and demand
           except during         done, assumed to have       gaps. WHO & UNICEF                                     CAP is                compliance on
           emergencies like      been done at central        avail financial                                        complementing the     reporting
           recent floods meets   level.                      information for                                        PRDP. Some            requirements
           weekly). CAO part                                 planning; other                                        agencies are slow     and
           of the DDMC                                       agencies do not                                        to transform from     information
           making                                            readily share financial                                emergency mode to     sharing for
           implementation                                    information. Reporting                                 the recovery and      planning.




                                                                                                                                               205
District   Coordination          Stakeholder Mandate        Planning &                Implementation Of          Return, Recovery       Comments
           Forum                 and MOUs Status            Information Sharing       Minimum Health Care        & Resettlement
                                                                                      Package                    (3Rs)
           and follow-up                                    has greatly improved.                                resettlement mode
           possible.                                        Out of phase planning                                (e.g. promotion of
                                                            cycles for GOU and                                   CORPs as opposed
                                                            agencies is a challenge                              to VHTs)
                                                            to planning.
Moroto     Forum meets           MOUs signed between        Planning is done          NGOs compliant with the    The Karamoja           District had
           monthly chaired       district and most of the   jointly and               MOH guidelines, most of    development plan       little input
           by DHO, agenda        NGOs and CBOs.             information shared        them are in general        is much                into the KDP
           jointly determined.   Registration status of     but only for some of      public health and not      generalized and        formulation.
           List of NGOs          Some NGOs and their        them. Some partners       direct clinical care.      not health specific.
           operating in the      staff not verified.        still do not easily                                  Areas of priority
           district known and                               share financial                                      for health sector
           provided.                                        information                                          are known
                                                                                                                 following research
                                                                                                                 and
                                                                                                                 recommendations
                                                                                                                 made in 2004
           Existent, meets       Samples of signed          Information is shared     Many partners reported     District has costed    Close
           quarterly shared      MOUs provided. Content     and used for planning     to be non-compliant with   plan for recovery      monitoring of
Katakwi    leadership between    jointly determined and     but often comes late      MOH treatment              and resettlement       CBOs
           DHO and the           CAO, DHO and               often when the            guidelines and HIV         estimated at about     increases on
           NGOs/CBOs. List       NGO/CBO sign. NGO          planning process is       testing protocols          800 million but no     the
           of NGOs operating     Status verified for some   complete and here                                    clear financing        compliance
           in the district       and not clear for others   estimates are used.                                  strategy.              with MOH
           known and                                                                                                                    guidelines
           provided. Forum
           found useful and
           described as
           effective for
           partnership and
           teamwork.




                                                                                                                                             206
      Annex 5.4:    Progress report on implementation of the 2006 National Health Assembly resolutions


No.           Resolution                                    Progress report                                                                     Overall
                                                                                                                                                assessment
              Health Financing

NHA4: 1       NHA resolves that government should           During the budget process for FY 2006/07, the Ministry of Health together           Not achieved.
              increase resources for the health sector      with development partners continued to lobby Ministry of Finance,                   % of GoU budget
              towards the Abuja target of having 15% of     Planning and Economic Development for increased resource allocation to              allocated to
              the national budget allocated to the health   the health sector. The proportion of the national budget allocated to the           health sector
              sector in order to improve the delivery of    health sector during FY 2006/07 however was only 9.6%. The GoU                      remained at
              health care with emphasis on human            allocation to the health sector therefore still fell short of the Abuja target of   9.6%
              resources,    basic   infrastructure   and    15% of the national budget.
              equipment and essential medicines and
              health supplies.
              Human Resources for Health

NHA4: 2       MoH should develop clear, objective and       The Ministry of Health in consultation with key stakeholders particularly           Not achieved
              transparent criteria for identifying          Ministry of Public Service have been discussing the broader framework of
              districts with hard to reach areas and        describing hard-to-reach areas. The Ministry of Public Service has now
              these be disseminated to all districts.       finalized a policy on hard to reach and is due to consult with the District
                                                            Local Governments to establish pockets of hard to reach areas within
                                                            districts. The out come of the consultations will guide payment of the 30%
                                                            approved by Cabinet.
              Human Resources for Health

NHA4: 3       Local    Governments  and    stakeholders     The Ministry of Local Government and stakeholders especially Ministries of          Partially
              (MoLG, MoH, MoPS, MoES, MoFPED, HSC           Health, Finance, Public Services and Education and Sports have been                 achieved
              and     Development   Partners)    should     discussing modalities of attracting and retaining health workers in
              coordinate and work out modalities for        districts. Stakeholders have agreed that recruitment of health workers
              attracting and retaining ethical health       should be continuous. Ministry of Health will therefore be assisting
              workers in their districts including the      districts with central advertisement of vacancies at the districts. Ministry
              PNFP facilities.                              of Health is also working on a coordinated approach comprising of bonding
                                                            health workers undergoing training so that they are employed by District
                                                            Service Commissions with hard to reach circumstances.

                                                            In order to address the problem of low pay for health workers, Ministry of
                                                            Health has prepared a proposal for increasing the salaries of health
                                                            workers. The proposal has been submitted to Ministry of Finance for




                                                                                                                                                      207
No.       Resolution                                   Progress report                                                              Overall
                                                                                                                                    assessment
                                                       consideration and support.

                                                       Besides providing monetary incentives, Ministry of Health has continued to
                                                       provide funds to Local Governments for constructing staff houses to
                                                       accommodate of health workers.
          Health Infrastructure

NHA4: 4   The    Ministry    of   Health   &   Local   The Ministry of Health and Local Governments have continued to provide
          Governments      should   accelerate   the   support for functionalizing HC IVs. Ministry of Health and Local
          functionalization of HC IVs through          Governments have continued to prioritize recruitment of critical cadres of
          improvements on infrastructure, provision    health workers, especially Medical Officers, Anaesthetic Officers and        Not achieved.
          of equipment and staffing in order to        Midwives, for HC IVs every year based on the revised and expanded            Functionality of
          increase the percentage of functional HC     staffing norms of Local Governments. Ministry of Health has continued to     HC IV slightly
          IVs from 22% to 60% by October 2007 and      provide theater equipment to completed HC IV theaters. During FY             declined from
          100% by October 2008.                        2006/07, the following HC IV theatres received complete sets of theater      22% in FY
                                                       equipment: Kityerera HC IV in Mayuge District, Busesa HC IV in Iganga,       05/06 to 20% in
                                                       Busia HC IV in Busia District, Kibuku HC IV in Pallisa District, Bugobero    06/07
                                                       HC IV in Manafwa District, Tokora and Nabilatuk HC IVs in Nakapiripirit
                                                       Dist, Aduku HC IV in Apac District and Amach HC IV in Lira District.

                                                       During FY 2007/08, the following HC IVs received complete sets of theater
                                                       equipment: Aboke HC IV in Apac District, Atiak HC IV in Amuru District,
                                                       Karugutu HC IV in Bundibugyo District, Kibiito HC IV in Kabarole District,
                                                       Kyabugimbi HC IV in Bushenyi District, Lalogi HC IV in Gulu District,
                                                       Madi Opei HC IV in Kitgum District, Naru Okora HC IV in Kitgum District
                                                       and Ogur HC IV in Lira District

                                                       Ministry of Health has continued to provide funds for remodeling some HC
                                                       IV theatres to collect some architectural faults. Funds have also been
                                                       provided for construction of some additional wards, staff houses and other
                                                       infrastructural requirements on a number of HC IVs.
          Medicines & Health Supplies Procurement
          and Management
                                                                                                                                    Not achieved.
NHA4: 5                                                Overall the utilization of the PHC Conditional Grants for Essential          Utilisation
          The Local Governments should improve         Medicines and Health Supplies at National Medical Stores and/or Joint        slightly
          utilization of the PHC conditional grant     Medical Stores slightly increased from 55% during FY 2005/06 to 58% in       increased from




                                                                                                                                          208
No.       Resolution                                     Progress report                                                                 Overall
                                                                                                                                         assessment
          indicative budget for essential medicines      FY 2006/07. It is not clear at this stage how much was actually spent           55% in FY
          and health supplies from 60% to 100% by        elsewhere, especially the private sector, with a view to improving              05/06 to 58% in
          October 2007 in order to increase              availability of EMHS. To confirm this, there will be need for special auditor   FY 06/07
          availability of medicines in the health        of the expenditures.
          facilities.
          Medicines & Health Supplies Procurement
          and Management

NHA4: 6                                                  Health sector partners developed a three year Comprehensive Procurement         Partially
          Health sector stakeholders (MoH, NMS and
                                                         Plan for Essential Medicines and Health Supplies. The plan was discussed        achieved.
          LGs and Partners) should harmonize
                                                         and endorsed at the April 2007 Technical Review Meeting. Partners have
          procurement, storage and distribution of
                                                         therefore agreed to commit themselves to the harmonized procurement;
          essential medicines and health supplies by
                                                         storage and distribution of Essential Medicines and Health Supplies and
          next TRM - April 2007.
                                                         implementation modalities for the plan are being discussed.
          Reproductive Health

NHA4: 7   Districts/Hospitals should prioritize          Districts/Hospitals have continued to prepare integrated annual work-
          reproductive health services during the        plans for the delivery of the Uganda National Minimum Health Care               Partially
          planning and budgeting to ensure adequate      Package. However, in view of the high proportion of the disease burden          achieved
          availability of reproductive health supplies   caused by maternal and childhood conditions, districts have started to          through good
          in particular mama kits and basic              seriously prioritise maternal and child health care during the planning and     planning and
          equipment so that pregnant women are not       budgeting process. Hospitals and health centres have started involving in-      prioritizing
          required to provide such items.                charges of maternity centres/wards in quantifying and requesting for            resource
                                                         reproductive health supplies for their units.                                   allocation to
                                                         The Ministry of Health and partners have increased funding and                  RH.
                                                         procurement of reproductive health supplies in particular mama kits and
                                                         basic equipment for maternity and these are included in the Credit Line
                                                         facilities at the NMS and JMS for hospitals and health centres to Pull.
                                                         This could have resulted in increased availability of reproductive health
                                                         supplies in health facilities and possibly resulted in observed increased
                                                         proportion of expectant mothers delivering in health from 29% during FY
                                                         2005/06 to 32% in FY 2006/07.
          Reproductive Health
                                                                                                                                         Not achieved at
NHA4: 8   Local Governments should commit                A number of districts enacted by-laws and ordinances on sanitation,             all. The target
          themselves to enacting and enforcing by-       functionalized District Water and Sanitation Committees and marked              set by NHA was




                                                                                                                                               209
No.        Resolution                                   Progress report                                                               Overall
                                                                                                                                      assessment
           laws and ordinances on sanitation in order   Sanitation Week in order to improve sanitation in the district. The overall   too high. Latrine
           to improve pit latrine coverage to 100% by   national pit latrine coverage however didn’t increased but remained           coverage has
           October 2007.                                stagnant at 58%. The ambitious target set by the 2006 National Health         stagnated at
                                                        Assembly of achieving 100% latrine coverage by October 2007 was               58% for the last
                                                        therefore not achieved.                                                       3 years
           Health Systems

           District/Urban Councils should formally      The final Aide Memoire of the 2006 National Health Assembly and Health        Partially
NHA4: 9    adopt the NHA resolutions and JRM            Sector Joint Review Mission containing the NHA resolutions and JRM            achieved
           Undertakings within two months of the end    Undertakings was disseminated to all districts during Regional Planning
           of the NHA/JRM. The resolutions should be    Meetings and copies of the report circulated. District/Urban Councils were
           implemented and monitored as part of         encouraged to adopt the resolutions and undertakings during their council
           their annual work plans.                     meetings. Many of the districts implemented the resolutions and
                                                        undertakings but the degree of implementation varies across districts.
           Health Systems

NHA4: 10   Health sector stakeholders (MoH, MoFPED,     Health sector stakeholders continued to provide resources for rolling out     Not achieved at
           MoLG and partners) should expedite the       Village Health Teams for ensuring effective community mobilization for        all. VHT roll out
           roll out of Village Health Teams to 100%     health. The support facilitated Ministry of Health and some Local             requires alot of
           national coverage in order to ensure         Governments to conduct training of VHTs and provision of logistics to the     resources,
           effective community mobilization for         trained VHTs in a number of districts. The support provided however           currently not
           health.                                      wasn’t adequate to ensure 100% national coverage.                             available in the
                                                                                                                                      budget


           Health Systems

NHA4: 11   o   To call upon H. E. The President to      The Ministry of Health held several meetings with stakeholders including      Not achieved.
               mobilize all actors in all sectors of    Medical Associations, partners to discuss the Road Map for accelerating
               Government particularly MoH, MoLG,       the reduction of maternal and newborn deaths. The consultative
               MoGLSD, MoES, MoWE, MoEMD,               meetings with stakeholders provided valuable inputs on the strategy.
               MoWT, DPs, Civil Society, Religious      The Road Map is scheduled to be discussed with Parliamentary Social
               Leaders and Media to mobilize            Services Sectoral Committee at the end of October 2007.
               resources for implementation of the
               Road Map to accelerate the reduction     The Ministry of Health has mobilized resources from partners for
               of maternal and new born deaths and      equipping training institutions, family planning campaign, capacity
               mobilize communities to participate      building and Information, Education and Communication (IEC). The




                                                                                                                                            210
No.   Resolution                               Progress report                                                       Overall
                                                                                                                     assessment
          and utilize services.                health sector is already implementing some sections of the Road Map
      o   The MoH shall report annually to     using the already available resources with the routine budget.
          Parliament on the progress made on
          the Road Map to accelerate the
          reduction of maternal and newborn
          deaths.
      o   MoH and Districts report to NHA
          annually on progress made




                                                                                                                          211
      Annex 5.5:      Progress report on Undertakings of the October 2006 Joint Review Mission


No.    Undertaking                           Plan of Action                                         Progress report                              Overall
                                                                                                                                                 assessment
1.     Human Resources for Health            •   Determine the financial requirement to close       •   Financial requirement to close
       Health sector budget for FY               the remuneration gap between PNFP and                  remuneration gap (Ushs. 8 bn) was
       2007/08 to cater for funds to close       public health workers                                  determined. In the Medium Term           Not achieved
       the remuneration gap between          •   Advocacy with MoFPED and MoPS to mobilise              however, there are no funds in the
       PNFP and Public Health workers.           the funds for catering the remuneration gap            budget to close the gap.
                                             •   Discuss and agree with stakeholder’s esp.          •   Held advocacy meetings with MoF &
                                                 MoFPED, MoPS and PNFPs on best options for             MoPS, but no results yet.
                                                 accessing these funds initially and how to         •   Modalities for payment of hard-to
                                                 later mainstream the funds into the budget.            reach allowance have been agreed with
                                             •   Continue with negotiations with MoF on hard            MoF and MoPS.
                                                 – to – reach allowances.
2.     Human Resources for Health            •   Cleaning up the HRH Strategic Plan 1st draft       •   Technical review of the draft plan
       Finalise and operationalize the       •   Cost the plan                                          including the monitoring indicators
       Human Resources for Health            •   Carry out detailed editing to produce 2nd draft        was carried out and inputs for costing   Fully achieved
       Strategic Plan 2006-2020              •   Hold consultation meetings with stakeholders           identified.
                                             •   Produce final draft HRH Strategic Plan
                                             •   Present final draft to HPAC                        •   Two consultation meetings held with
                                             •   Present final draft to TMC of MoH for approval         stakeholders on the draft plan
                                             •   Prepare and forward Cabinet memo on HRH
                                                 Strategic Plan fro approval                        •   Costing of the plan completed
                                             •   Print and disseminate
                                             •   Operationalise the HRH Strategic Plan              •   Plan finalised and printed.
3.     Health Infrastructure                 •   Inventory of completed theatres                    •   Inventory of theatres undertaken.
       Equip all the remaining 23            •   Procurement of theatre equipment                   •   Procurement orders placed and
       completed Theatres by October         •   Allocation and distribution of available theatre       equipment from ORET I project for 10     Fully achieved
       2007.                                     equipment                                              theatres received.
                                                                                                    •   Equipment allocated to benefiting
                                                                                                        theatres
                                                                                                    •   Pre-installation work carried out on
                                                                                                        the benefiting theatres (except in
                                                                                                        Kotido due to insecurity)
                                                                                                    •   Equipment installed at 21 HC IV
                                                                                                        theatres.




                                                                                                                                                    212
No.   Undertaking                           Plan of Action                                      Progress report                               Overall
                                                                                                                                              assessment
4     Medicines & Health Supplies           •   Prepare a plan for development of MoH           •   Plan for building MoH institutional
      Procurement and Management                institutional capacity to coordinate, monitor       capacity developed
                                                and review the plan, and to ‘drive’ the road                                                  Fully achieved
      Prepare and implement a road map
                                                map
      to effectively roll out the 3 year
                                            •   Harmonize the health development partners       •   Inputs of development partners
      comprehensive procurement plan
                                                inputs and procurement modalities in line           received and incorporated
      for medicines and health supplies.
                                                with the MoU between GoU/HDPs for HSSP II
                                                (section 6.5 on procurement)
                                            •   Prioritise the establishment of a Department    •   MoPS approved the establishment of
                                                of Pharmaceutical Services within MoH;              the Pharmacy Division in MoH. Plans
                                                outcome of discussions with MoPS;                   are underway to recruit and fill the
                                                                                                    approved positions of the new
                                            •   Agree and adopt a new fee scale and billing         Division.
                                                system for NMS handling of Third Party          •    New fees scale and billing system for
                                                supplies; new MoU signed by MoH and NMS.            NMS discussed and agreed.

                                            •   Draft a road map and finalise the               •   Comprehensive Procurement Plan for
                                                Comprehensive 3-year Procurement Plan (FY           Medicines and Health Supplies
                                                06-07 to 08-09).                                    prepared and completed.

                                            •   Review the rolling plan, confirm commitments    •   Road map for the rolling plan prepared
                                                for FY 07-08, and new inputs for FY 09-10;          and completed
                                                new plan attached to BFP 07-08;                 •   Review of the rolling plan on-going
                                                                                                    with support of Consultant provided
                                                                                                    by WHO
5.    Medicines & Health Supplies           •   Develop Terms of Reference for the              •   ToR for the assessment prepared and
      Procurement and Management                assessment                                          circulated.
                                            •   Invite competent firms to bid for the           •   WHO supporting the process. However       Not achieved
      Undertake an assessment of the
                                                Assignment                                          due to need to concretise the
      capacity of National Drug Authority
      with a view of documenting its        •   Receive and Evaluate bids                           appropriate structure of NDA in line
                                            •   Award contract to most suitable firm                with new roles, there was need for
      current capacity and existing gaps
                                            •   Carry out assignment and submit Draft               senior mgt of NDA to make a study
      in order to optimally fulfil its
                                                Report to MoH                                       tour to understudy similar institutions
      mandates in the Health Sector
                                            •   Present Draft Report to HPAC                        within the African Region.
                                            •   Prepare Final Report                            •   Assessment to start immediately after
                                            •   Present final report to JRM                         study tour




                                                                                                                                                 213
No.   Undertaking                           Plan of Action                                       Progress report                                Overall
                                                                                                                                                assessment
6.    Maternal Health                                                                            •   Equipment credit line opened which
      Scale up EmOC to ensure:                                                                       includes EmOC equipment.
      1. Provision of Comprehensive         •   Ordering and procurement of EmOC                 •   Districts are ordering equipment           Partially
          EmOC in all hospitals (100%)          equipment                                            according to inventory requirement         achieved
      2. Provision of Comprehensive         •   Allocation and distribution of EmOC                  and financial ceiling.
          EmOC in 50% of HC IVs                 equipment                                        •   EmOC scale up on going in Districts
      3. Provision of Basic EmOC in         •   Support supervision to hospitals, HC IVs and         using Performance improvement
          50% of HC IIIs                        HC IIIs                                              Framework.(PIF)
                                                                                                 •   Training in Life saving skills ongoing.
                                                                                                 •   Training, equipment and ambulances
                                                                                                     availed to 9 Northern Districts of
                                                                                                     Acholi and Lango sub Regions under
                                                                                                     Northern Region emergency response.
                                                                                                 •   Equipment and Transportation for
                                                                                                     Karamoja region ordered.
                                                                                                 •   MVA Kits procured and distributed to
                                                                                                     health units which had trained
                                                                                                     providers
7.    Maternal Health                       •   Hire competent individuals to carry out FP       •   Reproductive Health Commodity
      1. Zero tolerance for stock out for       commodity assessment                                 security coordinator recruited and
         contraceptive supplies             •   Present report on FP assessment to HPAC              posted to RH division.                     Partially
                                            •   Implement recommendations                        •   Regular FP revitalisation meetings         achieved
                                            •   Procure and disseminate the FP eligibility           ongoing.
                                                Criteria to all District Health Teams            •   3 years procurement plan for
                                            •   Deliver FP Commodities to all districts              contraceptives developed and first year
                                            •   Provide support supervision for FP service           of the plan has committed funding.
                                                delivery                                         •   Logistics Management training
                                            •   Conduct logistics management refresher               ongoing.
                                                training to health workers with limited skills   •   Training of Health workers in FP skills
                                                in FP                                                ongoing.
                                            •   Conduct assessment on progress                   •   Support supervision being carried out.
                                                                                                 •   Emergency contraceptives procured
                                                                                                     and distributed.
                                                                                                 •   Regional dissemination of FP eligibility
                                                                                                     criteria carried out.
                                                                                                 •   Districts are ordering FP commodities




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No.   Undertaking                            Plan of Action                                      Progress report                               Overall
                                                                                                                                               assessment
                                                                                                     using a pull system.
                                                                                                 •   FP commodity tracking to identify
                                                                                                     which facility has ordered excess stock
                                                                                                     or not ordering is being carried out.
8.    Child Survival                         •   Develop and agree a framework and ToRs for      •   Consultant to facilitate the process
      Based on the HSSP II, articulate the       developing rolling plan for child survival.         recruited and started working
      Medium Term rolling plan for Child     •   Hire consultant to facilitate the work          •   Consultation meetings with                Fully achieved
      Survival with the objective of         •   Produce draft proposal and discuss with key         stakeholders held
      achieving a sustained scaling up of        stakeholders                                    •   Draft report prepared and shared with
      known/new cost effective               •   Incorporate comments from stakeholders              stakeholders.
      interventions towards attainment of    •   Present draft proposal in HPAC                  •   The initial comments made by
      MDG 4.                                 •   Incorporate comments from HPAC                      stakeholders on report incorporated in
                                             •   Finalise the proposal                               the draft
                                             •   Present final proposal to 07 JRM                •   The revised draft discussed at
                                                                                                     Stakeholders Meeting at end of
                                                                                                     September 07
                                                                                                 •   Costing of the Child Survival strategy
                                                                                                     undertaken with support of UNICEF
                                                                                                     and WHO
                                                                                                 •   Final costed Child Survival Strategy
                                                                                                     finalized and ready for discussion at
                                                                                                     October JRM
9.    Finance & Procurement                  •   Revise ToRs for the undertaking                 •   ToR for the proposal for finalising the
       Finalise the Harmonized and           •   Identify procurement related plans/activities       plan prepared and circulated to HPAC      Not achieved
      Comprehensive Procurement Plan             for each use department, and identify gaps          for approval
      for the health sector (carried         •   Aggregate the activities into a procurement     •   HPAC demanded for scaling down of
      forward)                                   plan                                                the budget
                                             •   Develop a procurement schedule for each         •
                                                 activity
                                             •   Cost the activities
                                             •   Finailise a harmonised & comprehensive plan
                                                 for the sector
                                             •   Present to HPAC and other relevant bodies
10.   Finance & Procurement                  •   Develop/adopt Assessment tools to the sector
      Institutionalize the National          •   Disseminate results of the SHSSSP which has     •   Adopted Appraisal Tool discussed and      Not achieved
      Planning Authority PRIA approach           been assessed as an example                         agreed




                                                                                                                                                  215
No.   Undertaking                Plan of Action                                        Progress report                      Overall
                                                                                                                            assessment
      for appraising all         •   Administer/apply the tools to all projects, new   •   Project submitted for analysis
      projects/programmes with       and on going routine basis
      reference to HSSP II.      •   Prepare project appraisal reports




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