THE REPUBLIC OF UGANDA MINISTRY OF HEALTH ANNUAL HEALTH SECTOR PERFORMANCE REPORT

Transcription

1 THE REPUBLIC OF UGANDA MINISTRY OF HEALTH ANNUAL HEALTH SECTOR PERFORMANCE REPORT Financial Year 2014/2015

2 THE REPUBLIC OF UGANDA MINISTRY OF HEALTH Annual Health Sector Performance Report Financial Year 2014/2015

3 yy Annual Health Sector Performance Report for Financial Year 2014/15 Hon. Dr. Elioda Tumwesige Honourable Minister of Health Hon. Sarah Opendi Minister of State for Health/ Primary Health Care Hon. Dr. Chris Baryomunsi Minister of State for Health/ General Duties i

4 yy Annual Health Sector Performance Report for Financial Year 2014/ /15 yy 2014/15 Dr. Asuman Lukwago Permanent Secretary Hon. Dr. Elioda Tumwesige Honourable Minister of Health Dr. Jane Ruth Aceng Director General Health Services Hon. Sarah Opendi Minister of State for Health/ Primary Health Care Hon. Dr. Chris Baryomunsi Minister of State for Health/ General Duties Dr. Henry Mwebesa Ag. Director of Health Services/ Planning and Development Prof. Anthony Mbonye Director Health Services/ Community and Clinical Services ii i

5 yy Annual Health Sector Performance Report for Financial Year 2014/15 iii

6 yy Annual Health Sector Performance Report for Financial Year 2014/15 FOREWORD The Annual Health Sector Performance Report for 2014/15 Financial Year provides analysis of health sector performance against set targets, goals and objectives for the Financial Year 2014/15 with a comparative analysis of the previous trends towards achieving the HSSIP 2010/ /15 targets. The report is premised on an analysis of commitments in the National Development Plan, Ministerial Policy Statement, Budget Framework Paper, the HSSIP, the 20th JRM Aide Memoire and the annual sector workplans at various levels. The report is discussed at the Annual Health Sector Joint Review Mission, and is based on the assessment of what has been achieved and what has not, and reasons why, to guide future programming. The sector is committed to refocusing priorities to interventions aimed at making positive progress towards implementing the strategies of the National Health Policy II, and achieving the National Development Plan targets and Millennium Development Goals. The sector continues to prioritize interventions defined in the Uganda National Minimum Health Care Package under a Sector-Wide Approach arrangement, with emphasis on recommendations of the HSSIP 2010/ /15 Mid-Term review. This is further supported by the resolutions of the World Health Assembly, the International Health Partnerships, the Paris Declaration on Harmonization and Alignment and the Accra Agenda for Action and related initiatives. The Government of Uganda recognizes the contribution of Health Development Partners, Civil Society, the Private Sector and the community in the reported sector performance. Sector performance cannot be improved and sustained without the dedicated efforts of all categories of health workers, working under sometimes challenging conditions, especially in the rural and hard-to-reach parts of the Country. I commend the dedicated and productive health workers, and I implore those health workers whose work ethic, behaviour and conduct hold back sector progress, to improve. I wish to thank the Health Policy Advisory Committee members for always giving policy guidance to the sector and for their contribution in the preparation of the Joint Review Mission. Special gratitude goes to the JRM Secretariat, Task Force and Subcommittees that ensured that this annual report was compiled. For God and My Country Hon. Dr. Elioda Tumwesigye, MP MINISTER OF HEALH iv

7 yy Annual Health Sector Performance Report for Financial Year 2014/15 TABLE OF CONTENTS FOREWORD... iv LIST OF FIGURES... vi TABLES... vii ACRONYMS... ix Executive Summary... xvi CHAPTER ONE Introduction Background The process of compiling the report Outline of the report... 1 CHAPTER TWO Overall sector performance and progress Overall sector performance and progress Health Impact Indicators Health Output Indicators Other health determinants and risk factors and behaviour Service access, readiness, quality and safety Health Investments and Governance Local Government Performance District League Table (DLT) Regional Performance Level Performance Hospital Performance National referral hospitals General Hospital Performance Functionality of HC IVs Achievements against Planned Outputs in the MPS 2014/ Finance and Administration Planning Quality Assurance Clinical and Community Communicable Disease Prevention and Control Semi-Autonomous Institutions Regulatory Bodies PNFP Sub-Sector Annex v

8 yy Annual Health Sector Performance Report for Financial Year 2014/15 LIST OF FIGURES Figure 1: institutional maternal mortality ratio during hssip period... 4 Figure 2: Number of registered health workers 2014/ Figure 3: Distribution of the health workforce by employment status Figure 4: GoU health expenditure as of total government expenditure Figure 5:Government allocation to the Health Sector 2010/11 to 2014/ Figure 6: Per capital public health exp (US $) Figure 7: Trends in PHC Grant Allocations FY 2010/ /15 in Ushs billions Figure 9: A map of Uganda showing percentage of reports with action taken during 2014/15 FY Figure 8: Top ten conditions among under fives and above in 2014/15 FY Figure 9: Volume of Outputs for RRHs and Large PNFPs 2014/ / /13 FYs. 43 Figure 10: Recurrent / SUO and Bed Occupancy Rate in RRHs Figure 11: Histogram for distribution of ALOS 2014/ Figure 12: Trends in Caesarean Section and Blood transfusion 2008/ / Figure 13: Post Bank Assessed Homes and WASH Loans provided Figure 14: The improved latrine facilities constructed after provision of the WASH Loans Figure 15: Number of active ART clients in the country: 2003 December Figure 16: National Malaria Prevalence Figure 17: Trends in ITN Ownership and Use Figure 18: Blood Collection for FY 2004/05 to 2014/ Figure 19: Natural Family Planning Contacts in UCMB Hospitals in 5 years Figure 20: Staffing in UPMB hospitals, HC IVs and LLUs Figure 21: Standard Unit of output in UPMB hospitals vi

9 yy Annual Health Sector Performance Report for Financial Year 2014/15 TABLES Table 1: Comparison of the Impact Indicators Performance aagainst the HSSIP Targets... 3 Table 2: Comparison of Maternal deaths notified by facilities to those reported through HMIS... 4 Table 3: Causes of maternal deaths over the HSSIP period... 5 Table 4: Common factors underlying maternal deaths... 6 Table 5: Leading causes of Under 5 In-patient Mortality... 7 Table 6: Performance for health services core indicators... 9 Table 7: Progress against the Other health determinants and risk factors and behaviour Table 8: Availability of individual tracer medicines 2010/ / Table 9: Progress against the service access and quality indicators Table 10: Staffing level in various public sector institutions Table 11: Staffing levels in Regional Referral Hospitals Table 12: Staffing by cadre Table 13: Performance of investments and governance indicators over the past 5 years Table 14: Government allocation to the Health Sector 2010/11 to 2014/ Table 15: Institutional Budget Performance 2014/15 FY Table 16: Budget Categories Table 17: Primary Health Care Grants FY 2010/ /15 in Ushs billions Table 18: Average PHC Non-wage allocation by level to public health facilities and DHOs 2014/15 FY Table 19: Report statistics over the months in the year of 2014 / Table 20: Action taken by stakeholders or relevant action centers during the period Table 21: 10 Districts with Highest Number of Action Taken Table 22: HPAC Institutional representatives attendance Table 23: Progress in implementation of the Country Compact during FY 2014/ Table 24: Progress in implementation of the IHP+ commitments Table 25: Trends in national average performance in the DLT Table 26: Fifteen (15) Top and Bottom performing districts FY 2014/ Table 27: District ranking for Districts Excluding district with RRHs Table 28: District ranking for hard-to-reach districts as per the DLT Table 29: District ranking for new districts Table 30: district ranking by Region 2014/15 FY vii

10 yy Annual Health Sector Performance Report for Financial Year 2014/15 Table 31: Top ten causes of hospital based mortality for all ages 2014/ Table 32: Financial Performance for 14 RRHs for FY 2014/15 (UGX Billions) Table 33: Key Hospital Outputs and Ranking of RRHs and Large PNFP Hospitals Table 34: Summary of Key Outputs for RRHs and Large PNFPs Table 35: Selected Efficiency Parameters for RRHs and Large PNFP Hospitals FY 2014/ Table 36: Selected Quality of Care Parameters for RRHs and Large PNFP Hospitals 2014/15 46 Table 37: Summary of Outputs from the General Hospitals FY 2014/15 (N=132) Table 38: The Top 15 high volume General Hospitals Table 39: Summary of Outputs from the HC IVs FY 2014/15 (N=195) Table 40: Summary of Efficiency & Usage Measurements of HC IVs Table 41: Performance on TB outcome and Output indicators Table 47: UCMB Facility Staffing Table 43: FAMILY PLANNING SERVICES IN UCMB HEALTH FACILITIES Table 44: UCMB facilities performance in Key HIV indicators in FY 2014/ Table 45: 5-Year Trend of UCMB Health Facilities Average Cost/SUO and Average User Fees/SUO Table 46: Trends in income for recurrent cost in UCMB network (Hospitals + LLHFs) Table 48: Key Outputs for the UMMB Facilities Table 49: Staff training in UMMB Facilities Table 50: DLT ranking for the 112 districts 2014/15 FY Table 51: DLT ranking for the 14 districts 2014/15 FY with Referral Hospitals Table 52: Ranking of the 31 New Districts 2014/15 FY Table 53: League Table for Hard to reach Districts Table 54: Regional Ranking 2014/ Table 55: General Hospital Performance Table 56: Summary of General Hospital Performance Table 57: Outputs and Ranking of HC IVs 2014/ viii

11 yy Annual Health Sector Performance Report for Financial Year 2014/15 ACRONYMS ACT AHSPR AIDS AMREF ANC ART ARVs BFHI CAO CB-DOTS CBO CCM CDC CDD CDP CDR CEmOC CLTS CPR CPT CSO CYP DHIS DHO DHMT DLT DOTS DPs DPT DQA EAC EAPHL ECSA-HC EID EMHS EmOC emtct FP FY Artemisinin Combination Therapies Annual Health Sector Performance Report Acquired Immuno-Deficiency Syndrome African Medical and Research Foundation Ante Natal Care Anti-retroviral Therapy Antiretroviral Drugs Baby Friendly Health Initiative Chief Administrative Officer Community Based TB Directly Observed Treatment Community Based Organization Country Coordinating Mechanism Centres for Disease Control Control of Diarrhoeal Diseases Child Days Plus Case Detection Rate Comprehensive Emergency Obstetric Care Community Led Total Sanitation Contraceptive Prevalence Rate Cotrimoxazole Preventive Therapy Civil Society Organization Couple Years of Protection District Health Information Software District Health Officer District Health Management Team District League Table Directly Observed Treatment, short course (for TB) Development Partners Diphtheria, Pertussis (whooping cough) and Tetanus vaccine Data Quality Assessment East African Community East African Public Health Laboratories East Central and Southern Africa - Health Community Early Infant Diagnosis Essential Medicines and Health Supplies Emergency Obstetric Care Elimination of Mother-to-Child Transimission Family Planning Financial Year ix

12 yy Annual Health Sector Performance Report for Financial Year 2014/15 GAVI GBV GFTAM GH GoU HAART HC HCT HDP HIV HMBF HMDC HMIS HPAC HPC HRH HSD HSS HSSIP HSSP ICB ICCM ICU IMCI IDSR IEC IMAM IMCI IPT IRS ITNs JAF JBSF JICA JMS JPP JRM KCCA KDS LG LLHF Global Alliance for vaccines and Immunization Gender Based Violence Global Fund to fight TB, Aids and Malaria General Hospital Government of Uganda Highly Active Anti-Retroviral Therapy Health Centre HIV/AIDS Counselling and Testing Health Development Partners Human Immuno-Deficiency Virus Home Based Management of Fever Health Manpower Development Centre Health Management Information System Health Policy Advisory Committee Health Professional Council Human Resources for Health Health Sub-Districts Health Systems Strengthening Health Sector Strategic Investment Plan Health Sector Strategic Plan Institutional Capacity Building Integrated Community Case Management Intensive Care Unit Integrated Management of Childhood Illnesses Integrated Disease Surveillance and Response Information Education and Communication Integrated Management of Acute Malnutrition Integrated Management of Childhood Illness Intermittent Presumptive Treatment for malaria Indoor Residual Spraying Insecticide Treated Nets Joint Assessment Framework Joint Budget Support Framework Japan International Cooperation Agency Joint Medical Stores Joint Program on Population Joint Review Mission Kampala City Council Authority Kampala Declaration on Sanitation Local Government Lower Level Health Facility x

13 yy Annual Health Sector Performance Report for Financial Year 2014/15 LLINs Long Lasting Insecticide Treated Nets LTFPM Long Term Family Planning Methods MCH Maternal and Child Health MDGs Millennium Development Goals MDR Multi-drug Resistant MIP Malaria in pregnancy MKCCAP Mulago Hospital and the City of Kampala Project MMR Maternal Mortality Ratio MOFPED Ministry of Finance, Planning and Economic Development MoGLSD Ministry of Gender, Labour and Social Development MOH Ministry Of Health MOLG Ministry of Local Government MOPS Ministry of Public Service MOU Memorandum of Understanding MOWE Ministry of Water and Environment MPDR Maternal Perinatal Death Review MDR/XDR Multi-drug and extra-drug resistant TB MTEF Medium Term Expenditure Framework MTR Mid-Term Review NCD Non Communicable Diseases NCRI National Chemotherapeutic Research Institute NDA National Drug Authority NGOs Non-Governmental Organizations NHA National Health Assembly NHP National Health Policy NMCP National Malaria Control Programme NMS National Medical Stores NTD Neglected Tropical Disease NTLP National Tuberculosis and Leprosy Control Program ODF Open Defecation Free OOP Out-Of-Pocket Payments OPD Out Patients Department OPM Office of the Prime Minister OPV Oral Polio Vaccine ORS Oral Rehydration Salt ORT Oral Rehydration Therapy PHA People with HIV/AIDS PHAST Participatory Hygiene and Sanitation Transformation PHC Primary Health Care PLWHA People with HIV/AIDS PMDT Programmatic Management of Multi-Drug Resistant TB xi

14 yy Annual Health Sector Performance Report for Financial Year 2014/15 PMTCT PNFP PPPH PRDP QI RH RPMT RRH RMNCAH SDS SGBV SLD SMC SMER SP SPARS STI SUO SWAP TB TMC TSR TT TWG UACP UAIS UBOS UBTS UCI UCMB UDHS UGFATM UHSSP UHI UMIS UMMB UNEPI UNFPA UNHRO UNICEF UNMHCP Prevention of Mother to Child Transmission Private Not for Profit Public Private Partnership for Health Peace Recovery and Development Plan Quality Improvement Reproductive Health Regional Performance Monitoring Team Regional Referral Hospital Reproductive health maternal, newborn and child health Strengthening Decentralization for Sustainability Sexual and Gender Based Violence Second Line Drugs Senior Management Committee Supervision, Monitoring, Evaluation and Research Sulphadoxine/Pyrimethamine Supervision Performance Assessment Recognition Strategy Sexually Transmitted Infection Standard unit of Output Sector-Wide Approach Tuberculosis Top Management Committee Treatment Success Rate Tetanus Toxoid Technical Working Group Uganda Aids Control Program Uganda AIDS Indicator Survey Uganda Bureau of Statistics Uganda Blood Transfusion Services Uganda Cancer Institute Uganda Catholic Medical Bureau Uganda Demographic and Health Survey Uganda Global Fund for AIDS, TB and Malaria Uganda Health Systems Strengthening Project Uganda Heart Institute Uganda Malaria Indicator Survey Uganda Muslim Medical Bureau Uganda Expanded Programme on Immunization United Nations Fund for Population Activities Uganda National Health Research Organization United Nations Children s Fund Uganda National Minimum Health Care Package xii

15 yy Annual Health Sector Performance Report for Financial Year 2014/15 UPMB USF UVRI VHT WHO Uganda Protestant Medical Bureau Uganda Sanitation Fund Uganda Virus Research Institute Village Health Team World Health Organization xiii

16 yy Annual Health Sector Performance Report for Financial Year 2014/15 Summary assessment of the 26 HSSIP core indicators Indicator Overall progress Baseline Achievement 2014/15 HSSIP Target MMR 435/100,000 (UDHS 2006) IMR 76/1,000 (UDHS 2006) Under 5 Mortality Rate 137/1,000 (UDHS 2006) NMR 29/1,000 (UDHS 2006) Proportion of households 28 experiencing catastrophic (2009/10) payments pregnant women attending 4 ANC sessions 360/100,000 (WHS 2014) 45/1,000 (WHS 2014) 69/1,000 (WHS 2014) 23/1,000 (WHS 2014) 37 (NHA 2011/12) 131/100,000 41/1,000 56/1,000 23/1, deliveries in health facilities children under one year immunized with 3 rd dose Pentavalent vaccine one year old children immunized against measles pregnant women who have completed IPT 2 of children exposed to HIV from their mothers accessing HIV testing within 12 months U5s with fever receiving malaria treatment within 24 hours from VHT ART coverage among those in need No data No data (2013 WHO Guidelines) Households with a pit latrine U5 children with height /age below lower line (stunting) U5 children with weight /age below lower line (wasting) 38 (2006) 16 (2006) Contraceptive Prevalence Rate 24 of new TB smear + cases notified compared to expected (TB case detection rate) TB Treatment Success Rate (2006) 39.8 (2009/10) 68.6 (2009/10) (UDHS 2011) (UDHS 2011) (UDHS 2011) xiv

17 yy Annual Health Sector Performance Report for Financial Year 2014/15 Per capita OPD utilisation rate 1.0 (2009/10) of health facilities without 41 stock outs of any of the six tracer medicines in previous 3 (2009/10) months of functional HC IVs 24 (providing EMOC) (2009/10) clients expressing satisfaction with health services of approved posts filled by health workers (public health facilities) annual reduction in absenteeism rate of villages / wards with trained VHTs 46 (2008/09) 56 (2009/10) 46 (09/10) (Absenteeism) 72 (09/10) No data 20 reduction from previous year GoU health expenditure as of total government expenditure 9.6 (09/10) xv

18 yy Annual Health Sector Performance Report for Financial Year 2014/15 Executive Summary The annual sector performance report (AHSPR) highlights progress, challenges, lessons learnt and proposes mechanisms for improvement. The report focuses on the progress in implementation of commitments in the Ministerial Policy Statement, overall sector performance against the targets set for the FY 2014/15, and trends in performance for selected indicators over the previous FYs. The compilation process of the was participatory with involvement of all the 14 Technical Working Groups and Senior Management Committee. The overall coordination and technical support was by the MoH Joint Review Mission Task Force. Data The report focuses on the core indicators for monitoring performance of the HSSIP 2010/ /15 which are linked with the monitoring of the National Development Plan (NDP) and international initiatives such as the Millennium Development Goals (MDGs). The report is based on the health facility and district reports gathered as part of the routine Health Management Information System (HMIS), administrative sources and programme data, including both quantitative and qualitative data. Generation of output indicators for this report largely utilized data from the integrated HMIS, with completeness of monthly reporting for the year under review standing at 83 up from 74 in 2013/14 and timeliness of 88 from 70 in 2013/14. Coverage estimates in the HMIS data uses the UBOS 2013 mid-year population projections to estimate the target populations. Health impact Impact is assessed using MMR, NMR, IMR, U5MR, and incidence of catastrophic household expenditure on health. The WHO Health Statistics Series 2014 report shows positive trends, with a progressive and constant reduction of all mortality indicators as compared to the previous ten to fifteen years. In particular IMR and U5MR showed a significant decline with the likelihood of achieving the MDG and HSSIP targets. The MMR stands at 360 per 100,000 (WHO 2014) live births [that of Kenya is 400 per 100,000 live births (WHO 2014) and Tanzania is 460 per 100,000 (World Bank 2012)]. This is below the HSSIP and MDG and HSSIP target of 131 per 100,000 live births. The HMIS reports show that the institutional maternal death rates have dropped from 146 per 100,000 in 2013/14 to 118 per 100,000 in 2014/15. There has been progressive decline over the five years in average annual facility based maternal deaths from 194 per 100,000 lives (2010/11) live births to 118 per 100,000 live births in 2014/15. In addition to increased institutional deliveries, this could be attributed to improved effective ANC to prevent, detect, and treat problems such as malaria, anaemia, HIV/AIDS and other infections, which are important indirect causes of maternal death, and the scale up of quality improvement interventions in hospitals e.g. Maternal and Perinatal Death notification and reviews and use of partographs. xvi

19 yy Annual Health Sector Performance Report for Financial Year 2014/15 The three classic delays (home, on the way, and at facility) must be addressed to reign in unacceptably high maternal morbidity and mortality. The top causes of maternal deaths in 2014/15 FY included 1) haemorrhage (42), 2) pregnancy related hypertension (12) and 3) postpartum sepsis (11). The high burden of maternal and perinatal deaths needs to be addressed through implementation of the target interventions for targeted populations. Service coverage Despite increase in staffing levels, availability of EMHS, all Reproductive Health (RH) indicators are still below the HSSIP targets. The percentage of pregnant women attending at least 4 ANC sessions increased only slightly from 32.4 in 2013/14 to 36.6 in 2014/15 (target was 60). The percentage of deliveries in health facilities remarkably increased from 44.4 in 2013/14 to 52.7 in 2014/15) and IPT2 coverage increased from 49 to Despite improved efforts at recruitment and deployment, human resource constraints (adequacy, distributional disparities and skills) still adversely affect the delivery of quality RH services. There is need to available appropriate numbers of skilled RH providers and mobilize the community to utilize RH services. The sector has sustained the good progress in immunization of children over the HSSIP period. The percentage of children under one year immunized with 3 rd dose of pentavalent vaccine now stands at (104.5 males & 99.5 females), from 93 (91 males & 95 females in 2013/14. The percentage of one year old children immunized against measles stands at 90 compared to 87 in 2013/14. These achievements need to be sustained and propelled further through further strengthening existing EPI services and targeting poorly performing districts, hard to reach areas and populations. The percentage of children exposed to HIV from their mothers accessing HIV testing within 12 months increased from 54 to 58 in 2014/15 and also short of the target of 75 by the end of the HSSIP. The percentage of people who are on ARVs increased from 48 (680,514 / 1,405,268) in 2013/14 to 750,896 (56) by 2014 of those in need (adults 694,627(58) and children 56,269 (38). Risk factors and behaviour Latrine coverage is improved from 74.6 in 2013/14 to 77 surpassing the HSSIP target of 72. This is attributed to the creation of a District Sanitation Fund in 89 districts, the Uganda Sanitation Fund Project in 30 districts. The status of coverage for the other health determinants i.e. wasting, stunting and Contraceptive Prevalence Rate was not assessed during this HSSIP period since there was no Demographic Health Survey since Service access, readiness, quality and safety TB case detection rate (TB CDR) increased from 36.6 in 2013/14 to 45 in 2014/15 far below the HSSIP target of 70. TB Treatment Success Rate was 79 compared to 80.7 in xvii

20 yy Annual Health Sector Performance Report for Financial Year 2014/ /14. The slow progress relates to inadequate systems for TB case detection, adherence monitoring (poor DOT) and testing relapses for drug sensitivity. Per capita OPD utilization from 1.0 in 2013/14 to 1.2 in 2014/15. OPD utilization rate was consistently achieved throughout the HSSIP period. The medicines situation in the public sector has improved significantly in the last five years, facilities reporting no stock outs of the indicator items. The percentage of health units with no stock outs of any indicator medicines in the previous six months was at 64 in 2014/15 from 57 in 2013/14 and 43 in 2010/11. The larger proportion going to HIV, TB and malaria commodities with the smaller proportion of about $1 going to basic EMHS. This is not adequate to meet the population medicines need. The percentage of HC IVs conducting cesarean section was 51 and 38 were able to perform blood transfusion during FY 2014/15. This represents an improvement, as compared to the previous FY which reported 45 and 36 respectively. The percentage of clients expressing satisfaction with health services improved from 46 in 2008 to 69 (barely short of the HSSIP target of 70) in 2014 under the UHSSP Client satisfaction Survey. The common reasons in support of the Customer Satisfaction index included availability of caring personnel, medicines, free medical services. Health investments and Governance There has been a gradual improvement in the level of investments into the health sector over the HSSIP period. The percentage of approved posts filled by health workers in the public sector increased from 69 to 70 in 2014/15. Over the HSSIP period there was improvement from 56 in 2010/11 and this was as a result of the recruitment drive that was supported by government and Development Partners in During this FY there was no significant investment in building the capacity of Village Health Teams (VHTs) and has remained at 78 of the villages in the country having trained VHTs. Much effort was towards reviewing the VHT concept, studying establishment of the Community Health Extension Workers (CHEWs) and development of a CHEW policy and strategy. Financial investment in health by GoU declined from 8.7 in 2013/14 to 8.5 in 2014/15 FY of the overall National Budget. This is short of the HSSIP target of 10. Budget performance for the appropriated GoU budget was 100. This translates into a government contribution of US$ 13.7 per capita on health (The per capita public expenditure increased from US$12 to US$13.7 due to additional government, GAVI and Global Fund financing). This is still below the recommended per capita government expenditure on health of US $ 34 per capita as per the WHO Commission of Macro Economics and Health (CMH). It is also below the HSSIP target of per capita government expenditure on health of US $ 17. xviii

21 yy Annual Health Sector Performance Report for Financial Year 2014/15 Recurrent expenditure was 52 of the total expenditure while 48 was development expenditure (of which 42 is donor-funded, and 6 GoU funded). There is inadequate funding for sector activities especially PHC Services. Only Ushs 327 billion excluding the medicines budget was allocated as recurrent budget to run health service delivery. There is a challenge of the alignment of off-budget funding to sector priorities and skewed input mix in financing health facilities. There has not been commensurate funding for recurrent costs for utilities and/or maintenance arising from the construction of new buildings and equipment especially for hospitals at all levels. According to the National Health Accounts (NHA) reports, the level of out of pocket (OOP) expenditure, as percentage of the Total Health Expenditures, has been increasing in real terms in the past years though reducing in percentage terms. It was estimated at 42 in FY 2009/10 (NHA, 2013). The OOP expenditure was 37 in 2012/13 (NHA, 2014), showing a reduction, attributed to increased partner support for health, mostly through the private sector. The high OOP on health care negatively impacts on households incomes and affects household demand for, and access to health care. Consequently, the proportion of people facing catastrophic expenditure leading to house hold impoverishments, especially of the lower income quintiles is high. Significant progress has been made in the rehabilitation of infrastructure and supply of new equipment in the sector at various levels. Work was done at National, RRHs, in KCCA, and selected General hospitals. In addition, work was done at in Local Governments in the areas of staff houses, maternity wards, OPD and Transport among others. Investments in health infrastructure has continued and this included construction of new and rehabilitation of old infrastructure at various levels, provision of medical equipment and hospital furniture; provision of solar lighting, improvement of operations and maintenance of health infrastructure; strengthening the referral system by providing ambulances, general transport and Information Communication and Technology (ICT) equipment and services in selected health facilities; and renovation/construction of selected health facilities. Monitoring Implementation of the Country Compact and IHP+ Functionality of the HPAC is very crucial in monitoring implementation of the Compact and provision of advice on the implementation of the HSSIP and policies. Attendance of HPAC meetings by the various stakeholders was varied, with the HDP representatives attending more consistently than other members. There is less than satisfactory presence of Private Sector Representatives, while most concerning is the very low participation of other Line Ministries, RRHs and district representatives, whose activities have a significant influence on the determinants of health, and thus on overall population health. Central Level Performance The sector has prioritized stewardship, resource mobilization, standards and guidelines development, monitoring and supervision. A situation analysis of the supervision, xix

22 yy Annual Health Sector Performance Report for Financial Year 2014/15 monitoring and inspection (SMI) system in the health sector showed that there is inadequate leadership at all levels to demand and enforce regular SMI and ensuring followup of the recommended actions. The established structures (RPMTs, DHTs, Hospital Boards and HUMCs) for monitoring health sector performance are not functioning optimally. There is lack of comprehensive plans, poor coordination of the SMI activities of different programs and at all levels; thus overwhelms districts and facilities. The SMI framework needs to be strengthened to harmonize monitoring and supervision. Hospital Performance The MoH Health Facility Inventory July, 2013 the total number of hospitals (public and private) is 155. Of these 2 are National Referral Hospitals (Mulago and Butabika), 14 are RRHs and 139 are GHs. In terms of ownership, 65 are government owned, 63 private not for profit - PNFP and 27 are Private. There are 139 GHs in the country providing; preventive, promotive outpatient curative, maternity, inpatient, emergency surgery and blood transfusion and laboratory services. The 14 RRHs and 4 large PNFP hospitals assessed registered an increase in SUO in 2014/15 compared to 2012/13 from 8,727,279 to 9,598,602. Mbale hospital continues to lead in volume of outputs pushed by the very high number of admissions 70,183 (37 higher than 2013/14). Masaka retains the second slot registering a 36 increase compared to the year before. Hoima, St. Marys Lacor, Moroto all registered more than 20 increases. For reasons yet to be established Kabale had a 29 reduction in outputs compared to the year before. Hospital based deaths especially maternal deaths and fresh still births are indicators of quality of care. The total maternal deaths reported in 14 RRHs and 4 PNFP hospitals were 321 with a mean death of 18 mothers per hospital per year with a minimum of 2 in Mengo and maximum of 37 in Mbarara RRH. The total SUO for GHs has increased from 15,514,147 in 2013/14 to 16,256,818 this is generally attributed to increased number of hospitals reporting in the DHIS2 from 133 to 132. The average outputs were lower for all the listed outputs in the table below except for postnatal and family planning. The minimum SUO for GHs was 708 and maximum 543,117. The range in outputs is so big and calls in to question the classification of some health units as hospitals. The 5 top performing (high volume) hospitals were Iganga, Busolwe, Kitgum, Mityana and Tororo. Compared to the year 2013/14, Busolwe and Kitgum are new entrants to the top 5. Bwera and Kawolo dropped off the top 5. Among the PNFP the highest volume hospital is Angal St. Luke. The 5 lowest volume hospitals were JCRC, Kitintale, Ntinda, Middle East Bugolobi and Family Care hospital. There is need to re-visit the level classification of some of the very low volume hospitals. These hospitals tend to have very low bed capacities well below the minimum number (60) defined in the definition of hospitals by the hospital policy. xx

23 yy Annual Health Sector Performance Report for Financial Year 2014/15 Maternal deaths were reported in 79 GHs, a total of 407 deaths compared to 449 in 2014/15 were recorded giving an average of 5 (5.8 in 2013/14) deaths per hospital. However taking the denominator as hospitals conducting deliveries (126) the average death per hospital is 3.2. The minimum is 0 and the maximum is 18 as observed in Iganga. Public-Private Partnership in Health The health sector benefits from the partnerships with the private sector (PNFPs, Private Health Providers and CSOs). To strengthen the partnership and operationalize the national policy on PPPH, MoH has established a PPP Unit. The Unit will facilitate collaboration among partners under the stewardship of the MoH. The contribution from the private sector to the achievement of the national health objectives is included in this report, which gives a good overview of PNFP performance, mainly from UCMB and UPMB. Contribution from some of the PHP and CSOs has also been documented. The inability to generate comprehensive reports from the private sector is still a major challenge, though some significant contribution is from PHPs and CSOs. This is largely due to lack of HMIS tools, capacity gaps in utilization of HMIS tools, and lack of feedback on reported data. However, the introduction of DHIS2 has considerably improved the reporting rate for PNFP facilities. At the same time, most PHP facilities are still lacking the required human resources, equipment and infrastructure to effectively report. The PNFPs continue to provide significant inputs (financing, infrastructure, skilled human resources, training, etc) into the health system, despite growing evidence of declining financing. 65 of training capacity especially for nurses and midwives is by the PNFP training schools. Data from DHIS2 indicates that over 40 of outputs are from PNFPs. The sub-sector is critical to the health system as it has a more diversified geographical distribution that enables deeper service reach, and has been critical in sustaining service provision during times of conflict and epidemic outbreaks. Local Government Performance There is an improvement in the DLT national average performance from 74 in 2013/14 to 78.6 in 2014/15. The improvement in performance was observed for all indicators. Among all the 112 LGs the top five are Gulu (89), Kampala (87.4), Kabarole (85.4), Jinja (84.7) and Rukungiri (84). The bottom five LGs in performance are Nakapiripit (60.9), Kotido (60.2), Buvuma (59.3), Bulambuli (57.3) and Amudat (46.6). Among the 98 LGs excluding the 14 districts with referral hospitals, the top five LGs in this category are Rukungiri (84), Butambala (83.4), Lamwo (82.6), Mityana (82.5) and Lyantonde (82.4). At least 5 of the 31 new districts achieved total scores above the national average of These are Butambala (83.4), Lamwo (82.6), Serere (82.2), Agago (80.3) and Nwoya (78.6). xxi

24 yy Annual Health Sector Performance Report for Financial Year 2014/15 Overall, during the FY 2014/15, 48 districts registered improvement while 64 districts declined, based on the DLT performance indicators. In terms of total scores, Gulu and Soroti regions registered the highest scores (79.2 and 77.6 respectively) while Mbale and Moroto regions registered the lowest scores (69.1 and 61.4 respectively). However, of the 12 regions, only Gulu region scored above the national average of xxii

25 CHAPTER ONE 1 Introduction 1.1 Background The Annual Health Sector Performance Report (AHSPR) 2014/15 highlights progress, challenges; lessons learnt and propose ways of enhancing sector performance. This fourteenth AHSPR marks the last year for the Health Sector Strategic and Investment Plan (HSSIP) 2010/ /15. Progress over 2014/15 is reviewed for: i) Effectiveness of interventions, responsiveness and equity in the health care delivery system, ii) Comparison with performance trends for the core indicators with the previous year s performance and against the target for the year. Since this is the last year of the HSSIP trends over the last 5 years are also reflected, iii) How well the integrated support systems have been strengthened, iv) Status of programme implementation. The report takes into account the undertakings and commitments of the following documents: National Development Plan (NDP I) 2010/ /15, the second National Health Policy (NHP II) 2010/ /20, HSSIP 2010/ /15, Millennium Development Goals (MDG), Medium Term Expenditure Framework (MTEF), Budget Framework Paper (BFP) and Ministerial Policy Statement 2014/15, the 2013/14 Joint Review Mission Aide memoire and quarterly progress reports. 1.2 The process of compiling the report The development process of the commenced with development of the concept note and the constitution of a Task Force. The composition of the Task Force was drawn from all departments of MoH, private sector and HDPs to ensure representation of all key stakeholders. The respective Ministry of Health (MoH) Technical Working Groups (TWGs) were responsible for compiling and reviewing the information and data presented by programme areas. The Health Policy Advisory Committee (HPAC) and Senior Management Committee (SMC) provided guidance and monitored progress of the entire process. Sources of information of used in compiling the AHSPR were mainly; the HMIS aggregated monthly reports from the District Health Information Software (DHIS2), programme and project reports, survey reports and studies, quarterly sector performance reports and surveillance data. Population figures used for the league table analysis were based on the UBOS 2014 population census. 1.3 Outline of the report The first chapter presents the background to the Annual Health Sector Performance Report. Chapter two reports on performance based on specific indicators in the M&E Framework, the 1

26 chapter is organized by level of indicators i.e. impact, outcome, outputs, and inputs. It also includes an analysis of district, hospital and Health Center (HC) IV performance as ranked by the league tables and Standard Unit Output (SUO). Chapter 3 provides detail on performance of the different departments, divisions and programmes in delivery of the Uganda National Minimum Health Care Package (UNMHCP), and the health system support functions and Private-Not-For-Profit (PNFP) sector. 2

27 CHAPTER TWO 2 Overall sector performance and progress 2.1 Overall sector performance and progress This section provides an overview of the sector performance against the HSSIP performance indicators for FY 2014/15 and progress on implementation of recommendations in the Aide Memoire of the 20 th Joint Review Mission (JRM). Special focus has been put on assessing performance against commitments of the Ministerial Policy Statement (MPS) for FY 2014/15, and performance of districts, hospitals and HC IVs in service delivery Health Impact Indicators Over the HSSIP period, the health sector aimed at improving the following health impact indicators: Maternal Mortality Ratio 1 (MMR), Neonatal Mortality Rate 2 (NMR), Infant Mortality Rate 3 (IMR), Under-5 Mortality Rate 4 and mitigating impact of catastrophic payments for health care on households as a proxy measure for financial risk (protection). TABLE 1: COMPARISON OF THE IMPACT INDICATORS PERFORMANCE AAGAINST THE HSSIP TARGETS Indicator UDHS 2006 baseline UDHS 2011 WHO (2014 World Health Statistics series) 2015 HSSIP target MMR 435/100, /100, /100, /100,000 IMR 76/1,000 54/1,000 45/1,000 41/1,000 Under 5 Mortality Rate 137/1,000 90/1,000 69/1,000 56/1,000 NMR 29/1,000 27/1,000 23/1,000 23/1,000 Proportion of households experiencing catastrophic payments 28 (2009/10) 37 (NHA 2011/12) Source: UDHS 2006, 2011, NHA 2011/12 and WHO statistics series Table 1 above presents progress on the impact indicators against HSSIP targets of The WHO statistics series 2014 results have been used since the NHA 2013/14 is still underway and the UDHS 2015 is yet to be undertaken. According to the WHO Health Statistics series report 1 Maternal Mortality Ratio: Number of mothers dying per 100, 000 live births 2 Neonatal Mortality Rate: Number of deaths during the first completed 28 days of life per 1000 live births 3 Infant Mortality Rate: Number of deaths of children aged less than 1 year dying per 1000 live births 4 Child Mortality Rate: Number of deaths of children aged less than 5 years dying per 1000 live births 3

28 MMR per 100,000 live births Annual Health Sector Performance Report for Financial Year 2014/ , there is progress in all the impact indicators with the exception of the of households experiencing catastrophic health expenditure. The sector made significant progress and is likely to achieve HSSIP targets for child mortality rates by end of 2015, but it s unlikely to achieve targets for Maternal Mortality Ratio. 1) Maternal Mortality Over the HSSIP period, significant achievements have been realized in reducing institutional maternal mortality by approximately 40 as shown in Figure 2 below. The HMIS data shows that the risk of a mother dying in the health facility while giving birth reduced from 194/100,000 (2 deaths in 1,000) in 2010/11 FY to 118/100,000 in 2014/15 FY which approximates to 1 maternal death in 1,000 live births. This is a 40 reduction over the HSSIP period. This could be attributed to the FIGURE 1: INSTITUTIONAL MATERNAL MORTALITY RATIO DURING HSSIP PERIOD improvements in the health facility maternal healthcare delivery systems, improving the implementation of effective RMNCAH interventions at all levels. During the HSSIP period there was specific focus on scaling up of maternal and perinatal death notification and review at hospital and HC IV level. Table 2 shows an annual increase in the number of maternal; deaths notified from 129 (6.4 of maternal deaths reported through HMIS) in 2012/13 FY to 371 (21.3 of facility maternal deaths reported through HMIS) in 2013/14. The Maternal Perinatal Death Review (MPDR) report for the FY 2014/15 is under compilation and will be reported on in the 2015/16 report. TABLE 2: COMPARISON OF MATERNAL DEATHS NOTIFIED BY FACILITIES TO THOSE REPORTED THROUGH HMIS / / / / /15 Item 2010/ / / /14 Total number of deaths notified from MPDR Number of maternal deaths reported through HMIS 1,005 1,206 1,169 1,147 Expected Number of Maternal Deaths ( *live births) 2,330 2,581 2,009 1,740 of maternal deaths notified compared to total maternal deaths of maternal deaths notified compared to reported in HMIS Financial Year

29 Source: MoH HMIS 2014/15 and MPDR 2013/14 Table 3 below presents categories of the main causes and trends of maternal deaths during the HSSIP period. It is observed that Obstetric haemorrhage is still the highest cause of maternal deaths (42). There was significant reduction in maternal deaths due complications of unsafe abortion from 13 in 2013/14 to 3 in 2014/15. TABLE 3: CAUSES OF MATERNAL DEATHS OVER THE HSSIP PERIOD Causes 2011/ / / /15 Freq Freq Freq Freq Obstetric haemorrhage Obstructed labour and uterine rupture Pre-eclampsia and eclampsia Postpartum sepsis Complications of unsafe abortion Other direct causes Indirect causes aggravated by pregnancy Unknown Total Source: Maternal Perinatal Death Reports, 2012/13, 2013/2014 and 2014/2015 Health seeking behavior issues were the major underlying factors for maternal deaths, followed by health delivery systems issues, then adequacy or availability of health services (Table 4). In the health seeking behavior, most factors related to delay of the woman seeking help (56) although this reduced from 63 in 2013/14. During the FY 2014/15 the following major investments were made in relation to maternal health services: Procurement of partographs and protocols on post partum heamorrhage, post abortion care, use of magnesium sulphate and Helping Babies Breath (HBB). Distribution of ambulances to Anaka, Moyo, Nebbi, Kiryandongo, Masindi, Apac, Nakasero, Mityana, Itojo, Entebbe, Iganga, Buwenge, Bukwo, Moroto, Kitgum, Mubende, Lyantonde, Bugiri and Pallisa hospitals. Infrastructure developments in twenty six HC IVs (theatres, maternity wards, bore holes, walk ways) is ongoing. 5

30 TABLE 4: COMMON FACTORS UNDERLYING MATERNAL DEATHS Delay Factors Underlying factors 2011/ / / /15 Freq Freq Freq Freq Health Seeking Behaviour A. Personal/ Family/ Woman factors 1. Delay of the woman seeking help 2. Lack of partner support Herbal medication Refusal of treatment or admission 5. Refused transfer to higher facility Total Reaching the health 1. Lack of transport from service point B. Logistical systems home to health facilities 2. Lack of transport between health facilities Total Receiving C. Health 1. Health service adequate health service communication breakdown 2. Lack of blood products, care supplies &consumables D. 1. Staff non-action Health 2. Staff over-sight personnel 3. Staff misguided action problems 4. Staff lack of expertise Absence of critical human resource 6. Inadequate numbers of staff Total Source: MPDR Report 2011/12, 2012/13, 2013/14, 2014/15 2) Child Mortality Rates The IMR of 54 (UDHS 2011) per 1,000 live births and World Health Statistics series (2014) estimate of 45 per 1,000 live births both fall short of the HSSIP target of 41 per 1,000 live births. Similarly the Under 5 Mortality Rate target of 69 per 1,000 live births fell short of the HSSIP target of 56 per 1,000. This was considerable improvement despite the inability to meet the planned targets. According to the HMIS reports, malaria and pneumonia remain the leading causes of under 5 inpatient mortality accounting for 22.6 and 12.2 of all deaths respectively (Table 5). There is an apparent reduction in the percentage of under five inpatient deaths due to malaria from 28.8 in 2013/14 to 22.6 in 2014/15. Over the last three years the percentage of under five inpatient 6

31 deaths due to other respiratory infections has markedly reduced and in 2014/15 it was not recorded among the top ten causes. TABLE 5: LEADING CAUSES OF UNDER 5 IN-PATIENT MORTALITY 2012/13 FY 2013/14 FY 2014/15 FY Diagnosis No. Diagnosis No. Diagnosis No. Malaria 3, Malaria 4, Malaria 3, Pneumonia 1, Pneumonia 1, Pneumonia 1, Anaemia 1, Anaemia 1, Perinatal Conditions (in new borns 0-7 days) Perinatal Conditions (in new borns 0-7 days) Neonatal Septicaemia Respiratory Infections (Other) 1, Perinatal Conditions (in new borns 0-7 days) Neonatal Septicaemia Respiratory Infections (Other) 1, , Anaemia 1, Neonatal Septicaemia Septicemia Septicemia Septicaemia Diarrhoea Acute Perinatal Perinatal Injuries - (Trauma Conditions (in Conditions (in due to other new borns 8-28 newborns 8-28 causes) days) days) Diarrhoea Diarrhoea Injuries - Road Acute Acute Traffic Accidents Severe Malnutrition (Kwashiorkor) Severe Malnutrition (Kwashiorkor) Severe Malnutrition (Kwashiorkor) Others 2, Others 2, Others 3, Total 13, , , Source: MoH HMIS *Injuries other than road traffic accidents 7

32 2.2 Health Output Indicators Performance of the core output indicators for the HSSIP and the 2014/15 FY is highlighted as follows; The percentage of pregnant women attending at least 4 ANC sessions increased from 32.4 in 2013/14 to 36.6 in 2014/15 (target was 60). The percentage of deliveries in health facilities remarkably increased from 44.4 in 2013/14 to 52.7 in 2014/15. The HSSIP targets for percentage of women attending at least 4 ANC sessions, deliveries in health facilities, women who completed IPT2 were not met. The percentage of children immunized with the 3 rd dose pentavalent vaccine increased from 93 (91 males & 95 females in 2013/14 to (104.5 males & 99.5 females). The percentage of one year old children immunized against measles increased to 90 (92.3 males and 87.7 females) compared to 87 in 2013/14. The percentage of children exposed to HIV from their mothers accessing HIV testing within 12 months increased from 54 to 58 in 2014/15 and also short of the target of 75 by the end of the HSSIP. A total of 70,634 exposed to HIV from their mothers received PCR 1 test and of these 4,185 (5.9) were HIV positive compared to 6.3 (3,402/54,013) in 2013/14. The sector has realized significant progress in increasing the number of children exposed to HIV from their mothers receiving the first PCR test from 22,705 in 2011/12 to 54,013 in 2013/14 and this increased to 70,634 in 2014/15. The percentage of babies born to HIV positive mothers testing positive at first PCR has also reduced from 6.3 in 2013/14 to 5.9 in 2014/15. This is attributed to the sustained efforts and scale up of the EMTCT programme with active participation of the Honorable First Lady. The percentage of people who are on ARVs increased from 48 (680,514 / 1,405,268) in 2013/14 to 750,896 (56) by 2014 of those in need (adults 694,627(58) and children 56,269 (38). 8

33 TABLE 6: PERFORMANCE FOR HEALTH SERVICES CORE INDICATORS Indicator Source 2010/ / / / /15 HSSIP Target pregnant women HMIS attending 4 ANC sessions deliveries in health HMIS facilities children under one HMIS year immunized with 3 rd (M) F) (M) (F) (M) (F) dose Pentavalent vaccine one year old children HMIS immunized against (M) (F) (M) (F) (M) (F) measles pregnant women who have completed IPT2 of children exposed to HIV from their mothers accessing HIV testing within 12 months U5s with fever receiving malaria treatment within 24 hours from VHT ART coverage among those in need HMIS EID database HMIS No data No data No data No data No data 85 ACP based on 2010 WHO Guidelines (52 based on 2013 WHO Guidelines) 48 (680,514 / 1,405,268) NA 57 (2013 WHO Guidelines) 9

34 2.3 Other health determinants and risk factors and behaviour Latrine coverage is improved from 74.6 in 2013/14 to 77 surpassing the HSSIP target of 72. This is attributed to the creation of a District Sanitation Fund in 89 districts, the Uganda Sanitation Fund Project in 30 districts. There was increased advocacy with 60 district leaders signing commitments to implement hygiene and sanitation resolutions. A total of 72 villages were able to achieve 100 latrine coverage and access to hand washing. A total of 2,046 villages were triggered during the FY, with 549 (27) becoming ODF. Over 4 years, a total of 6,026 villages have been triggered with 2,534 villages (42 of those triggered) reported to be ODF. Progress in relation to the following indicators; U5 children with height /age below lower line (stunting), U5 children with weight /age below lower line (wasting) and Contraceptive Prevalence Rate (CPR) is still based on the UDHS 2011 (Table 7). Couple Years of Protection (CYPs) was used to monitor access to FP services in health facilities and there was a decline from 4,059,810 in 2013/14 to 3,308, / / / /2015 Couple Years of Protection 1,780,578 3,275,403 4,059,810 3,308,142 TABLE 7: PROGRESS AGAINST THE OTHER HEALTH DETERMINANTS AND RISK FACTORS AND BEHAVIOUR Indicator Source 2010/ / / / /15 HSSIP Target Households with a pit latrine Program Reports U5 children with height /age below lower line (stunting) U5 children with weight /age below lower line (wasting) Contraceptive Prevalence Rate UDHS 38 (2006) UDHS 16 (2006) UDHS 24 (2006) 33 No data No data No data No data No data No data No data No data No data 43 10

35 2.4 Service access, readiness, quality and safety This section provides an overview of the sector performance in relation to service access, readiness, quality and safety. TB case detection rate (TB CDR) increased from 36.6 in 2013/14 to 45 in 2014/15 far below the HSSIP target of 70. TB Treatment Success Rate was 79 compared to 80.7 in 2013/14. Consequently, TB death rate increased over the HSSIP period from 4.7 in 2010/11 to 4.9 by 2013/14 and 6 by 2014/15. The slow progress relates to inadequate systems for TB case detection, adherence monitoring (poor DOT) and testing relapses for drug sensitivity. Community link services for tracing contacts with TB patients and patients support for adherence are functioning less than optimal due to lack of sustainable funding. OPD utilization is a proxy measure for access to services and the sector realized increase in Per capita OPD utilization from 1.0 in 2013/14 to 1.2 in 2014/15. OPD utilization rate was consistently achieved throughout the HSSIP period. The medicines situation in the public sector has improved significantly in the last five years, facilities reporting no stock outs of the indicator items. The percentage of health units with no stock outs of any indicator medicines in the previous six months was at 64 in 2014/15 from 57 in 2013/14 and 43 in 2010/11. Availability of individual tracer medicines in the previous six was high for most of the items with the exception of ORS which was at 79 and Artmenther/Lumenfantrine which has stagnated at 87 for the last 2 years (Table 8). TABLE 8: AVAILABILITY OF INDIVIDUAL TRACER MEDICINES 2010/ /15 Indicator Achievements Target 2010/ / / / / /15 Availability of individual tracer medicines in the previous six months Artmenther/Lumenfantrine Cotrimoxazole tab 480mg Depo-provera Oral Rehydration Salt Sulphadoxine / Pyrimethamine Measles Vaccine Per capita government expenditure on EMHS in the FY 2014/15 was about US$ 2.4 which is below the estimated requirement in the HSSIP of US$ 12. The larger proportion going to HIV, TB and malaria commodities with the smaller proportion of about US$1 going to basic EMHS. This is not adequate to meet the population medicines need. Donor support to medicine financing 11

36 has come in to cover part of the gap and private sector mainly through out of pocket expenditure. 5 Human resources inadequacies, capital investment and logistical management issues (orders versus actual supplies) are hindering the public sector mandate of providing medicines to meet the requirements for universal access. 51 (100/195) of the HC IVs were functional meaning able to do cesarean section and this is the HSSIP target of 50. For blood transfusion 38 (75/195) were able to provide this service. Those able to provide both cesarean section and blood transfusion were 33 (65/195). There is an improvement compared to the functionality of 2013/2014 when 45 (88 out of 196) of the HC IVs were able to do cesarean section and 36 able to do blood transfusion. The percentage of clients expressing satisfaction with health services improved from 46 in 2008 to 69 (barely short of the HSSIP target of 70) in 2014 under the UHSSP Client satisfaction Survey. The common reasons in support of the Customer Satisfaction index included availability of caring personnel, medicines, free medical services. Client satisfaction surveys conducted by the Medical Bureaus show higher levels of satisfaction compared to the public facilities e.g. in the UPMB facilities general satisfaction was 83. TABLE 9: PROGRESS AGAINST THE SERVICE ACCESS AND QUALITY INDICATORS Indicator Source 2010/ / / / /15 HSSIP Target TB case detection rate NTLP reports/ HMIS TB Treatment Success Rate NTLP reports Per capita OPD utilisation rate of health facilities without stock outs of any of the six tracer medicines in previous 3 months of functional HC IVs clients expressing satisfaction with health services HMIS Annual Drug availability survey HMIS (100/195) MoH survey Panel Panel (UHSSP Survey Survey Survey) Annual Pharmaceutical Sector Performance Report 2013/

37 2.4.1 Health Investments and Governance Human Resources Records from the Health Professional Councils (HPCs) indicate that the total number of health workers available in the health market as of August 2015 was 81,982, compared to 63,872 in September 2014, an increase of 28 in just one year. This increase in the health workforce does not represent a similar surge in outputs from Health Training Institutions. Rather, it most probably reflects an improvement in licensure of health workers by the HPCs. Over the past one year, the HPCs have intensified their efforts in actively tracking and registering professional health workers, and in validating the inventory using the electronic Human Resource for health Information System (HRIS); through Regional Teams and District Health Supervisory Authorities (DHSAs). As shown in Figure 2, two-thirds (55,206) of the workforce are constituted by Nurses and Midwives. FIGURE 2: NUMBER OF REGISTERED HEALTH WORKERS 2014/ Sep-14 Aug AHP Nurses & Midwives Doctors Pharmacists Source: MOH/USAID/SHRH Project FIGURE 3: DISTRIBUTION OF THE HEALTH WORKFORCE BY EMPLOYMENT STATUS Other, 29,654, 36 PNFP, 9,798, 12 Public, 42,530, 52 This number (81,982) represents the stock of qualified health workers available for recruitment in both public and private sector. Records from the HPCs show that 42,530 (52) are currently employed in the public sector; at least 9,798 (12) are employed in the PNFP sector, while about one-third (29, 654) are either private practitioners, unemployed or have emigrated. Source: MoH and USAID/SHRH Project Reports,

38 Staffing level in Public Sector Table 10 shows the distribution of the 42,530 health workers employed in the public sector by type of institution. This number represents the health workers who were in post. They consist of health workers already on payroll (40,938), new recruits who had reported on duty but are not yet on payroll (1092); and health workers hired on contracts by various Implementing Partners (500). These Human Resource for Health (HRH) data were aggregated to form the national staffing levels for public institutions comprising the MoH headquarters, National Referral Hospitals, 3 central specialized institutions, 14 Regional Referral Hospitals (RRH), 47 General Hospitals (GH), 166 HC IVs, 962 HC IIIs and 1,321 HC IIs. Staffing levels are presented for each of these levels. TABLE 10: STAFFING LEVEL IN VARIOUS PUBLIC SECTOR INSTITUTIONS Type of Institution Units Approved Staffing level Filling rate positions On Recruits Contract Total According Total payroll Jul 15 on duty staffing to payroll Central level institutions RRH 14 4,744 3, , Butabika Mulago Complex 1 2,801 1,792-1, UBTS UCI UHI MOH Sub-total 9,424 7, , Local Governments District staffing ,851 30,950 1, , Municipla Councils KCCA 17 3,933 2,792-2, Sub-total 50,960 33,853 1, , NATIONAL TOTAL 60,384 40,938 1, , Source: MOH and USAID/SHRH Project Reports, 2015 The overall staffing level at central-level institutions has declined slightly, to 77, from 79 in FY 2014/15. Although RRHs are generally better staffed, staffing is notably low in Moroto (44), Mubende (56) and Naguru RRHs (66), as shown in Table 11. The figures for last year were 41, 55 and 67 respectively. 14

39 Staffing in the public sector by cadre An analysis was carried out for selected clinical cadres at the district level for staff who were on payroll as of July Overall, Nursing officers and Nursing Assistant are in excess of the staffing norms at the district level as shown in Table 12. The number of clinical officers and enrolled nurses are also fairly adequate (94 and 85 respectively). The following health cadres are severely in short supply: Pharmacists/dispensers (37), Anaesthetic staff (23), ophthalmic cadres (15) dental staff (13) and Cold chain technicians (CCT) (5). TABLE 11: STAFFING LEVELS IN REGIONAL REFERRAL HOSPITALS Name Approved On payroll On contract Total Filling rate staffing Arua Fort Portal Gulu Hoima Jinja Kabale Lira Masaka Mbale Mbarara Moroto Mubende Naguru Soroti Grand Total 4,744 3, Source: MoH and USAID/SHRH Project Reports, 2015 TABLE 12: STAFFING BY CADRE Cadre Norm Actual Filling rate Medical Officers Clinical Officers 2,538 2, Nursing Officers (N&MW) 2,895 3, Enrolled Nurse 6,961 5, Enrolled midwife 4,918 3, Pharmacist/Dispenser/PharmAsst Dental: Surg/Asst/PHDO Lab Technologist / Technician/Asst 2,444 2, Ophthalmic

40 Cadre Norm Actual Filling rate Anaesthetic Nursing Assistant 4,421 4, Theatre Assistant Radiographer Orthopaedic / Physiotherapist CCT Source: MoH and USAID/SHRH Project Reports, 2015 Table 13 displays the performance of key indicators for health investments and governance. The overall national staffing level of 42,530 health workers in the public sector represents a filling rate of 70 of approved positions (norm) in the sector, an increase of 1 from 69 in last Financial Year. In keeping with previous trends, central-level institutions are better staffed (77) than the district health systems (69). However, staffing at the district level has risen to 69, from 68 at the end of FY 2014/15. This increase is attributed to new recruitments & contracting health workers under development partners. The new recruits and contract workers included mainly nurses, midwives, doctors and laboratory staff. TABLE 13: PERFORMANCE OF INVESTMENTS AND GOVERNANCE INDICATORS OVER THE PAST 5 YEARS Indicator Source 2010/ / / / /15 HSSIP Target of approved posts filled by health workers (public health facilities) annual reduction in absenteeism rate of villages / wards with trained VHTs HRIS Survey No data No data 71 attendance (Panel Survey) Public:34. 1 NGO:14.6 * No data 20 reduction from previous year HMIS No data HRH mapping shows that some districts are still in red - having staffing below 50 which means it is difficult for them to implement the minimum health care package with the size of health workforce that have. The maps in Annex Figure 30 show that in 2010, the number of districts falling under this category was almost one half of the total districts. The situation has since 16

41 changed with increases recruitment of health workers. In 2014, the figure shows more green (more than 75 staffing) in most parts of the country including Karamoja region. During this FY there was no significant investment in building the capacity of Village Health Teams (VHTs) and has remained at 75 of the villages in the country having trained VHTs. Much effort was towards reviewing the VHT concept, studying establishment of the Community Health Extension Workers (CHEWs) and development of a CHEW policy and strategy Health Financing The trend in allocation of funds to the health sector shows that there has been an increase in budget allocation over the past 5 years of the implementation of the HSSIP as illustrated in the Table 14. The increment is largely attributed to additional wage allocation and project external financing towards health. TABLE 14: GOVERNMENT ALLOCATION TO THE HEALTH SECTOR 2010/11 TO 2014/15 Year GoU Funding (Ushs bns) Donor Projects and GHIs (Ushs bns) Total (Ushs bns) Per capita public health exp (UGX) Per capita public health exp (US $) GoU health expenditure as of total government expenditure 2010/ , / , / , / , / , , The GoU health expenditure as a percentage of the total Government expenditure has been fluctuating over the 5 years with an average of 8.4 over the 5 years. The variation has been on account of increasing total health expenditure but with some sectors like energy and works getting a relatively bigger share of the increase. 17

42 UGX (Billions) Annual Health Sector Performance Report for Financial Year 2014/15 FIGURE 4: GOU HEALTH EXPENDITURE AS OF TOTAL GOVERNMENT EXPENDITURE / / / / /15 The total public sector budget in Medium Term Expenditure Framework (MTEF) increased from UGX 1,127 Billion in FY 2013/14 to UGX 1,282 Billion in 2014/15 representing 14 increase. The total allocation translated to US$ 13.7 per capita public health financing in FY 2014/15. The increase was majorly for human resource recruitment and wages. FIGURE 5:GOVERNMENT ALLOCATION TO THE HEALTH SECTOR 2010/11 TO 2014/ / / / / /15 FIGURE 6: PER CAPITAL PUBLIC HEALTH EXP (US $) The per capita public expenditure increased from $10 to $13.5 in FY 2014/15 due to additional financing from government and global health financing initiatives. Out of the Shs 1,281 billion, Shs 1,254 billion (excluding import taxes) was released in the FY 2014/2015, constituting 98 release of the budget. The unspent funds were due to delays in 18

43 B u d R g e l t e a s B B e u u d d g g R e e t t l r e a l B s a u e s d B g u e d R t g e l r t e a l s e B e a u s d B e g u e d t g R e r t l e a l B s a u e s d e g d e t Annual Health Sector Performance Report for Financial Year 2014/15 procurement processes and unpaid wages. Program budget implementation was also affected by reallocations within the MoH budget for critical expenses which had to be incurred. Table 15 shows the institutional budget performance in the FY. TABLE 15: INSTITUTIONAL BUDGET PERFORMANCE 2014/15 FY Institution Wage (billion) Nonwage (billion) Development (billion) Total (billion) RRH HSC Mulago Butabika UAC UHI UCI NMS UBTS MoH PHC KCCA Health Grant District Health Sanitation Grant TOTAL In the FY 2014/15, the allocation to wage and the non wage recurrent constituted an equal share of the total public budget at 26 each while the Development budget including the Donor contribution constituted 48. The details are as shown in the table 16. TABLE 16: BUDGET CATEGORIES Budget Sources FY 2013/14 of the FY (UShs of the total (UShs Bn) total budget Bn) 2014/15 budget Recurrent- wage Recurrent-Non wage Sub total Recurrent Domestic dev t Grant Donor Subtotal Development Total Budget performance 1, , Source: MTEF FY 2015/16 19

44 Primary Health Care Allocations (PHC NWR FY 2014/15) There has been steady increase in PHC wages over decade with no significant increase in the remaining components of the non wage PHC grant. The result shows overall increment in PHC allocation. The lack of relatively commensurate investments between non wage allocation, development grant annual increases and additional staff recruited into the health sector means that the recurrent costs for the maintenance of the infrastructure and carrying out immunization outreaches is inadequate. This affects the productivity at the health facilities governance issues notwithstanding. Excluding medicines and health suppliers, PHC grants represent 30 of the total health sector budget. TABLE 17: PRIMARY HEALTH CARE GRANTS FY 2010/ /15 IN USHS BILLIONS FY PHC Wages PHC (Non- wage) PHC NGOS General Hospitals PHC (Dev't Grant) Sanitation grant Total 2010/ / / / / Source: Approved Budget of revenue and expenditure FY 2014/15-MoFPED TABLE 18: AVERAGE PHC NON-WAGE ALLOCATION BY LEVEL TO PUBLIC HEALTH FACILITIES AND DHOS 2014/15 FY PHC Non Wage Grant Allocations top PHC facilities (Ush bn). Level of health service delivery Number Ratios Number (Adjusted for ratios) Total annual NWR allocation per level Annual average per individual facility/ office Monthly average per facility/ office DHOs + Municipality ,168,000,000 23,124,088 1,927,007 HC IV ,071,444,609 12,478,582 1,039,882 HC III ,415,704,579 6,239, ,941 HC II ,184,850,812 3,119, ,970 20

45 FIGURE 7: TRENDS IN PHC GRANT ALLOCATIONS FY 2010/ /15 IN USHS BILLIONS Challenges Uganda, like many other developing countries, faces numerous challenges financing its health system. The unrelenting burden of disease and the ever increasing costs of medicines and the associated new technologies continue to overwhelm the system. To compound all this, Uganda has one of the fastest growing populations in the world, which puts pressure on the current health system. The other challenges in the sector are increasing costs, which will in the medium term continue to be of concern. The main cost drivers include;(a) increased demand for RMNCAH services as a consequence of a rapidly growing population due to high fertility; (b) increase in the NCDs burden due to demographic and urban transition when communicable diseases are still high on the agenda; (c) high public demand for access to high quality but affordable care as a result of the marketing of new expensive technologies; and, (d) the high cost of improving health infrastructure in keeping with the need to move services closer to the community. There is inadequate funding for sector activities especially PHC Services. Only Ushs. 327 Billion excluding medicines budget was allocated to run health service delivery. In FY 2014/15, the sector experienced a challenge of the alignment of some off-budget funding to sector priorities. Funding for operational costs such as; running the referral system, maintenance of facilities and vehicles, utility bill payments, carrying out outreaches has been a constraint to scaling up health service delivery in LGs and referral hospitals in the year under review. General Government allocation for health as percentage of the total Government budget has averaged about 8.4 from 2010/11 to 2014/15, which is 1.6 short of the HSSIP target of 10 of the budget by 2014/15. The allocation still below the recommended per capita government 21

46 expenditure on health of US$ 34 per capita as per the WHO Commission of Macro Economics and Health. It is also below the HSSIP target of US $ 17 per capita government expenditure on health. Ability to mobilize general public revenues (compulsory prepayment) depends on the level of economic development. The reality is that whereas Uganda s tax revenues as percent of GDP have risen from 6.5 in 1989/90 to 14.2 in 2012/13, the tax base is still small with 50 of the revenues generated by only a few large taxpayers. According to the National Health Accounts (NHA) reports, the level of out of pocket (OOP) expenditure, as percentage of the Total Health Expenditures, has been increasing in real terms in the past years though reducing in percentage terms. It was estimated at 42 in FY 2009/10 (NHA, 2013). The OOP expenditure was 37 in 2012/13 (NHA, 2014), showing a reduction, attributed to increased partner support for health, mostly through the private sector. The high OOP on health care negatively impacts on households incomes and affects household demand for, and access to health care. Consequently, the proportion of people facing catastrophic expenditure leading to house hold impoverishments, especially of the lower income quintiles is high. Quarterly reporting by LG Health offices to the MoH on quarterly performance has been a big challenge. Only about 40 of the LGs submit timely quarterly reports and this affects comprehensiveness of national health reports, accountability and timely reporting of performance of the health sector. Way Forward The questions on fiscal space for health should be addressed; (a) how to increase government contribution to health; (b) how to make the health system operations more efficient; (c) how to harness the contribution of the untapped, not easy to tax large sector comprised of small farmers and informal players; and, (d) how to increase insurance contributions, in the quest to meeting government s goal of UHC with a minimum package of essential services. The finalization of the Health Financing Strategy is one of the policy documents that can be used to expand the fiscal space for health. One of the possible health financing interventions, to mitigate the high OOP expenditure is introduce Performance Based Financing (PBF) and the National Health Insurance Scheme (NHIS) The sector needs to reprioritize and spend more funds for PHC if the inequities in health service delivery are to be minimized and preventive, promotive and curative services are to be scaled up. Financial reporting, accountability, leadership and financial management need to be improved at all levels of the health system. 22

47 Health Infrastructure and Equipment Investment in health infrastructure has continued and this included construction of new and rehabilitation of old infrastructure at various levels, provision of medical equipment and hospital furniture; provision of solar lighting, improvement of operations and maintenance of health infrastructure; strengthening the referral system by providing ambulances, general transport and Information Communication and Technology (ICT) equipment and services in selected health facilities; and renovation/construction of selected health facilities. Specific achievements under infrastructure over the FY 2014/15 include; The distribution of general, specialized medical equipment and instruments under UHSSP. Procurement and distribution of 19 ambulances worth of US$ 1.5 million. Procurement of two (2) mobile workshop vehicles procured for Mubende and Moroto RRHs. Renovation and expansion civil works ongoing in the following hospitals: Mityana, Nakaseke, Kiryandongo, Nebbi, Anaka, Moyo, Entebbe and Iganga GHs; and Moroto RRH under UHSSP. Under GoU, the following hospitals are being renovated; Adjumani, Kiboga, Bundibugyo and Kapchorwa. Kawolo hospital is under renovation with support from Spanish Aid. Contracts were signed and work commenced for renovation of 26 HC IVs under UHSSP: Kasanda, Kiganda, Ngoma, Mwera, Kyantungo, Kikamulo, Kabuyanda, Mwizi, Kitwe, Rubare, Aboke, Aduku, Bwijanga, Bullisa, Padibe, Atyak, Obongi, Pakwach, Buvuma, Budondo, Ntenjeru-Kojja, Buyinja, Nankoma, Bugono, Kiyunga, Kibuku and Budaka. Updated the health facilities inventory list for 2014 and developed equipment database for 95 of HC IIIs in the country. Mapping of Health facilities in the 112 districts was also done and geo-referenced maps produced with support from UBOS, OPM, WHO and CDC. The exact location of health facilities was captured using Global Positioning System devices, commonly referred to as GPS s to enable analysis of physical accessibility. This should give the possibility to have a reliable estimate of the proportion of the Ugandan population living within 5 km of a health facility. In addition, solar power was installed in 55 additional HCs bringing the total under the ERT II to 665 HCs, and maintenance of solar systems in 519 HCs in 23 districts was undertaken. Procured medical equipment for selected health facilities in Arua and Rwenzori regions. Procured one Ambulance to replace accident ambulance in West Nile region. 23

48 Successfully procured and installed a digital X-Ray machine for Kilembe Mines hospital. Procured Public Address systems for all district Health Offices in the Arua and Rwenzori regions, including RRHs. Procured engraving equipment and digital cameras for all districts Arua and Rwenzori regions including RRHs and HMDC. Procured ICT equipment for the Fort Portal and Arua RRHs. Procurement of Ambulance Uniforms for District Ambulance teams in the two regions. Procurement of solar equipment for selected DHOs in the two regions (to be awarded) Sinking boreholes at Kyenjojo Hospital and Water Harvesting System at Virika Hospital. NUSAF 11 project Ushs. 7,748,978,745/= to 160 Staff House subprojects and Ushs. 1,682,725,491/= for 20 OPDs. all the 443 staff houses, 3 Maternity Wards, 2 General Wards, 34 OPDs, 2 stand alone solar power installation subprojects, 7 Fencing subprojects and 8 stand alone VIP latrines worth Ushs. 46,504,762,380/= funded under NUSAF2 Project have been completed. Construction works commenced and are at roofing stage for both Hoima and Kabale RRHs and shipment of medical equipment for Fort Portal, Hoima and Kabale RRH commenced - JICA support. Developed a 30-year Master Plan and 5-year Investment Plan for Mulago NRH. Kawempe and Kiruddu HCs are being upgraded to general referral hospital status of about 170 beds each. Works will be completed by 31 st December By close of the FY, the overall progress of work was 64.0 for Kiruddu and 52 for Kawempe. Mulago NRH is undergoing extensive rehabilitation including revamping electromechanical works and equipping the hospital with state of the art medical equipment to provide advanced medical services. The overall progress of phase I, which represents 60 of the total works, is at 50. Phase II and III will be undertaken during FY 2015/16. Procurement of Medical equipment for Kawempe and Kiruddu at US $ 4M for each Hospital and is at evaluation of bids stage. The medical equipment and furniture is projected to be installed around December Procurement of Medical equipment for Mulago hospital was split into two categories: front load and main procurement. Contracts for 10 Lots of front loaded medical equipment worth US $ 8.2M were signed in October 2014 and delivered in April 2015 loaded equipment. By close of the FY, verification of the equipment for compliance to specifications was still ongoing. Construction of a 320 bed Maternal & Neonatal Health Care Unit at Mulago commenced funded by Islamic Development Bank. 24

49 Governance Looking at sector governance, the sector stewardship has been changing at the highest level, leading to frequent changes in stewardship direction. There has been high turnover at Senior and Top management of the MoH during the HSSIP period. There were also some gaps in technical departments that were limiting capacity to provide comprehensive guidance. At the district level, the functionality of the management and stewardship structures like the Social Services / Health Committee, District Health Management Teams (DHMTs), District Health Teams (DHTs) in some districts was supported through projects like Strengthening Decentralization for Sustainability (SDS), though many persons managing the districts lack the necessary skills and expertise. Using mtrac, client feedback / redress was managed under the anonymous hotline (Service delivery complaints toll-free number for people to call or SMS to express opinions about health service-related issues, e.g. good service, HCs closed during working hours, stock-outs of essential medicines in facilities) and U-Report (U-Reporters participate in weekly SMS dialogue on community issues, are informed about services in their areas, and provide regular feedback on developmental issues. - The anonymous hotline where we receive feedback from the community on health service delivery; in the FY 2014/15 received 9214 reports from communities all over Uganda. - 3,687 (40) reports were actionable; i.e. each report submitted had some information that could be used for follow up e.g. district, health facility, village, subcounty in addition to the complaint / compliment. - 2,184 reports i.e. 24 had the location mentioned in addition to the complaint / compliment whereas were lacking location data for follow up. - All 112 district communities all over the country at least submitted a report or more during the FY; with Wakiso, followed by Mbarara having the highest. TABLE 19: REPORT STATISTICS OVER THE MONTHS IN THE YEAR OF 2014 /15 Month No of Reports Month No of Reports July 684 January 673 August 579 February 398 September 530 March 421 October 2,441 April 481 November 767 May 461 December 621 June

50 The increase in number of reports received in October was due to the high number of inquiries on the Epidemic outbreak at the time of Marburg. Table 20 summarizes the action taken so far on the reports submitted:- TABLE 20: ACTION TAKEN BY STAKEHOLDERS OR RELEVANT ACTION CENTERS DURING THE PERIOD Number Percentage Actionable Reports 3, Number of Reports Assigned to Districts 2, Number of Reports with District Missing 7, District Reports Open District Reports Escalated District Reports Ignored District Reports Claimed District Reports Closed 1, District Reports Action Taken 1, District Reports Action Taken by MHSDMU TABLE 21: 10 DISTRICTS WITH HIGHEST NUMBER OF ACTION TAKEN District Action Taken Total Reports Masaka Wakiso Mbarara Mukono Bukomansimbi Lwengo Mbale Mpigi Kasese NB: Please note that all the above reports summarize the action taken by DHTs and relevant national stakeholders. 26

51 FIGURE 8: A MAP OF UGANDA SHOWING PERCENTAGE OF REPORTS WITH ACTION TAKEN DURING 2014/15 FY Partnerships With regard to sector partnerships, most of the existing structures for partnership engagement are largely moribund, and not providing the needed forums for sector engagement. Some partners are therefore sidestepping these structures, and providing support that is not coordinated and harmonized. The SWAp process and the HPAC functionality are therefore compromised, with current focus primarily on statutory actions (e.g. endorsing proposals) as opposed to being forum for dialogue. The Technical Working Groups (TWGs) and Intersectoral coordination functionality are sub optimal, and there is limited real engagement of some stakeholder groups. Merit however needs to be given to the tenacity of the partnership and coordination structures, like HPAC and Health Development Partners (HDPs) forum which have largely continued to exist in spite of this environment. In the Compact for implementation of the HSSIP, Partners and GoU made commitments for technical and financial assistance for the HSSIP implementation. The partnership in the Compact draws from all sectors, including HDPs, PNFP, PHP and CSOs, which are collectively referred to as health sector partners. This section assesses progress in implementation of the partnership commitments made in the HSSIP Compact. The commitments in the Compact focus on maintaining policy dialogue, promoting joint planning and supporting implementation and monitoring of the HSSIP. The HPAC provides overall oversight and stewardship for monitoring implementation of the Compact. 27

52 In the HSSIP, three areas were planned for monitoring implementation of the Compact 2010/ /15, and these have been assessed for this reporting, including: Planning and budgeting, Monitoring programme implementation and performance, and Policy guidance and monitoring. Performance in these areas of the Compact is here below presented. TABLE 22: HPAC INSTITUTIONAL REPRESENTATIVES ATTENDANCE Representatives Average Annual Attendance Rate 2010/ / / / /15 MoH (11) HDP (4) CSO (3) Private (1) NA NMS (1) Medical Bureaus (2) N/A N/A N/A District (1) NRH (2) RRH (1) Line Ministries (5) Source: HPAC Minutes 2014/15 TABLE 23: PROGRESS IN IMPLEMENTATION OF THE COUNTRY COMPACT DURING FY 2014/15 # Compact Indicator Targets/Means of Verification 1.0. Planning and Budgeting Achievement Comments 1.1. MoH Annual Work plan reflecting stakeholder contribution Partners' support is captured in the plan Not all resources in one MoH Annual Work plan Some donors still prefer off-budget support 1.2. All new sector investments are appraised by SBWG 1.3. All planned procurements reflected in the Comprehensive procurement plan Submission of new projects to SBWG Adherence to procurement plan Increase in submission of new projects to SBWG Annual integrated comprehensive procurement plans were made SBWG met regularly to review new projects. Procurement plan followed. 28

53 # Compact Indicator Targets/Means of Verification 1.4. Response to Auditor Timely response to AG's General's report report 1.5. Implementation of harmonized Technical Assistance (TA) Plan HPAC approval of ToRs & procurement of short & long term TA 2.0. Monitoring Programme Implementation and Performance Achievement Response to all audit reports were made. TA procurement is implemented under individual projects, but not consolidated into one TA plan. Comments Advise of the AG s advice is being used in improving accountability systems There is still need for better coordination of TA support Area Team Visits - Quarterly Reports 2.2. MoH Quarterly Performance Assessment 2.3. Technical Review Meeting 2.4. Technical Working Group meeting 2.5. Annual Health Sector Performance Report 2.6. Submission of Annual Report to OPM 2.7. Joint Review Mission - review of performance 2.9. End of HSSIP Evaluation 3.0. Policy Guidance and monitoring Presentation of reports to HPAC within 30 days after completion of visits Presentation of reports to HPAC within 30 days after completion of MoH quarterly review. Present of report from TRM to HPAC by 30 April Target 80 of TWG meetings held Submission of Final Report by 30 Sept Submission to OPM by 30 September Aide Memoire presented to HPAC by 30 Nov Completion of end of HSSIP review by December 2015 Briefs on Area Team reports submitted to HPAC. One annual performance assessment was done (covering all the four quarters). TRM not done 70 of TWGS held meetings and briefs informing policy presented to senior management and HPAC. Report written, discussed at the 20 th JRM and disseminated Bi-annual and GAPR submitted to OPM on time. The JRM was held on schedule and Not done to inform the HSDP Reports submitted though after 2 months. Report yet to be submitted. Funding was limited Some TWG need to be revived and to sit regularly. AIDE Memoire was signed in January The activity was not budgeted for 3.1. Senior Management Committee 3.2. Health Policy Advisory Committee 3.3. Country Coordination Mechanism 12 SMC meetings 11/12 SMC meetings were held Technical issues from TWGs discussed. 12 meetings All 12 meetings were held Discussed issues with policy implications. 4 meetings CCM met quarterly and had other adhoc meetings. International Health Partnerships+ Most of the targets for Aid Effectiveness (Paris Declaration and IHP+ indicators) assessed in 2014 showed significant progress on the country performance (Table 24). TABLE 24: PROGRESS IN IMPLEMENTATION OF THE IHP+ COMMITMENTS 29

54 Issue monitored Government Indicator Achievement Associated DP indicator 1. Health development cooperation A sector results 100 Development is focused on framework in place Partners use the results that meet developing country results countries priorities framework 2. Civil Society operated in an environment which maximized its engagement in and contribution to development 3. Health development cooperation is more predictable Government supports meaningful participation of CSOs in health sector policy processes including planning, coordination & review mechanisms. Government funds disbursed predictably Projected government expenditure on health provided for 3 years. 4. Health aid is on budget A national health plan in place that has been jointly assessed. 5. Mutual accountability among health development cooperation actors is strengthened through inclusive reviews 6. Effective institutions: developing countries systems are strengthened and used; Financial & Procurement Systems Source: IHP+ Country Card, 2014 Mutual assessment mechanisms in place. Quality of country public financial management systems (score) 2.5 Local Government Performance 80 Development Partners support meaningful engagement of CSOs Not available DP funds disbursed predictably 100 Government has information on DP expenditure plans for three years ahead 100 DP Cooperation reported on budget 100 DPs use mutual assessments mechanisms 3.26 out of 6 DPs use country public financial management systems Achievement (Most HDP indicative expenditure is for annual) District League Table (DLT) The DLT is a tool used to assess district performance and identify areas of strengths and weakness and use it to identify ways in which that performance can improve. In this report, the 112 districts are used as the units of analysis with key objectives of comparing performance between districts; provide information to facilitate the analysis for good and poor performance at districts and thus enable corrective measures which may range from increasing the amount of resources (financial resources, human resources, infrastructure) to the LG or more frequent and regular support supervision; and increase LG ownership of achievements/ performance. The specific objectives of the DLT are:

55 Financial Year Population DPT3 Coverage () Deliveries in gov t and PNFP facilities () OPD Per Capita HIV testing in children born to HIV+ women () Latrine coverage in households () IPT2 () ANC 4 () TB TSR () Approved posts filled () Monthly reports sent on time Completeness monthly reports Completeness facility reporting Medicine orders submitted timely () National Average () Annual Health Sector Performance Report for Financial Year 2014/15 To compare performance between districts and therefore determine good and poor performers. To provide information to facilitate the analysis for good and poor performance at districts thus enable corrective measures. Appropriate corrective measures which may range from increasing the amount of resources (funds, human resource, infrastructure) to the LG or more frequent and regular support supervision. To increase LG ownership for achievements the DLT to be included in the AHSPR to be discussed at the NHA or JRM with political, technical and administrative leaders of districts. To encourage good practices good management, innovations and timely reporting. For the year 2014/15, ten indicators were used to evaluate and rank district performance: 8 coverage and quality of care indicators, given a collective weight of 80; and 2 management indicators, accounting for the remaining 20. The indicators were selected for consistency with the 26 core HSSIP 2010/ /15 indicators. The primary data source for majority of the indicators were derived from the routine HMIS and some of the indicator data was provided by the respective MoH programmes such as HIV/AIDS, TB and environmental health division. Data validation of the DHIS2 data was conducted in 16 districts with annual reporting rates below 50 prior to finalization of the DLG. Annual reporting rates less 50. There is an improvement in the DLT national average performance from 74 in 2013/14 to 78.6 in 2014/15. The improvement in performance was observed for all indicators. TABLE 25: TRENDS IN NATIONAL AVERAGE PERFORMANCE IN THE DLT 2010/11 31,752, /12 33,544,

56 2012/13 33,568, /14 36,652, /15 34,844, Table 26 shows the top and bottom 15 performing districts among the 112 districts with their ranks and total scores. The full district league tables can be seen in the Annex Table 50. The top five LGs in performance are Gulu (89), Kampala (87.4), Kabarole (85.4), Jinja (84.7) and Rukungiri (84). The bottom five LGs in performance are Nakapiripit (60.9), Kotido (60.2), Buvuma (59.3), Bulambuli (57.3) and Amudat (46.6). TABLE 26: FIFTEEN (15) TOP AND BOTTOM PERFORMING DISTRICTS FY 2014/15 District Rank District Rank Gulu Manafwa Kampala Wakiso Kabarole Kibuku Jinja Yumbe Rukungiri Sembabule Butambala Buyende Lira Kween Lamwo Kaabong Mityana Buhweju Lyantonde Moroto Serere Nakapiripirit Mbale Kotido Bushenyi Buvuma Masaka Bulambuli Luwero Amudat Table 27 shows the top and bottom 15 performing districts among the 98 districts excluding the 14 districts with referral hospitals. The top five LGs in this category are Rukungiri, Butambala, Lamwo, Mityana and Lyantonde. TABLE 27: DISTRICT RANKING FOR DISTRICTS EXCLUDING DISTRICT WITH RRHS District Total Rank National Rank District Total Rank National Rank Rukungiri Mayuge Butambala Manafwa

57 Lamwo Wakiso Mityana Kibuku Lyantonde Yumbe Serere Sembabule Bushenyi Buyende Luwero Kween Agago Kaabong Nebbi Buhweju Katakwi Nakapiripirit Kaberamaido Kotido Oyam Buvuma Dokolo Bulambuli Mukono Amudat The hard to reach districts have mixed performance with some of them in the top 15 and others in the bottom 15. TABLE 28: DISTRICT RANKING FOR HARD-TO-REACH DISTRICTS AS PER THE DLT Top 5 Hard-To-Reach Bottom 5 Hard-To-Reach District Rank District RANK Gulu Moroto Lamwo Nakapiripirit Agago Kotido Mukono Buvuma Nwoya Amudat At least 5 of the 31 new districts achieved total scores above the national average of TABLE 29: DISTRICT RANKING FOR NEW DISTRICTS Total National Total National District Rank Rank District Rank Rank Butambala Gomba

58 Lamwo Mitooma Serere Rubirizi Agago Ntoroko Nwoya Zombo National 78.6 Luuka Otuke Napak Kyegegwa Kole Buikwe Kyankwanzi Ngora Kibuku Kalungu Buyende Sheema Kween Kiryandongo Buhweju Bukomansimbi Buvuma Namayingo Bulambuli Lwengo Amudat

59 2.5.2 Regional Performance Level Performance The health sector has 12 regions based on the referral hospitals catchment areas namely; Kampala, Jinja, Mbale, Soroti, Lira, Moroto, Gulu, Arua, Hoima, Fort Portal, Mbarara and Masaka. Overall, during the FY 2014/15, 48 districts registered improvement while 64 districts declined, based on the DLT performance indicators. In terms of total scores, Gulu and Soroti regions registered the highest scores (79.2 and 77.6 respectively) while Mbale and Moroto regions registered the lowest scores (69.1 and 61.4 respectively). However, of the 12 regions, only Gulu region scored above the national average of The table below summarizes performance ranking of districts within the different regions for FY 2014/15. TABLE 30: DISTRICT RANKING BY REGION 2014/15 FY Arua- Jinja- Masaka- Mbarara- Rank Rank Rank 2,661,000 3,609,484 1,856,922 4,347,294 Rank Nebbi 1 Jinja 1 Lyantonde 1 Rukungiri 1 Koboko 2 Iganga 2 Masaka 2 Bushenyi 2 Arua 3 Kamuli 3 Rakai 3 Isingiro 3 Adjumani 4 Namutumba 4 Kalungu 4 Kanungu 4 Zombo 5 Bugiri 5 Kalangala 5 Kiruhura 5 Maracha 6 Namayingo 6 Bukomansimbi 6 Kabale 6 Moyo 7 Luuka 7 Lwengo 7 Mbarara 7 Yumbe 8 Kaliro 8 Sembabule 8 Sheema 8 Fort Portal- Rank Mbale- Rank Mayuge 9 3,716,204 Ntungamo 9 2,589,652 Buyende 10 Mbale 1 Kisoro 10 Kabarole 1 Central Rank Tororo 2 Ibanda 11 Kyenjojo 2 7,390,170 Busia 3 Mitooma 12 Kamwenge 3 Kampala 1 Pallisa 4 Rubirizi 13 Kyegegwa 4 Butambala 2 Budaka 5 Buhweju 14 Bundibugyo 5 Mityana 3 Sironko 6 Moroto- Kasese 6 Luwero 4 Kapchorwa 7 988,429 Rank Ntoroko 7 Mukono 5 Bududa 8 Abim 1 Gulu- Rank 1,511,614 Mpigi 6 Bukwo 9 Napak 2 Gulu 1 Nakaseke 7 Butaleja 10 Kaabong 3 Lamwo 2 Kayunga 8 Manafwa 11 Moroto 4 Agago 3 Buikwe 9 Kibuku 12 Nakapiripirit 4 Nwoya 4 Mubende 10 Kween 13 Kotido 6 35

60 Kitgum 5 Nakasongola 11 Bulambuli 14 Amudat 7 Soroti- Amuru 6 Gomba 12 1,703,720 Rank Pader 7 Wakiso 13 Serere 1 Hoima- Rank Buvuma 14 Soroti 2 2,399,988 Lira- Rank 2,069,618 Katakwi 3 Hoima 1 Lira 1 Kaberamaido 4 Kiboga 2 Oyam 2 Kumi 5 Masindi 3 Dokolo 3 Amuria 6 Kibaale 4 Amolatar 4 Ngora 7 Kiryandongo 5 Otuke 5 Bukedea 8 Buliisa 6 Apac 6 Kyankwanzi 7 Alebtong 7 Kole 8 36

61 2.6 Hospital Performance The total number of hospitals (public and private) in Uganda is 155. Of these 2 are National Referral Hospitals (Mulago and Butabika), 14 are RRHs and 139 are GHs. In terms of ownership, 65 are government owned, 63 PNFP and 27 are private. Hospitals are major contributors to outputs of essential clinical care and take up a large volume of human and financial resources. In the financial year 2014/15 almost similar to the year before, hospitals produced 54 of all inpatient admissions, 19 of total outpatients, and 36 of all deliveries. Owing to the new DHIS2 reporting from hospitals has improved compared to the previous years although completeness remains a challenge. Information analyzed is from 93 of GHs (listed in DHIS2), 100 of Regional hospitals and National referral hospitals, there was an improved reporting by private hospitals compared to the year before. Analysis of hospital information largely looks at outputs of hospitals and relates inputs to outputs and outcomes. We will continue to use the Standard Unit of Output (SUO) 6. The SUO is a composite measure of outputs that allows for a fair comparison of volumes of output of hospitals that have varying capacities in providing the different types of patient care services. The SUO attempts to attribute the final outputs of a hospital a relative weight based on previous cost analyses taking the outpatient contact as the standard of reference. The SUO converts all outputs to outpatient equivalents. The basis of this parameter rests on the evidence that the cost of managing one inpatient is 15 times the cost managing one outpatient, one immunization 0.2 times more, one delivery 5 times more and one (ANC+MCH+FP) client 0.5 times the cost of managing one outpatient. Basic efficiency indicators for resource use are generated and tables comparing hospitals generated Main causes of mortality and morbidity in hospitals Malaria, respiratory infections including pneumonia, diarrhea, worms, skin diseases, eye infections, injuries, ear nose and throat diseases and urinary tract/pelvic inflammatory diseases / Sexually Transmitted Diseases (STDs) are the commonest causes of morbidity in hospitals as shown in the figures below. Non-infectious diseases are increasingly prominent as causes of morbidity notably hypertension, and injuries other than road traffic accidents and injuries due to road traffic accidents. 6 SUO stands for standard unit of output an output measure converting all outputs in to outpatient equivalents. SUO total = (IP*15 + OP*1 + Del.*5 + Imm.*0.2 + ANC/MCH/FP*0.5) based on earlier work of cost comparisons. 37

62 FIGURE 9: TOP TEN CONDITIONS AMONG UNDER FIVES AND ABOVE IN 2014/15 FY Hospital Based Mortality for all Ages A total of 22,504 death among under fives and 8,949 among adults hospital deaths were reported during 2014/15 FY. Malaria remains the top most 13.8 cause of all deaths followed by pneumonia and anemia as shown in the table below. Perinatal condition are featuring more prominently unlike the year before, contributing to 5.8 of all death. Like the year before, injuries, tuberculosis and cardiovascular conditions still feature prominent. TABLE 31: TOP TEN CAUSES OF HOSPITAL BASED MORTALITY FOR ALL AGES 2014/2015 Conditions Under 5 5 and Over Total Malaria 1,725 1,380 3, Pneumonia 1,132 1,053 2, Anaemia 1, , Perinatal Conditions (in new borns 0-7 days) 1, , Injuries - Road Traffic Accidents Other Tuberculosis Cardiovascular Diseases (Other) Septicemia Injuries - (Trauma Due To Other Causes) Neonatal Septicaemia Others 15,900 2,941 18, Total 22,504 8,949 31,

63 2.6.2 National referral hospitals Mulago National Referral Hospital Mulago Hospital is the main NRHand a teaching hospital for the Makerere College of Health Sciences it also serves as a general hospital for Kampala City; currently it has a bed capacity of 1,790. Inputs In 2014/15 Mulago had 1,880 staff 7 this constituted 67 of the staffing positions leaving a gap of 581 staff to be filled. Mulago hospital had an annual budget of billion in 2014/15. The total release was billion, 104 of the budget. Outputs The patient load in Mulago hospital continues to be too heavy and affecting quality of services. During the year, there were 829,817 outpatient visits; 761,573 inpatients; 61,568 emergencies; 28,759 total ANC visits; 39,081 deliveries, 11,120 postnatal visits; 1,738,652 lab tests; 33,949 x- rays; 27,142 ultrasound scans; 49,680 immunization contacts; 13,397 major surgeries; 9,701 FP contacts. The bed occupancy rate for the hospital was Butabika Mental Referral Hospital Butabika hospital offers super specialized and general mental health services, conducts mental health training, carries out mental health related research and provides support to mental health care services in the country for economic development. During the FY, the hospital had 359 staff representing 85 of approved positions. The hospital used the following financial resources to deliver the services in 2014/15. The hospital had an approved budget of 9.11 billion and received billion in the course of the year. During the year Butabika had the following outputs; 7,436 patients admitted.; 29,253 lab investigations carried out, 1,218 in X-rays and 1,298 in Ultrasound scans; 26,961 Mental Outpatients were treated in the mental health clinic, child health mental clinic, Alcohol drug unit and trauma; 49,200 Outpatients treated in the OPD clinics i.e. General, Dental, Orthopedics, Family planning, Minor surgery, HIV/AIDS, Eye, TB and STD. 60 outreach clinics were conducted,; 13,074 patients seen in outreach clinics; 21 visits to regional mental units; 614 resettled upcountry; 274 resettled in Kampala/ Wakiso; 1,148 patients were 7 MoH Human Resource for Health Biannual Report April

64 rehabilitated to normal functioning; and 138 patients were reintegrated into the community and are now engaged in gainful employment. 1,234 students were received from various institutions of higher learning for mental health placement. These included; undergraduates, postgraduates of different specialties, student nurses as well as Clinical Officers. 4 Mental Health Research activities conducted.; A research on Health seeking for Epilepsy among patients at Butabika Hospital was conducted.; Study on Prevalence and correlation of Hypertension, diabetes and Metabolic syndrome in newly diagnosed patients with severe mental illness; A research on Violence among children with mental illness was conducted; and Research of Exposure to interpersonal traumas and Post-traumatic Stress Disorder with severe mental illness in Butabika Hospital. Regional Referral Hospitals Regional referral hospitals are meant to provide specialized and general health care, train workers and conduct research in line with the requirements of the MoH. For the year 2014/15, reports have been received from all the 14 RRHs (public) and the 4 large PNFP hospitals (Nsambya, Rubaga, Mengo and Lacor) through the DHIS2 and other hospital reports. It makes sense to analyze them in the RRHs group as they would be outliers under GHs. Inputs - Finance The total approved budget for RRHs was UShs billion Shs. and actual release was UShs billion. Overall, the percentage of the funds released against the approved budget was 106 in non-wage, 96 in development budgets but only 94 for the wage budget. The total budget performance was 98. Financial performance for the 4 large PNFP hospitals has not been included in the analysis due to lack of the comprehensive financial reports from these hospitals. (Table 32) TABLE 32: FINANCIAL PERFORMANCE FOR 14 RRHS FOR FY 2014/15 (UGX BILLIONS) Institution Wage Nonwage Development Total Performance Approved Approved Approved Approved budget Release budget Release budget Release budget Release 2014/ /14 Arua 2,975 2,975 1,382 1,394 1,000 1,000 5,357 5, Fort Portal 3,432 2,998 1,306 1, ,438 5, Gulu 2,546 2, , ,628 4, Hoima 2,458 2, ,019 1,200 1,200 4,621 4,

65 Institution Wage Nonwage Development Total Performance Approved Approved Approved Approved budget Release budget Release budget Release budget Release 2014/ /14 Jinja 3,617 3, ,001 1,000 1,000 5,574 5, Kabale 2,385 2,223 1,293 1, ,378 4, Lira 2,569 2,567 1,094 1,360 1,000 1,000 4,663 4, Masaka 2,574 2,515 1,066 1,044 1, ,740 4, Mbale 3,826 3,758 1,882 2, ,508 6, Mbarara 3,279 2,921 1,147 1,183 1, ,426 5, Moroto 1,734 1, , ,551 3, Mubende 2,138 2, ,000 1,000 3,926 3, Soroti 2,617 2,655 1,090 1, ,507 4, CUFH - Naguru 3,420 2, ,020 1,105 5,256 4, Total 39,570 37,589 15,532 16,515 13,471 12,934 68,573 67, Source: MoH Financial Report, FY 2014/15 Human Resources As of April , the 14 RRHs had a total staffing of 3,820, this represented 81 of the established positions with a total staffing gap of 924. Outputs These 18 hospitals produced more outputs in the year 2014/15 compared to the year before; a total of, 3,177,200 outpatients (2013/14 = 2,856,343); 107,619 deliveries (2013/14 = 99,648) and 384,550 admissions (2013/14 = 346,704) among other outputs. On average each hospital attended to; 176,511 outpatients (2013/14 = 158,686), conducted 5,979 deliveries (2013/14 = 5,536) and 21,364 admissions (2013/14 = 19,261). Similarly the hospitals have registered an increase in SUO in 2014/15 compared to 2013/14 from 8,727,279 to 9,598,602. Mbale hospital continues to lead in volume of outputs pushed by the very high number of admissions 70,183 (37 higher than 2013/14). Masaka retains the second slot registering a 36 increase compared to the year before. Hoima, St. Marys Lacor, Moroto all registered more than 20 increases. For reasons yet to be established Kabale had a 29 reduction in outputs compared to the year before. TABLE 33: KEY HOSPITAL OUTPUTS AND RANKING OF RRHS AND LARGE PNFP HOSPITALS Facility Admissi ons Total OPD Deliverie s in unit Total ANC Postnatal Attend Family Planning visits Immuni zation SUO 2014/15 SUO 2013/14 Mubende 15, ,012 4,431 5,518 4,852 1,466 4, , ,977 8 MoH Biannual Human Resource for Health Report April

66 Facility Admissi ons Total OPD Deliverie s in unit Total ANC Postnatal Attend Family Planning visits Immuni zation SUO 2014/15 SUO 2013/14 Masaka 34, ,481 9,732 7,314 1,475 1,414 4, , ,723 Lubaga 14, ,836 5,527 12,073 2,746 NA 19, , ,521 Mengo 6, ,911 5,122 9,909 3, , , ,815 Moroto 12,977 47, ,358 3, , , ,090 Lira 20, ,810 6,235 7, ,527 8, , ,248 CUFH - Naguru 14, ,887 7,848 13, ,035 7, , ,559 St. Francis Nsambya 5, ,469 5,623 8,815 3,330 NA 13, , ,525 St. Mary's Lacor 22, ,160 4,236 4, NA 4, , ,108 Gulu 21, ,513 4,627 5, , , ,101 Arua 19, ,039 5,677 7,996 1, , , ,462 Soroti 20, ,934 4,950 3,527 1,870 1,724 5, , ,468 Jinja 23, ,193 6,233 6, ,992 3, , ,635 Hoima 19, ,820 6,290 6, , , ,062 Mbale 70, ,597 9,921 3,921 9,076 1,518 3,342 1,212, ,840 Kabale 14,028 63,133 4,209 4, ,610 2, , ,493 Mbarara 25, ,330 9,449 6,736 6, , , ,069 Fort Portal 21, ,549 6,701 5, , , ,585 Total 384,550 3,177, , ,975 42,225 18, ,456 9,598,602 8,727,281 Source: MoH HMIS TABLE 34: SUMMARY OF KEY OUTPUTS FOR RRHS AND LARGE PNFPS Facility Admissions Total OPD Deliveries in unit Total ANC Postnatal Attendances Family Planning Immunization SUO 2014/15 SUO 2013/14 Total 384,550 3,177, , ,975 42,225 18, ,456 9,598,602 8,727,281 Average 21, ,511 5,979 6,665 2,346 1,262 6, , ,849 Minimum 5,676 47, , , , ,090 Maximum 70, ,810 9,921 13,889 9,076 2,992 19,515 1,212, ,840 Source: MoH HMIS Figure 11 shows the variation of SUO in the last three years. 42

67 FIGURE 10: VOLUME OF OUTPUTS FOR RRHS AND LARGE PNFPS 2014/ / /13 FYS Source: MoH HMIS Efficiency Efficiency has been analyzed by comparing output to these inputs. The ratios calculated here are not adjusted for quality differences and should be interpreted with caution. The first efficiency indicator is utilization of beds, a more efficient hospital should have a high Bed Occupancy Rate (BOR) and vice versa, similarly the Average Length of Stay (ALOS) should be shorter for better efficiency. However WHO defines optimum bed efficiency as 85 BOR. Table 35 below shows variation across hospitals. The average BOR is 76 minimum 16 (there is a possibility of this being an error owing to incomplete reports) and maximum 139. Hospitals with BOR between 80 and 90 are considered optimally operating while those below that or above that need to make corrective actions to attain optimum state. One action is to address the ALOS more frequent rounds and setting discharge criteria. The second efficiency indicator analyzed is utilization of recurrent funds (wage and non-wage, excluding development). The recurrent cost per SUO and the recurrent cost per bed are shown in the table 35 and figure 12 below. The average recurrent cost per SUO is UGX 5,637 otherwise explained as 1 outpatient equivalent takes UGX 5,637 to produce. The minimum recurrent cost per SUO was shown by Masaka hospital (UGX 4,077) and the maximum UGX 11,785 shown by Kabale hospital. Recurrent cost per bed follows a similar pattern to that of recurrent cost/suo; the average cost per bed is UGX 9,521,999, the minimum UGX 8,883,117 (Mbarara hospital) and the maximum is UGX 34,410,000 (CUFH Naguru hospital). 43

68 Ultimately, efficiency has to be measured in financial terms; as such the recurrent cost per SUO can be considered the reference efficiency. Hospitals that have demonstrated high efficiencies are those that have managed to increase the utilization of their services TABLE 35: SELECTED EFFICIENCY PARAMETERS FOR RRHS AND LARGE PNFP HOSPITALS FY 2014/15 Facility Beds IPD Patient Days SUO BOR ALOS Recurrent Cost Recurrent cost / SUO Recurrent cost / Bed Mubende , , ,926,000,000 8,017 14,852,792 Masaka , , ,559,000,000 4,077 10,784,848 Lubaga , , Mengo , , Moroto , , ,607,000,000 10,457 14,324,176 Lira , , ,927,000,000 5,606 9,817,500 CUFH - Naguru , , ,441,000,000 7,994 34,410,000 St. Francis Nsambya , , St. Mary's Lacor , , Gulu , , ,525,000,000 7,000 9,425,134 Arua , , ,369,000,000 8,337 13,568,323 Soroti , , ,845,000,000 7,835 15,019,531 Jinja , , ,666,000,000 8,546 10,556,561 Hoima , , ,313,000,000 5,527 12,003,623 Mbale ,543 1,212, ,944,000,000 4,901 12,461,216 Kabale , , ,515,000,000 11,785 14,405,738 Mbarara , , ,104,000,000 6,973 8,883,117 Fort Portal , , ,363,000,000 6,877 11,697,051 Total 5,682 1,573,743 9,598,602 54,104,000,000 Average , , ,864,571,429 5,637 9,521,999 Minimum , , ,607,000,000 4,077 8,883,117 Maximum ,945 1,212, ,944,000,000 11,785 34,410,000 Source: MoH HMIS and Hospital Financial Reports 44

69 FIGURE 11: RECURRENT / SUO AND BED OCCUPANCY RATE IN RRHS Outcomes Hospital based deaths especially maternal deaths and fresh still births are indicators of quality of care. The total maternal deaths reported in 14 RRHs and 4 PNFP hospitals were 321 giving a mean death of 18 mothers per hospital per year with a minimum of 2 in Mengo and maximum of 37 in Hoima RRH. The risk of dying during delivery was highest in Hoima RRH, followed by Jinja and Soroti hospitals (a mother died for every 170, 201 and 206 deliveries respectively). This indicates a general improvement compared to 2013/14 where the risk was highest in Mubende RRH, followed by Arua and Hoima hospitals (a mother died for every 116, 162 and 165 deliveries respectively).the risk was lowest in Mengo, Nsambya and Kabale hospitals (a mother died for every 2,561, 1,874 and 1,403 deliveries respectively). For outliers, a follow up of these deaths to establish causes and related factors is necessary. The risk of a fresh still birth was highest in Mubende, followed by Hoima and Arua Hospitals (a fresh still birth was delivered for every 22, 25 and 36 deliveries) respectively. The risk of a fresh still birth was lowest in Gulu, followed by Lubaga and Mengo (one fresh still birth was delivered for every 185, 178 and 160 deliveries) in the above mentioned hospitals respectively. 45

70 TABLE 36: SELECTED QUALITY OF CARE PARAMETERS FOR RRHS AND LARGE PNFP HOSPITALS 2014/15 Facility IPD Admissions Deliveries in Unit IPD Deaths Maternal Deaths Fresh Still Births Maternal Death compared to Deliveries Risk of Fresh Still Birth compared to Deliveries Mubende 15,526 4, Masaka 34,933 9,732 1, Lubaga 14,076 5, Mengo 6,262 5, , Moroto 12, Lira 20,882 6, CUFH -Naguru 14,568 7, , St. Francis Nsambya 5,676 5, , St. Mary's Lacor 22,927 4,236 1, Gulu 21,685 4, Arua 19,304 5, Soroti 20,898 4, Jinja 23,265 6,233 1, Hoima 19,756 6, Mbale 70,183 9, Kabale 14,028 4, , Mbarara 25,732 9,449 1, Fort Portal 21,872 6, Total 384, ,619 12, ,990 11,504 1,419 Average 21,364 5, Minimum 5, Maximum 70,183 9,921 1, , Source: MoH HMIS 46

71 2.6.3 General Hospital Performance There are 139 GHs in the country providing; preventive, promotive outpatient curative, maternity, inpatient, emergency surgery and blood transfusion and laboratory services. The list of GHs in the DHIS2 (144) is not harmonized with that of the health facility inventory of clinical department. The assessment is largely based on the data aggregated through the DHIS hospitals had information in system, 4 PNFP large volume hospitals have been excluded as they have been analyzed with RRHs. Thus we have 132 hospitals in this analysis. (See Annex Table 55) Inputs Human Resource Staffing information in GHs was not analyzed due scarcity of information in the DHIS2. Finance The 43 public hospital had an allocation of Ush 5,943,066, for recurrent non-wage, 100 was released during the year. An additional Ush 3,200,000,000 was released for rehabilitation of Kiboga, Adjumani, Kapchorwa and Bundibugyo hospitals. Lack of staffing costs make it difficult to estimate the real cost of running GHs. Outputs Hospital performance is assessed using 5 main outputs which include; admissions, outpatient visits, deliveries, ANC/FP/PNC (Antenatal care, Family planning, Postnatal care) and immunization. The hospital indicators have been summed up in composite units the SUO. A total of 4,125,600 outpatient visits were made; the hospitals also conducted 173,258 deliveries and 730,313 admissions among other outputs. On average each hospital attended to; 31,493 outpatients, conducted 1,364 deliveries and 5,938 admissions. See Table 37 below. The total SUO for GHs has increased from 15,514,147 in 2013/14 to 16,256,818 this is generally attributed to increased number of hospitals reporting in the DHIS2 from 123 to 132. The average outputs were lower for all the listed outputs in the table below except for postnatal and family planning. The minimum SUO for GHs was 708 and maximum 543,117. The range in outputs is so big and calls in to question the classification of some health units as hospitals. 47

72 Facility Admissions Total OPD Deliveries Total ANC Postnatal Attendances Family Planning Immunization S UO 2014/15 Rank Annual Health Sector Performance Report for Financial Year 2014/15 TABLE 37: SUMMARY OF OUTPUTS FROM THE GENERAL HOSPITALS FY 2014/15 (N=132) # reporting Reporting Minimum Maximum Average Total 2014/15 Total 2013/14 # Reporting 2013/14 Average 2013/14 Admissions ,624 5, , , ,035 Total OPD ,381 31,493 4,125,600 3,849, ,077 Deliveries ,481 1, , , ,387 Total ANC ,738 1, , , ,665 Postnatal , ,521 55, Family Planning , ,482 41, Immunization ,121 5, ,209 1,286, ,462 SUO , ,158 16,256,818 15,514, ,131 Source: MoH HMIS The 5 top performing (high volume) hospitals were Iganga, Busolwe, Kitgum, Mityana and Tororo. Compared to the year 2013/14, Busolwe and Kitgum are new entrants to the top 5. Bwera and Kawolo dropped off the top 5. Among the PNFP the highest volume hospital is Angal St. Luke. The 5 lowest volume hospitals were JCRC, Kitintale, Ntinda, Middle East Bugolobi and Family Care hospital. There is need to re-visit the level classification of some of the very low volume hospitals. These hospitals tend to have very low bed capacities well below the minimum number (60) defined in the definition of hospitals by the hospital policy. TABLE 38: THE TOP 15 HIGH VOLUME GENERAL HOSPITALS Iganga 23, ,381 6,481 7,303 2,349 1,122 12, ,117 1 Busolwe 13, ,082 1,896 2, , ,312 2 Kitgum 15,186 84,480 2,770 2, , ,107 3 Mityana 14,533 64,275 5,763 6,431 1,971 1,221 7, ,434 4 Tororo 14,083 63,432 5,158 6,040 2, , ,433 5 Bwera 14,360 61,258 4,318 7, ,054 15, ,386 6 Pallisa 14,458 57,445 3,626 3,928 3,240 1,135 8, ,364 7 Kawolo 11,704 89,820 3,764 5, ,828 9, ,614 8 Apac 14,121 51,355 2,222 4, , ,

73 Facility Admissions Total OPD Deliveries Total ANC Postnatal Attendances Family Planning Immunization S UO 2014/15 Rank Annual Health Sector Performance Report for Financial Year 2014/15 Angal St. Luke 15,142 31,231 2,537 2, NA 5, , Atutur 11,543 78,229 1,737 2, , , Ibanda 15,078 21,862 2,447 1, NA 5, , Kayunga 11,319 68,930 3,045 3, , , Kagadi 14,134 21,917 3,729 4, , , Nebbi 12,667 49,810 2,367 3, , , Source: MoH HMIS Efficiency of use of services With the information available, we can only assess efficiency in utilization of beds. That is Bed occupancy rate and average length of stay. There was no financial or staff information available to do other efficiency analysis. The range of bed capacity was 15 beds (Senta Medicare) to 552 beds for KIU Teaching hospital Ishaka. The average BOR was 57. A majority (100) of hospitals were operating below the efficient range of bed occupancy; these hospitals can produce more without a large input of additional resources. They are not maximizing their fixed factors of production. Only 8 (Kayunga, Kiboga, Bududa, Atutur, Adumani, Apac, Kisoro and Kitagata) hospitals are operating within the efficiency range, however 14 (Gombe, Mityana, Nakaseke, Bugiri, Iganga, Katakwi General, Pallisa, Kaabong, Nebbi, Angal St. Luke, Yumbe, Bundibugyo, Bwera and Kiryandongo) hospitals are operating beyond the efficiency range BOR greater than 90. FIGURE 12: HISTOGRAM FOR DISTRIBUTION OF ALOS 2014/15 Outcomes The ALOS similarly has a very wide variance, the average is 3.8 days; the maximum ALOS is 8 days observed in Nakasongola Military, Gulu Military, Mildmay, Maracha and Matany. This is due to a case mix that has more patients needing longer rehabilitation or chronic care. For the current resources used in GHs, we are not getting the best return in terms of productivity. 49

74 Maternal deaths were reported in 79 GHs, a total of 407 deaths compared to 449 in 2013/14 were recorded giving an average of 5 deaths per hospital. However taking the denominator as hospitals conducting deliveries (126) the average death per hospital is 3.2. The minimum is 0 and the maximum is 18 observed in Iganga. Overall there was a maternal death for every 265 deliveries compared to 241 in 2013/14. The 5 hospitals with the highest risk of a maternal death were: Buliisa 1 death in 55 deliveries, Nyapea 1 in 80, Mt. Elgon 1 in 81, Dabani 1 in 100 and Buluba 1 in 118. The causes of maternal deaths in these hospitals needs to be investigated to reduce on the maternal death to deliveries ratio. 5 hospitals with the lowest risk of a maternal death were: Entebbe 1 death in 2,579 deliveries, Kalisizo 1 death in 2,340, Nakaseke 1 death in 2,390, Bombo 1 death in 2,063 Atutur hospital 1 death in 1,737 deliveries. Fresh stillbirths were reported in 104 hospitals, a total of 3,282 fresh still births were recorded, minimum 1 (Kitintale, Uganda Martyrs, Ruth Gaylord, Kakira and Kida hospitals) and maximum 152 (Iganga hospital). Overall the risk of having a fresh still birth taking total deliveries as the denominator is 1 in 43 deliveries. The minimum risk is 1 in 720 deliveries in St. Karoli Lwanga hospital Nyakibale and maximum is 1 in 12 deliveries in Dabani. 50

75 2.6.4 Functionality of HC IVs The key feature of the HSD strategy is that each HSD, which has an approximately 100,000 people, would have a Hospital or a HC IV. The facility should have the capacity to provide basic preventive, promotive, outpatient curative, maternity, inpatient health services, emergency surgery and blood transfusion and laboratory services. In addition, it should supervise and support planning and implementation of services by the lower health units in its area of jurisdiction. The total number of HC IVs is 206; of these 182 are government, 17 NGO and 7 privately owned. Information was available for 195 HC IVs in the DHIS2 and this form the basis of the analysis below. Inputs Human Resource Staffing information in GHs was not analyzed due scarcity of information in the DHIS2. Finance Staffing information in GHs was not analyzed dues to lack of reliable information on individual hospital financial performance. Outputs Functionality of HC IV is determined by outputs from selected 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. 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, as such HC IVs have been judged functional if they have been able to carry out at least one caesarean section. Using these criteria, 51 (100/195) of the HC IVs were functional meaning able to do cesarean section. For blood transfusion 38 (75/195) were able to provide this service. Those able to provide both cesarean section and blood transfusion were 33 (65/195). There is an improvement compared to the functionality of 2013/2014 when 45 (88 out of 196) of the HC IVs were able to do cesarean section and 36 able to do blood transfusion. Figure 14 shows the trend of these functionality indicators over the years. Government efforts and a number of partner efforts to make HC IVs functional are beginning to pay off. The recruitment of health workers for HC IVs and IIIs contributed to observed improvements. 51

76 FIGURE 13: TRENDS IN CAESAREAN SECTION AND BLOOD TRANSFUSION 2008/ /15 Source: MoH HMIS There are 14 HC IVs that perform more than 200 Cesarean sections a year like in many hospitals these are: Bishop Asili Ceaser HC IV, Mpigi HC IV, Mukono T.C. HC IV, Mukono CoU HC IV, Serere HC IV, Rwekubo HC IV, Kabuyanda HC IV, Rukunyu HC IV, St. Paul HC IV, St. Ambrose Charity HC IV, Kakumiro HC IV, Kyegegwa HC IV, Rubaare HC IV. These HC IVs need to be recognized and funded differently from other HC IVs. In total HC IVs attended to 4,218,757 outpatients; conducted 156,352 deliveries; and admitted 453,036 patients. The mean outpatient attended to was 21,635, mean deliveries 810 and mean admission 2,489 as shown in the table 39. The total SUO for HC IVs was 12,217,35 with a minimum of 2,295 and maximum of 199,837. TABLE 39: SUMMARY OF OUTPUTS FROM THE HC IVS FY 2014/15 (N=195) Admissions Total OPD Deliveries Total ANC Postnatal Attendances Family Planning Immunization Total 453,036 4,218, , ,278 84,813 76, ,302 12,217,356 Minimum ,295 Maximum 7,181 47,879 5,761 11,867 5,425 4,134 34, ,837 Valid Average 2,489 21, , ,205 62,653 # reporting SUO The 5 top performing HC IVs in 2014/15 were Mukono T.C, Luwero, Serere, Kitebi, Kumi. In 2014/15 the number of beds increased, from 6,324 in 2013/14 to 8,034; as expected. admissions also increased from 424,828 the year before to 453,036, with more admissions death 52

77 also increased. While the ALOS remained more or less the same, the BOR decreased to 38.7 from 49. Table 40 shows the comparisons. TABLE 40: SUMMARY OF EFFICIENCY & USAGE MEASUREMENTS OF HC IVS Output 2014/ / /2013 Number of Beds 8,034 6,324 6,065 Admissions 453, , ,898 Deaths 3,643 4,621 4,276 Case Fatality Rate Patient Days 11,36,300 1,125,651 1,031,096 Bed Occupancy Average Length of Stay Source: MoH HMIS 53

78 3 Achievements against Planned Outputs in the MPS 2014/15 This section highlights the performance of the MoH against the key outputs of the MPS by implementation level i.e. department, division or unit. These key outputs are derived from the core functions of the MoH headquarters are; policy formulation and dialogue, planning, setting regulations, standards and guidelines, supervision, monitoring, resource mobilization, HR capacity development and technical support, infrastructure development, health systems research and development and coordination of health programmes and projects Finance and Administration The achievements of F&A during the FY 2014/15 include; - 10 political supervisions of sector activities in the LGs & Referral Hospitals done; three briefs to Cabinet & four briefs to Parliament were made; 24 Press statements / briefings on sector matters were issued. - Board of survey was conducted and 54 vehicles were boarded off. - Responses to internal Audit, Auditor Generals and Public Accounts Committee reports for FY 2013/2014 were submitted. - Decentralization of payroll was implemented and salaries paid by 26th of every month cases for confirmation for study leave were submitted to Service Commissions for action; 191 critical positions were cleared at MoH Hqtrs, UVRI & RRHs submitted to Commissions for filling. - Health Service Commission recommended 387 decisions (new appointments, promotions, re-designation) and these were implemented. - Performance agreements for all RRH Hospital Directors were monitored. - Areas of Bilateral Cooperation identified and the MOUs drafted and approved by Solicitor General for the following countries: DRC, Ethiopia and South Africa. MoU of Ethiopia was signed and is under implementation. The MoU with Republic of South Africa and DRC ready for signing. MOUs drafted for Cuba, India and South Korea and submitted for Solicitor General Approval Bankable Project for rehabilitation of Masindi and Abim Hospital submitted to Ministry of Foreign Affairs for incorporation into the upcoming India - Africa Summit meeting for bilateral cooperation negotiations. - Participated in the: Joint Border Commission meeting between Uganda and Kenya (October 2014); Lake Victoria Basin Commission meeting (Bujumbura - March 2015) and made input towards improvement of the Public Health, Sanitation and Environment Project; Joint Ministerial Commission DRC August 2014; International Public Health Conference Salud- Cuba February 2015; bilateral cooperation dialogue at MoH with the 54

79 Challenges following delegations: Cuba, India, Germany; coordination meetings at Ministry of Foreign Affairs for bilateral cooperation with Iran, Ethiopia, DRC, India; country collaborative meetings with International Organization for Migration. a) Frequent interruptions and breakdown of the IFM System. b) Last minute budget cuts by MoFPED. c) Inadequate office space. Despite the opening of the new office extension, this has remained a challenge as a number of staff are still not accommodated Planning In order to guide the sector and facilitate formulation of sector policies and strategies the Planning Department accomplished the following; Planning - Completed the MPS, Budget Frame work paper and developed the Annual Workplan, FY 2015/16. - Printed and disseminated PHC grant guidelines for FY 2014/15; prepared and reviewed the LG negotiation paper with LGFC and ULGA; disseminated NHA report for FY 2011/12. - Developed the draft Health Sector Development Plan (2015/ /20), continued work on the draft Health Financing Strategy; prepared the AHSPR for the FY 2013/14; organized the 20th JRM; and held a DHO s consultative meeting. - Supported all LGs in preparing health sector component of district budgets and plans; carried out 4 workplan performance monitoring supervision and planning mentorship in 6 RRHs, 14 GHs and 25 LGs; and 1consultative meeting on the NDP II was conducted in Lira. Policy Analysis - In terms of policies and Acts, the following were accomplished; reviewed the Public Health Act & National Drug Authority Act, conducted 1 Policy workshop on Policy Formulation, Guided the development of the Palliative Health Care Policy & School Health Policy and developed a Policy Brief on Supply of Essential Life Saving Commodities. - Furthermore, the following were drafted, costed and submitted to Cabinet; Principles of National food and medicines Authority Bill 2014, Principles of Uganda Cancer institute Bill 2014,Principles of National health laboratories services Bill 2014, Protocol for elimination of illicit trade in tobacco products and Uganda Immunization Policy. 55

80 Human Resource Development - A concept to establish Health Manpower Development Center (HMDC) at Mbale as an autonomous institution with an Act of Parliament was finalized and is ready for presentation to cabinet. - Rehabilitation and upgrading of HMDC infrastructure: classrooms, dining hall, staff houses; installation of Local Area Network and internet; re-design of student hostels (self-contained) with support from ICB project. - Rolled-out of national Governance, Leadership & Management training course health managers at district, HSD and facility level in 15 districts and 2 RRHs. - Capacity building activities within the district and RRH workplans through Execution Agreements (Arua and Fort Portal). - Secured 350 bursaries for midwifery from Baylor Uganda, processed scholarships for 50 postbasic & post-graduate under GoU funding. - With support from ICB Project, Hospital Management Boards of 3 RRHs and 5 GHs were inducted in Leadership and Management. In addition, 90 Health Managers of RRHs, DHTs, GHs and HSDs all from West Nile and Rwenzori regions were also inducted - Another 62 health managers at lower level health facilities have completed the online course (in leadership & management) and 295 are still on the same course. Fifteen DHTs were trained in conducting Training Needs Assessment and they developed Training Plans (Rakai, Lyantonde, Lwengo, Sembabule, Bukomansimbi, Luweero and Nakaseke, Nakasongora, Buikwe, Kalungu, Kayunga, Mpigi, Kampala, Mubende and Mityana). - With support from MKCCAP 35 Top level Managers and 60 Mid level Managers trained in Governance and Leadership in Masaka; 40 Health workers trained in Use and Maintenance of medical equipment in Mulago Hospital; 15 Health workers trained in Renal transplant techniques in India; 6 H/W on the equipment committee attended a learning exhibition for medical equipment; 10 went for a benchmarking trip to Kourle Bou Hospital in Ghana; 240 Nurses trained in infection control measures; 15 Nurses trained in pulmonology in Mulago Hospital; and 13 H/W trained in physiotherapy. - One out of two inter-ministerial standing committee meetings between MoH and MOES was held to address issues pertaining to health training institutions. Resource Center - The Resource Center conducted 3 data validation exercises supported by GAVI and Global Fund. - 8 Support Supervision visits - 17 training & mentorship workshops in HMIS tools & e-hmis, - Produced final draft Statistical Abstract, - Developed the HMIS manual, 56

81 - Held 9 e-health TWG meetings - Finalized the e-health strategy. - Re-designed the MoH Website with support from ICB Project. - RPMTs worked with partners to improve the quality of data in the DHIS2. - Assessed the ICT capacity in districts with support from GFTAM. - Migration of training database from TASO to MoH Resource Centre initiated. - Developed Community-HMIS training materials Quality Assurance Major Achievements were; - The review of implementation of the MoH work-plan for 2014/15 FY was conducted in August Report was compiled and disseminated to key stakeholders. - Quarterly Regional Health Forum meetings held in West Nile and Rwenzori regions, for sharing and learning, as well as coordination of regional health systems and support with support from ICB project regional quarterly review meetings were organized by RPMTs with support from GFTAM. - The Quality Improvement Manual (2015) for the health sector was developed. Guidelines for development of the Client Charters in the health sector and the Key Client Charter messages for the Lower level health Facilities were developed. Other guidelines disseminated were the Uganda Clinical Guidelines (UCGs) which were made available to 21 districts in Eastern and Central region, and the Health Sector QI Framework and Strategic plan to 35 districts in the Teso sub-region. - Client Charters were disseminated to 7 RRHs. Client Charter key messages were also distributed to 65 districts including GHs and HC IVs to increase awareness and participation of the community to have feedback that could be used to increase health sector performance. The activity shall be extended to cover rest of the country during the new FY. - The Pre-JRM field visits took place in September 2014 and the report was shared during the 20 th JRM meeting. - The Health Sector Support Supervision, Monitoring and Inspection strategy was finalised and shared within the Sector Monitoring and Evaluation TWG. The strategy shall be rolled out in 2015/16. - QI Teams have been established in many districts and health facilities predominantly for Rwenzori, South-Western and West Nile regions. A total of 54 National QI facilitators were trained. - One out of the four planned support supervision field visits (Area Teams) took place to cover the 112 LGs. Impromptu inspection visits were conducted for 35 districts and reports were shared with both the district and the responsible MoH officials for action and follow-up. 57

82 3.1.4 Clinical and Community Clinical Services The Clinical Services Department achieved the following; - Developed draft policies on Palliative care and Control of Hepatitis B; a Bill on tobacco control was tabled in Parliament waiting to be passed into law, participated in the control of Typhoid in Kampala, and the malaria outbreak in Northern Uganda. - Supervised the 13 RRHs, 8 GHs and 5 LLHFs; health workers from 13 hospitals were trained in quality control using the concepts of 5S and Continuous Quality Improvement. - A number of international days were celebrated among which were World Oral Health Day, World No Tobacco Day, World Nursing/Midwifery Day, and World Hepatitis Day which aimed at increasing public awareness of services available at government health facilities. - Specialists camps were held on Fistula repair and dental treatment. The departments coordinated 12 meetings for the medical board to refer patients abroad and also approved requests for early retirement. - Initiated the Uganda National Ambulance services programme. Palliative Care - Palliative Care Policy developed and ready for presentation to Top Management; draft - Palliative Care communication strategy developed; - Capacity built for health workers in 8 districts; - Four districts accredited from July 2014 to June 2015 and districts providing palliative care raised from 86 to 90; - Stakeholders meetings held; - Support supervision provided for accredited palliative care units and Annual Hospice and Cancer Day marked in Rakai District. Mental Health - The Mental Health Bill was passed by Cabinet, printed, gazetted now awaiting tabling to Parliament; Tobacco Control Policy developed - Mental Health Strategic plan printed and disseminated to Jinja Kamuli and Kitgum districts. - Supported the mover of the Tobacco Control Bill in parliament, it was passed on 28th July

83 - National Mental Health day celebrated on 10/11/14 at Grand Imperial hote; World No Tobacco Day on 31st May 2015 at MoH gardens; and International day vs drug abuse and illicit trafficking on 25/06/15 at MoH board room - Radio and Television talk shows conducted on tobacco control drug abuse and Mental illnesses. - Support supervision to Mbale, Gulu, Lira and Soroti RRH Mental Health units. - Monthly Tobacco control coordination meetings held Pharmacy - Updated the National Medicines Policy and developed the National Pharmaceutical Sector Strategic Plan ( ); Developed and disseminated dispensing guidelines to all HC IIs one per copy and HC III two per copy in the 112 districts; Developed a draft addendum of UCG 2012 on RMNCAH and printed 5,000 copies and 2,000 additional copies of UCG Bimonthly stock status reports were produced health workers from 40 districts were trained in logistic management of vaccines. - Supervised 155 health facilities in 30 districts in medicines management related activities and undertook an assessment of procurement planning at selected hospitals and HC IVs. - Planned and monitored procurement of ARV's, TB, Malaria, Lab, Cotrimoxazole, Condoms and RH commodities ; Initiated procurement of ARVs, Condoms, Cotrimoxazole, Syphillis kits and Safe Male Circumcision commodities for 2015/2016 following the approved grants, covering the period between July 2015 and December 2017 and signed on June 25, In addition, Initiated the implementation of the awarded $20m Health Systems Strengthening Grant; Quantified requirements for Hepatitis B treatment, female condoms and the 13 lifesaving commodities 9under the UN- Commission. - Reviewed the national indicator on availability of tracer medicines, which will now include 41 high-volume products used to diagnose, prevent, and treat Uganda s 10 most common diseases or conditions. The programs covered include immunization, HIV/AIDS, malaria, tuberculosis, and RMNCAH. The revision took into consideration the newly revised HMIS 105 section that will track data on the 41 commodities. Challenges Inadequate and irregular releasing of funds delays implementation of support supervision. Inadequate human resources at points of service delivery lowers the quality of services delivered. About 90 of people in Uganda who need palliative care not receiving the services 9 59

84 Inadequate knowledge on palliative care at all levels Community Health Department This department is comprised of the RH, Child Health, Environmental Health, Vector Control, Veterinary Public Health, Disability and Rehabilitation, NCDs, School Health, Public oral health and hygiene, Health Education and Promotion and Nutrition. The achievements were; RMNCAH - Safe Motherhood day commemorated in Tororo District; Family Planning National conference held in Kampala. - Carried out Family Planning camps in Amudat, Arua, Bundibugyo, Gulu, Kitgum and Nakapiripirit districts. - Annual Stakeholder s meeting on Teenage Pregnancy in Sheema District; 2 national stakeholders meeting on ICCM and Newborn health were respectively held. - Carried out IMCI, school health, control of diarrhoeal diseases, and Integrated Child Health Days supervision in Bundibugyo and Ntoroko districts. - Mentored 351 Health workers on Emergency Obstetric and Newborn Care Districts of Sheema, Masindi, Pallisa, Wakiso, Kaabong, Kiboga, Namayingo, Bududa, Buyende and Kabale; Mentored 120 Health workers on Adolescent health in Arua, Amudat, Bundibugyo, Gulu, Kitgum, and Nakapiripit. - Trained 349 service providers in Long Term Family Planing Methods (LTFPM) in Soroti, Dikolo, Katakwi, Kaliro, Iganga, and Moyo Districts; trained 600 VHTs on Sayana press as Community based FP method in Katakwi, Kumi, Iganga, Amuria, Mubende, Gulu districts; Primary School teachers trained in life saving skills including Sexual Reproductive Health and Sexuality Education in Kampala district. - Developed and launched the Family Planning Costed Implementation Plan; printed 500 Copies of child health strategies; aligned newborn care and children guidelines with the revised HBB Plus curriculum (basic and hospital standards, newborn care standards and implementation framework; finalized guidelines on teenage pregnancy management; finalized maternal death surveillance and response guidelines. UNEPI - Revised Immunization practice in Uganda, Child cards, HMIS tools & printed IEC materials to include new vaccines information. 60

85 - Conducted support supervision in all districts for only one quarter; conducted active surveillance in districts with poor surveillance through the national and international STOP teams. - Held 4 out of the planned 12 EPI technical meetings; conducted 4 Regional review surveillance meetings. - Conducted two rounds of polio supplementary immunization activities (one national and one sub-national targeting high risk districts) were conducted in children aged 0 59 months. The National coverage for the first round was 106 and 99 for the second round; and 2nd round Periodic Intensified Routine Immunization activities in 20 districts. - Effective Vaccine Management Assessment was done through training of field assessors and actual assessment through administration of a questionnaire in selected districts. Findings were shared in a feedback meeting that was attended by 224 participants from 112 districts. - Cold chain maintenance was conducted in 112 districts to ensure that the vaccines are kept in optimal conditions. - Conducted Comprehensive review of the Immunization Program and PCV 10 post introduction evaluation (PCV-10 PIE) as recommended by WHO. Environmental Health and Sanitation - IEC materials on hygiene and sanitation were finalized and are due for distribution and dissemination districts received funds from District Sanitation Conditional Grants, an average of UGX 23 million. Most districts used the money to carry out Community Led Total Sanitation (CLTS) triggering of communities and follow up of triggered communities to ensure they become Open Defecation Free (ODF), while some districts carried out home improvement campaigns aimed to get 100 latrine coverage in the target communities, with improved homesteads and attainment of ODF status. - During FY 2014/15, UGX 2.18 bn (USD 764,774) was disbursed to 30 districts supported by the Uganda Sanitation Fund Project. A total of 2,046 villages were triggered during the FY, with 549 (27) becoming ODF. Over 4 years, a total of 6,026 villages have been triggered with 2,534 villages (42 of those triggered) reported to be ODF. - During FY 2014/15, UNICEF provided UGX 548 million to 16 districts to support school sanitation and CLTS implementation. A total of 182 villages were reported to have been triggered with funding from UNICEF. - There was increased advocacy and as a result, leaders from 60 districts signed commitments to implement hygiene and sanitation resolutions. A total of 72 villages were able to achieve 100 latrine coverage and access to hand washing. 61

86 - With support from SNV project working with local NGOs, on rural sanitation in 7 districts in West Nile region and 8 districts in the Rwenzori region, 1,047 villages have been triggered, of which 472 villages (45) have been declared ODF after one year of implementation. - The National Hand Washing Initiative (SNV is the new Secretariat) revised the Behaviour Change Communication (BCC) campaign and tool kit. Translated BCC campaign materials are available on request at the Hand washing secretariat (Visit for details). - The access to hand washing facilities at the toilet is estimated at 33.2 and improvement from 21 five years ago. The best performing districts were Mbarara (93), Bukomansimbi (78), Kyenjojo (78), Moyo (78) and Kumi (75). The worst performing districts included Butaleja, Kaabong, Kiboga, Moroto, Nakapiripirit and Napak. These districts have both low sanitation and hand washing coverage, with no ODF villages. Most rural households cannot afford to make a lump sum payment for the improved sanitation. To address this, several financing institutions have developed financing mechanisms to finance sanitation e.g. Post Bank Ltd. lent out UGX 931,460,000 to 370 people over a period of 1 year for sanitation, under its WASH loan. - According to the district reports the pupil: latrine stance ratio is 1:67 and this is a marginal improvement on what was reported last year. Only 7 districts meet the national target of a pupil: latrine stance ratio of less than 1:40. During FY 2014/2015, Kampala City Council Authorities (KCCA) constructed toilets in public schools and the pupil: stance ratio improved from 67:1 to 53:1. - UNICEF supported the construction of 23 latrines with 115 stances at primary schools in Kabarole, Lira, Ntoroko and Mukono, serving at least 4,600 pupils and constructed an 18 stance Biogas producing latrine in Tororo serving more than 720 pupils with sanitary facilities and cooking gas. 62

87 - Support was also extended to the Appropriate Technology Centre through the Ministry of Water and Environment (MOWE) towards the establishment of a low cost sanitary pad making project, so far covering 2 schools in Mukono district. FIGURE 14: POST BANK ASSESSED HOMES AND WASH LOANS PROVIDED FIGURE 15: THE IMPROVED LATRINE FACILITIES CONSTRUCTED AFTER PROVISION OF THE WASH LOANS (Photos courtesy of Post Bank Soroti) Vector Control - Launched tsetse and trypanosomiasis sleeping sickness Awareness regional information centre for six districts in northern Uganda. - Schistosomiasis baseline surveys conducted in Kibuku, Bukedea, Nakapiripirit, Napak, Zombo, Lyantonde, Sembabule and Sheema districts; Schistosomiasis Impact assessment surveys conducted in Busia, Kaberamaido, Serere, Soroti, Kamwenge, Rubirizi, Gomba 63

88 and Mpigi districts; Trachoma impact assessments conducted in Moroto, Kabong, Nakapiripirit, Amudat, Napak, Agago, Pader and Kotido districts. - Conducted trichiasis surgeries in 17 districts of Busoga region and Karamoja regions, The NTD Secretariat launched the Trachoma Action Plan. Veterinary Public Health - Conducted support supervision of hospitals in laboratory diagnosis of brucellosis in 10 districts in central and eastern Uganda was conducted. Health Education and Promotion - High level visit with key partners that included, UNICEF, WHO, World Vision, PACE, IRC and MoH was conducted in Sheema. - One dissemination meeting held for religious leaders. - Over 50,000 posters 10,000 leaflets developed, and printed on Marburg, Typhoid and cholera, lifesaving commodities, teenage pregnancy, Family Planning; disseminated IEC materials on Ebola, Marburg, Typhoid, cholera, Family Planning in 60 districts in western and eastern regions. - Carried out community film show sensitisations on Marburg outbreak, Safe Male Circumcision, EMTCT, Family planning, Ebola and ANC services in 50 districts. - Trained 40 district leaders namely; DHEs and surveillance Focal Persons, Health workers, and VHTs from districts bordering South Sudan on Viral Hemorrhagic Fevers from Southwest and northern. Disability and Rehabilitation - World sight and White Cane day cerebrated at Kampala Naguru Hospital; Older person s day cerebrated in Yumbe district; Disability day cerebrated in Kayunga district. - Radio programs on refractive errors evaluated in Arua, Yumbe, Moyo and Mbale districts held. Also held a workshop to finalize the draft Advocacy Strategy on refractive errors in Kampala. - Held regional trainings on Leadership and governance for Child Eye Health in (Kampala, Mbale Mbarara and Gulu); carried out capacity building of (12) Clinicians and (16) Technicians in wheelchair assessment, fitting and maintenance at LDS Church Kampala. - Received 270 wheelchairs for People With Disabilities and distribution still ongoing, MoH and Uganda National Bureau of Standards reviewed and passed the National Wheelchair Standards and Guidelines 2015 version. - Ophthalmic Clinical Officers Conference held in Mukono district. 64

89 Non-Communicable Diseases (NCDs) - NCD survey has been finalized in 2015 and report is being written for dissemination. - Developed a draft NCD policy, strategic plan which is being costed, NCD training materials for health facilities and recording tools for health facilities, draft NCD guidelines on diet and physical activity; draft NCD IEC materials. - Procured medical equipment for health facilities. - NCDs regional trainings conducted in the central, western, eastern and northern regions. - NCDs patient education meetings held in HC IVs, RRHs and NRHs. - Screening of NCDs has been done in Entebbe and the State house - Nakasero. Over 300 people were screened for NCDs at both gatherings. - Community sensitization workshops for leaders in the western region converging political leaders; RDC, CAO, LC V chairmen and their executives etc., religious leaders, VHTs, cultural leaders and district officials. Community sensitizations on NCDs through drama done in Entebbe. School health programme - Sports competitions in schools (both primary and secondary) been conducted in the Mukono and Mbarara district. Six schools per region participated with a total of 126 pupils per region. - Drama competitions in schools (both primary and secondary) in the Wakiso and Kamuli district. Six schools per region participated with a total of 200 schools per region - Health education talks in schools in 3 school in Wakiso,1 school in Isingiro and Kamuli district. Public Oral Health and Hygiene - Technical support supervision on public oral health and hygiene (33 in Eastern, 21 in Western, 20 districts in Northern). - Supervision on implementation of the National oral health policy was done in Masaka, Rakai, Kiruhura, Mbarara, Lwengo and Kalungu Districts. Health Education and Promotion - 2,500 spot messages disseminated on 66 radio stations, 4 TV stations and 2 newspapers on Marburg, Ebola, Typhoid, cholera, family planning and teenage pregnancy. - Held 2 orientation workshops for community leaders on Marburg/ Ebola prevention and control strategies in central, western districts press conferences on Marburg outbreak and Ebola, typhoid, teenage pregnancy, and Fistula, family planning. 65

90 - Rapid response provided to Marburg outbreak in Kampala, Kasese, Mpigi and Kamwenge districts. - Cholera in Kasese and Moyo districts and typhoid in central region contained. - Emergency technical supervision done in the districts of Kampala, Mukono,Wakiso, Kasese, Busia, Buliisa, Kayunga and Mbale. - Ebola sensitization and elaboration of the National Ebola Preparedness Workplan in 5 districts in Ruwenzori region conducted. Challenges noted in 2014/2015 Inadequate funding Shortage of human resources Importation of infection from neighboring countries. Slow behavior change Communicable Disease Prevention and Control Control of Diarrheal Diseases Key Achievements - Communities sensitized on diarrhea prevention and management. - Guidelines for prevention and control of diarrhoeal diseases disseminated to communities. - Health workers trained in early diagnosis/identification and confirmation, case management of diarrhoeal diseases. - Diarrheal disease outbreaks controlled (cholera and epidemic dysentery). Epidemic Disaster Prevention, Preparedness and Response As a result of successful implementation of the above planned activities the following achievements were registered: - Resettlement of Sudanese refugees in Northern Uganda: The sector worked with other stakeholders to resettle over 60,000 Sudanese refugees in refugee camps in Northern Uganda. These refugees are still hosted mainly in the districts of Arua, Adjumani and Kiryandongo. - Control and prevention of Meningococcal meningitis outbreak: an epidemic of meningococcal meningitis was detected, confirmed and controlled through immunization of most at risk communities in Arua and Adjumani districts. - Mitigation of the deadly floods in Kasese district: Kasese district was affected by serious floods during the month of may During this period the district was supported to 66

91 strengthen preparedness against epidemics as result no disease outbreak was registered due to floods. - Control of cholera outbreaks in Moyo and Namayingo districts: During the 4 th quarter of the financial year 2014/15, the two districts reported outbreaks of cholera in villages along the shores of the Nile and Lake Victoria respectively. These outbreaks were as result of poor sanitation and hygiene in these communities. Detection was quick for both outbreaks and control achieved to zero cases within two weeks of confirmation of outbreaks. A total of 78 cases and 4 deaths and 110 cases with 2 deaths were recorded in Moyo and Namayingo districts respectively. Efforts to consolidated activities to prevent similar outbreaks in future are ongoing in these districts. - EAPHL Project Steering Committee meetings, Regional Advisory Panel meetings, Regional TWG meetings and Viral Hemorrhagic Fever simulation meetings were organized and attended members from all the 5 East Africa Member States. HIV/AIDS Prevention and Control The AIDS Control Program registered significant achievements in the reporting period. With respect to prevention, the following outputs were made; - Facilitated quarterly BCC TWG Meetings and worked with UAC based message clearing house to review and provide guidance on quality improvement of HIV messages. - Developed and disseminated tailored print and electronic messages. With support from Communication for Healthy Communities, the OBULAMU Campaign messages were developed and disseminated. These messages were disseminated through billboards, posters, brochures, radio and TV. - Conducted tailored time bound BCC Campaigns namely Protect the Goal targeting young people using sports. This Campaign was launched by his Excellency the President. - Conducted 4 Regional EMTCT Campaigns for West Nile (Arua), East Central (Jinja), Mid-Western (Hoima) and Central (Masaka) regions with the office of the First Lady. - The Comprehensive Condom Programming strategy was reviewed. - A total of 172, 201,292 (56 of estimated national need) condoms were procured and distributed in the country. - Held a meeting of 25 districts which were identified as poorly performing in emtct using the indicators for- provision of ART to mothers, ARVs for prophylaxis to babies and MTCT positivity rate among babies tested. - Developed a draft protocol and initiated a process to measure the impact of the emtct program in Uganda with support from the AIDS Development Partners and Implementing Partners and the global Interagency Task Team for emtct to This study will help measure the attainment of the Uganda emtct plan. 67

92 - The program developed a draft policy for tetanus immunization in response to the tetanus adverse events. In the new policy, there are proposals for booster immunization doses for target eligible males, which will be costed. - Introduced viral load monitoring through a centralized viral load laboratory at CPHL supported by the sample transport network. Since August 2014 to August 2015, a total of 132,000 viral load tests have been conducted. - The Early Infant Diagnosis (EID) has continued to scale up services and last year over 98,000 tests were conducted and over 70,000 babies from 2,239 health facilities. - Conducted the 2014 round of the annual sentinel surveillance survey. - Worked with partners to prepare a protocol to conduct the Population HIV Impact Assessment.. The protocol is now ready and will be submitted to Institutional Review Boards at the Uganda Virus Research Institute, and to partner IRBs at the Centers for Disease Control (Atlanta) and ICAP (New York). - Quarterly TWG meetings for the BCC/IEC, Most at Risk Populations, ART/PMTCT, and Condom TWGs were conducted to provide coordination to stakeholders. - Conducted a technical review of the Public health response to the HIV and AIDS epidemic. The review brought together- AIDS development Partners, RPMTs, 112 DHOs, and Implementing Partners. - The AIDS Control program and the NTLP spearheaded the development of the joint TB- HIV Concept Note of the Global Fund New Funding Model and obtained over 171 million dollars for the period The grants for these funds were signed in June and became operational in July The AIDS Control Program provided technical input and reviewed the processes of the preparations for the PEPFAR COP15 process. The COP 15 will form the basis of the USG implementation for the FY 2016/2017. FIGURE 16: NUMBER OF ACTIVE ART CLIENTS IN THE COUNTRY: 2003 DECEMBER

93 Performance against the key program indicators - In 2014/15, 688,313 men were circumcised. To date a total of 2.4 million men have been circumcised since the program was initiated. - The percentage of people who are on ARVs increased from 53 in 2009 to 750,896 (56) by 2014 of those in need (adults 694,627(58) and children 56,269 (38). This coverage is based on the new HIV prevention and Treatment guidelines in which the number of people in need has gone up significantly. This coverage is based on the new HIV prevention and Treatment guidelines in which the number of people in need has gone up significantly. If this had been calculated based on the old guidelines the coverage would be in the range of HCT services available in all health facilities up to HCIIIs and to about 30 HC IIs (38 of health facilities with HCT services). All districts are implementing community level HCT; however, this is entirely dependent on the support from partners. - PMTCT services available in all health facilities up to HC IIIs and 20 of HC IIs ( of health facilities with PMTCT services; of HC IIs with PMTCT services). - The proportion of HIV infected pregnant and lactating mothers enrolled on ARVs for emtct increased from 52 in 2011 to 112,905 (95) in The number of people who tested for HIV in the reporting period was 10,273,927 out of a target of 7,421,024. Most of these tests were conducted in health facilities based on the PITC approach. The proportion of population who know their HIV status were last determined in the 2011 AIS and was 45 for men and 66 for women. This indicator will be determined again in the PHIA next year. - Access to ART services increased through accreditation of more sites. The number of health facilities providing ART increased from 407 in 2011 to 1,658 by the end of Reduced the number of health facilities reporting stock out of HIV commodities (HIV Test kits and FDC ARVs for emtct) from 50 in July 2013 to less than 3 in December Challenges Human Resources: The withdrawal of USG funding to Human Resources for the AIDS Control Program has affected program performance. The morale of staff previously funded by the USG through CDC support has gone down. A number of Senior staff have left their posts Funding Gaps: Funding for the AIDS Control Program activities was a challenge in the last year. Funding from Government to the Program has remained sub-optimal mainly as a result of the history of previous donor funding. The New funding regulations from USG meant that resources from USG are not available to support many of the planned activities which are now deemed unallowable. There are also funding gaps for HIV and AIDS 69

94 Commodities including HIV test kits, Safe Male Circumicision Kits, Laboratory commodities and drugs- ARVs and co-trimoxazole. TB and Leprosy Prevention and Control Program Progress on implementation of planned key activities - Construction of the National Tuberculosis Reference Laboratory is ongoing at Butabika. The physical structure is due for completion by end of the year more GeneXpert machines were procured bringing the total to 102 machines that are at various stages of being installed and put to use. - Trained staff from 89 health facilities in MDR-TB management centres to provide follow-up treatment; trained health workers in SPARS (Supervision, Performance Assessment, Recognition Strategy), which includes Logistics Management Information System to assure good stock management for anti-tb medicines and supplies, - IPT guidelines were developed and disseminated to all TB diagnostic and treatment facilities in 7 regions. - In collaboration with ACP, the NTLP strengthened systems for HIV/TB based on the One Stop Centre model through support supervision and mentorship. - Sustained community-based directly observed therapy (CB DOT) through support of CSOs and Community Based Organisations (CBO) by TB and TB/HIV IPs and support from the Global Fund. - Conducted four quarterly reviews to quality assure data and assess performance of the progress; improvement actions identified were implemented for continuous improvement of programme performance. With support from IPs, trained all Zonal TB/Leprosy Supervisors and staff in selected health facilities in data quality audit (DQA). Revision of recording and reporting tools was finalized and tools were integrated in the DHIS2. TABLE 41: PERFORMANCE ON TB OUTCOME AND OUTPUT INDICATORS Indicator HSSIP Baseline 2010/ / / / /15 TB CNR 10 increased /15 target TB CDR increased TB CR increased CNR Case Notification Rate; CR Cure Rate; TSR Treatment Success Rate; DOT Directly Observed Therapy; TSR Drug Sensitivity Test; DTU Diagnostic and Treatment Units; CPT Co-trimoxazole Preventive Therapy; ART Anti-retro Viral Therapy. 70

95 Indicator HSSIP Baseline 2010/ / / / / /15 target TB TSR TB death rate of TB cases on DOT of smear positive relapses done DST false negative tests DTUs reduced of TB patients tested for HIV TB/HIV patients started on CPT TB/HIV patients started on ART No. DR-TB patients enrolled on treatment < Performance on most programmatic indicators (CR, TSR, DOT, testing for HIV, TB/HIV on CPT, TB/HIV on ART and MDR-TB enrolment on treatment) improved greatly from HSSIP baseline values. The Programme surpassed HSSIP 2014/15 target for TB/HIV patients started on ART, and was close to achieving targets for of TB patients tested for HIV and of TB/HIV patients started on CPT. The Programmes was not able to achieve targets for indicators related to treatment success and cure rates, perhaps as a results of low adherence to treatment as evidenced by low achievement on DOT. Consequently, TB death rate increased over the HSSIP period. Moreover, CNR, CDR, DST and reduction of false negative tests declined over the period. The achievement relates to inadequate systems for TB case detection, adherence monitoring and testing relapses for drug sensitivity, as well as enrolment of MDR-TB patients on second line treatment 11. Community link services for tracing contacts with TB patients and patients support for adherence are functioning less than optimal due to lack of sustainable funding. This also affects follow-up of MDR-TB patients for enrolment into care and treatment. Major challenges Unknown burden of TB in the population: this affects accurate setting of targets for coverage and treatment outcomes. 11 Report of Joint External Review of National TB Programme in the Republic of Uganda,

96 Inadequate resources allocated for implementation of supportive activities for TB/leprosy control: for over half the HSSIP period, implementation of supportive activities that enhance programme performance was very limited due to severely reduced funding. Building capacity for nationwide rollout of programmatic management of MDR-TB: inadequate funding for supportive activities during the review period stagnated roll-out and setting systems for MDR-TB management. Sustaining awareness about the detection of leprosy among health workers and communities, and active search through screening of contacts with index cases in the households and community are the mainstay method for early detection, prevention of disability and further infection spread by isolation of cases. The long insidious onset of symptoms makes early detection and prevention of disability due to leprosy difficult. As a result, patients and health workers recognised leprosy late, when the disease has progressed to irreversible disability. Malaria Main achievements - Indoor Residual Spraying (IRS): IRS has now been shifted to 14 new districts in the Lango and East central districts - Launch of the larviciding project activities and community sensitization. - Conducted a Malaria Indicator Survey (UMIS). The 2014 showed impressive results/achievement in malaria control in Uganda. The national prevalence of malaria has dropped from 42 to 19 since Received funding from the GF NFM of 121 M USD for the period following a successful Concept Note application process. Implementation of activities on-going - Completed a Malaria Operational Planning exercise for FY 2016 funding by USAID/PMI. Developed a M&E Monitoring Plan for the UMRSP - With support from DFID developed a USD 12.4 M Capacity Development Plan for the NMCP that aligns with the UMRSP Produced four quarterly malaria bulletins highlighting important interventions coverage and routine and surveillance data trends - Integrated support supervision was done in selected health facilities in all the districts of the country. - Cross cutting supporting interventions including advocacy, social mobilization and behavioural change communication, monitoring and evaluation, drug efficacy studies and drug resistance monitoring were conducted. 72

97 FIGURE 17: NATIONAL MALARIA PREVALENCE FIGURE 18: TRENDS IN ITN OWNERSHIP AND USE Laboratories - Critical laboratory equipment were installed and made operational at the EAPHL 5 project sites (Mulago, Mbale, Arua, Mbarara and Lacor Hospital. - In line with the Stepwise Laboratory Improvement Process Towards Accreditation, one round of independent laboratory assessment was conducted in November 2014 and laboratory audit was carried out by the African Society for Laboratory Medicine in January Health workers have been trained on a number of topical areas. One hundred (100) health workers were trained in laboratory information management system and 35 in internal audit. - Plans to conduct operational research on Malaria, TB and Enterics were initiated. Research teams were trained, sites prepared for data collection and data collection was expected to start in August Money for the activity was disbursed to the Principal Investigators. 73

98 - Laboratory mentorship was conducted at the 5 satellite sites. This was done in each of the 4 quarters by the 6 project laboratory mentors. - Critical laboratory equipments were procured and installed at the satellite laboratories; and are now functional. - Developed Laboratory Information Management System - Cloud based video conferencing equipment procured and installed at Mbale, Mbarara, Lacor and Arua Hospitals. Endemic and epidemic disease control services - No cross border outbreak occurred. 2 cross border meetings held in Kenya and Uganda. VHF table tops simulation of all EAC countries including Democratic Republic of Congo health workers from Bugiri district trained in IDSR. - Study sites prepared and Arua to start operational research on Malaria, TB and Enterics in Sept Nursing Department Achievements - Conducted, 8 technical Support supervision visits to 2 NRH, 4 RRHs, 14 GHs and 5 HC Vs. - Carried out one integrated support supervision in Kotido and Kaabong districts supported by UNFPA. - Two QI mentorships conducted in Mubende and Kabale RRH. - Nurses and midwives addressed on issues of absenteeism, attitude and discipline and nurses and midwives scheme of service. - Consultative meeting for nursing policy held. - With support from AMREF, the department trained 10 midwives in Leadership, management and Governance; trained 12 health facilities in the concept of 5S. - Celebrated nurses International Day, Midwives International Day and International Women s Day - Held 3 nurse leaders meetings at wellness center in Mulago complex - Reviewed midwives curriculum 74

99 3.1.6 Semi-Autonomous Institutions Uganda Virus Research Institute (UVRI) During the financial 2014/15, UVRI; - Provided 4,014 sites with DTS PT, sprayed 9 villages in Arua, Nebbi and Zombo which reported plague cases and/or with rats, - carried support supervision and monitoring in the 4 UVRI field stations, - completed phase 2 of the national HIV testing algorithms. - extended the repository and stores in preparation for HIA, an inverter house, renovated the Rockefeller building, constructed a training center with WT funds, - Provision HBV diagnostics, - research on-going (Rota virus, HIVDR, AFP due to NPEV, Zoonoses among others), - more equipment for Influenza installed & commissioned. Uganda Cancer Institute (UCI) In FY 2014/2015 UCI; - Conducted 3,600 against the targeted 3,990 new patient admissions, 50 Oncology surgical, 44 major surgical operations and 120 minor surgical operations were performed. - 17,029 Chemotherapy reconstitutions were provided and 602 bone marrow aspirates and biopsies safely performed. - Through static cancer clinics and outreaches, a total of 7,181 persons were screened for cancer; with 2,980 screened for breast cancer, 1,975 for cervical cancer, 573 prostate cancer, 336 for other cancers including hepatitis B and other chronic illnesses while 337 were referred for further care Visiting Nursing officers, 35 Students involved in screening were enrolled for training in cancer screening. - Carried out 225,000 Education messages and awareness campaigns which included radio announcements and TV programs. - Primary designs of the radiotherapy Bunker that will house all imaging equipment necessary for cancer imaging services, were completed and the final process for development of the designs is almost complete. - The new six level cancer ward has been completed and is being equipped so as to reduce the current level of congestion at the Institute. - The UCI Bill is being developed through supporting benchmarking studies with similar or related outputs. 75

100 Challenges Inadequate stocks of essential medicines and anti cancer drugs. Inadequate supply of key specialized sundries like bone marrow needles. The lengthy procurement process delayed the final signing of contracts and delivery of the various equipment(s) that were procured. Uganda Heart Institute (UHI) Key achievements of UHI were as follows; - Conducted 90 (ninety) open heart surgeries out of the planned 100, the variation was as a result of delayed procurement process of specialized equipment which was delivered towards the end of the FY. - Performed 240 closed heart surgeries performed out of the planned 250, the variance was as a result of delay in recruitment of critical staff delayed thus gross understaffing during the first three quarters. Secondly, the delayed procurement process of specialized equipment that was delivered towards the end of the financial year contributed also to the lowered performance target. - Performed 9,450 ECHO s out of the planned 12,000 Echocardiography due to similar reasons mentioned above. - Conducted 261 cath-lab procedures as compared to the planned 400 procedures. - Out of the targeted 260 stress tests, 246 stress tests were performed, 87 out of the planned 100 pacemakers were performed, and 134 out of the planned 200 Holter monitoring were conducted. - A total of 17,109 (136.8 of the target) outpatients were seen, this was over and above the planned number for the period. That was as a result of high patient demand. Similarly, 1,663 (166.3) patients were admitted above the planned. - Facilitated expatriates for short term transfer of skills to local cardiologists and surgeons for heart surgeries. Cath-lab and surgical staff were trained in cardiology and cardiothoracic surgery. - Carried out support supervision to the 14 RRHs and to 120 specialized groups. Challenges Delays in procurement of the necessary equipment, most of which were only received towards the end of the FY. Delay in the recruitment process of the necessary staff by the Health Service Commission led to failure to fully operationalize the equipment and available resources. 76

101 Uganda Blood Transfusion Services (UBTS) Key achievements for UBTS during 2014/15 FY were; - 235,407 units of blood were collected against a target of 254,100 (92.6) and voluntary blood donation still stands at Arua and Masaka received Architect machines for testing blood. - Improved supply of quality blood products through testing all blood for TTIs and continued to operate an effective nationwide Quality Assurance program that ensures safety of the entire Blood transfusion process from vein to vein. - UBTS is working towards Africa Society of Blood Transfusion (AfSBT) Accreditation. - Blood distribution centers in Hoima, Masaka, Kabale, Rukungiri, Jinja and Soroti were established. - Expanded blood collection capacity to operate adequately within a decentralized health care delivery system; 20 mobile blood collection teams are in place plus 2 new teams created in Lira and Angal to make it 22 blood collection teams. - Introduced the Community Resource Persons program for mobilization of communities to donate more blood rather than relying on schools as our major source of blood. FIGURE 19: BLOOD COLLECTION FOR FY 2004/05 TO 2014/2015 According the information above which was captured from the blood and blood utilization survey, most of the blood goes for maternal and child health conditions (60) which includes anemia, surgery, hemorrhage, PPH followed by internal medicine and surgery (36) which includes malaria, cancer, HIV and anemia. According to the graph, UBTS is able to supply about 68 of the total blood requests by all health facilities in the country by type (2012/13 FY). 77

102 The main challenge faced by UBTS is the increase in demand for safe blood transfusion due to the improved health care delivery system in Uganda especially for Heart Surgery, Cancer treatment, HIV/AIDS related illnesses. Thus UBTS has an important task of meeting this increased demand which require additional resources. Uganda National Health Research Organization (UNHRO) Key Achievements 2014/15 - Policy, consultation, planning and monitoring services done; 2 out of 4 Board meetings held. Held stakeholder consultations on preparatory initiatives by IAVI to develop a vaccine in Uganda. - UVRI Strategic Plan finalised, the second draft UCI Strategic Plan 2014/17 developed. - Developed priorities on research agenda in collaboration with the CDC and Makerere School of Public Health. The second revised draft was discussed by a stakeholder seminar held May Revised Ethical standards for research involving human beings finalized and launched July 2014 at 6 th ANREC; organized and prepared the 7 th Annual National Research Conference on Ethics. - Developed data base/inventories for on-going research in country: Collected, collated and analysed technical, location and expertise in on-going health research. - Information sharing and Knowledge translation of findings into policy done: 127 scientific manuscripts were prepared and cleared for publication in international journals; a national workshop to discuss better HIV laboratory services and improved delivery was held in March DG/UNHRO published titled Managing Ebola from rural to urban slum settings: experiences from Uganda in March 2015; The book was launched by HE President Museveni on May 1, 2015 during the Labour Day celebrations in Kisoro; Malaria- discussed with stakeholders the effectiveness of mass drug treatment for the control of malaria; Reproductive Health 2 workshops held to discuss the three options from research systematic reviews that could improve RH indicators. The three options were: i) strengthening services at HC III ii) extending delivery to HC II and III) application of ambulatory facilities and accommodation pre delivery. - Three grants proposals (Malaria, HIV/TB, Ebola were developed and submitted to EDCTP and WHO for funding; Memorandum of understanding between UNHRO / Busitema University being developed. National Medical Stores - Continued with the Procurement and Distribution of Vaccines. 78

103 - Procured and distributed hospital mattresses to all GHs and HC IVs. - NMS finalised the acquisition of 10 acres of land at Kajjansi. This land is intended for immediate expansion of NMS by building a new state of art Warehouse and Administration block. The Construction is due to begin in FY 2015/ NMS pioneered and experimented the therapy for treatment of Jiggers. This was tested and found effective. It is awaiting the roll out by the MoH. - Two more Customer Care Regional Offices were opened and adequately equipped with Human Resources and other tools of operations, in Arua and Moroto. This brought the number of Customer Care Regional Offices to Nine, which has brought NMS much closer to its clients. - As part of Corporate Social Responsibility (CSR), NMS finalised the Procurement of an Oxygen Plan for Mbarara RRH. Installation is expected to be completed by October National Chemotherapeutics Research Institute - Laboratory evaluation of medicinal plants materials collected is ongoing. (Mitiyana analyses completed). Follow up of patients and review of patient records to be done (Emmanuel and Mitiyana sample) THPs, VHTs and Community leaders trained on Herbal medicine manufacture and value addition in line with the NDA guide lines for regulation and sale of herbal medicines; 100 THPs, VHTs and traders in Herbal medicines in Wakiso and Kampala districts trained on herbal medicines regulation and standardization THPs trained on conservation of medicinal plants; 23 endangered medicinal plants documented, and collected for laboratory evaluation and herbarium specimen collection; 8 medicinal plants were scientifically identified. - Baseline assessment of nutritional needs conducted in Wakiso and Jinja districts. - Baseline survey conducted in Kampala on 20 herbal drug outlets and information disseminated to researchers Regulatory Bodies National Drug Authority (NDA) - Dossier evaluation conducted and approved 196 Human & 30 veterinary drugs for registration - Inspection and Licensing of pharmacies and drug shops was done; 943 pharmacies were inspected of which 938 pharmacies were approve and done; all previously licensed drug shops was were inspected of which 7,534 (75) drug shops were licensed. 79

104 - Inspected facilities for Good Pharmacy Practices (GPP); 1,002 (100) outlets were inspected, out of which 486 were certified. - Post Marketing Surveillance and Support Supervision activities conducted; 3,613 drug outlets and clinics were inspected countrywide, 935 outlets were closed for various reason, including clinics displaying medicines, illegal operations, and unsuitable premises. - Conducted 100 cgmp inspection of foreign pharmaceutical manufacturing sites; 102 foreign facilities were inspected, 81 reports were presented, 21 reports pending presentation, and 27 complied through document review assessment. - Conducted GMP inspection of local private manufacturing facilities; 14 local facilities were inspected; 08 facilities were licensed. - Processed verification certificates for drug imports and exports; 7816 Verification certificates were issued, of which Imports for unregistered drugs=884, Provisional import permits=579, Exports=251 Narcotic/psychotropic substances Permits=81 Queried= Inspection of drugs at ports of entry done; 4,659 consignments inspected of which: - Released: 4,548 Rejected: 5 Queried: Testing of samples (drugs, condoms and medical gloves); Tested 188 drug samples of which 177 passed the tests done and 11 failed tests were done. Tested 360 condom samples; 328 passed and 32 batches failed. Tested 146 glove samples of which 134 Passed and 12 batches Failed, Tested 74 LLINs and all passed. - Sensitized health workers on drug regulation, ADR monitoring & reporting. In total, 1061 health workers were sensitized in various parts of the country. 165 health workers from private drug outlets were sensitized. - Management of ADR reports done; 471 reports received of which 167 were entered into Vigiflow. - Established and maintained a database for promotional materials. Received at least 80 promotional materials, vetted and entered in the database; 144 applications were approved, 4 applications were rejected. - Evaluated Protocols for clinical trials. Received - 32 applications, Approved 27 applications & Rejected expert reviewers co-opted to review BCG Trial. Conducted site visits to JCRC Kampala, Fort portal, Mbarara, MRC sites in Masaka and Kyamulibwa, IDRC Tororo and Mbale Hospital. - NDA/National Food and Drug Administration transformation process fast tracked. Presented to Cabinet & obtained approval of additional Principles for the proposed NFMA Bill. Challenges - Gaps in the NDP&A Act - Inadequate office space and storage facilities have remained a challenge especially in light of proposed staff increases. 80

105 - Staffing and motivation of the regional pharmacovigilance centre coordinators remains a challenge. The coordinators are MoH employees and are routinely transferred causing a high turnover and need for more support supervision and orientation. - Increasing litigation against NDA by stakeholders. Uganda Medical and Dental Practitioners Council (UNMDPC) The following were the achievements of the UMDPC; - Assessed 36 foreign trained doctors for using theory and clinical exams and 13 foreign, trained specialist Doctors (Peer Review) for purpose of registration - Conduct 5 field operations for investigations and 3 cases are I court while 2 are at police - Developed one tool on standards for HU inspections and was applied pretested in 16 districts - In collaboration with other Professional Councils we supported the formation and operations of 8 District Health authorities in Karamoja while 8 were supported in Teso region. - Printed and distributed 4,690, copies of literature on what constitutes professional misconduct and the subsequent punishments. - Produced 6,632 copies of the Act and 4,690 copies of guidelines on complaints. - Two Regional ethical sensitization meeting; Conducted university ethical sensitization. - Supervised and inspected 280 out of the 400 targeted health facilities in Kampala and 370 out of planned 900 health facilities upcountry. - Hosted 22 against 30 cases on medical inquiries. - Carried out Community sensitization 4 TV shows and 12 Radio Talk shows. Pharmacy Council - Enforcement of adherence to professional standards and ethics in Jinja, Bugiri, Iganga, Mbale and Soroti. - Registered of 78 newly qualified Pharmacists. - Practice standards enforced in 12 districts. - One quality assurance visit to Pharmacy Schools and Internship Centers. Allied Professionals Council Achievements of Allied Professional Council over the reporting period are: - Nine Health training institutions were inspected. - The registrar s office carried out support supervision to four (4) regional offices (Mbale, Jinja, Masaka (Entebbe, Wakiso, Buikwe) and Soroti) to evaluate their functionality and to sensitize professionals/ and employers on council mandate. - Quality Assurance officer supported inspection of Medical laboratories in Serere, Kampala, Gulu, Arua, Kabale, Lira, Kabarole and Hoima. 81

106 - Registered and Renewed 1,221 units against the 1,500 Allied health units planned annual output target. - Renewed Annual Practicing Licenses of 12,025 professionals more than the 10,000 annual planned output target. - Registered 3,035 professionals compared to 2,791 annual planned output target. - Registered 357 Labs against the 951 annual planned output target. - Inspected 2,669 health facilities countrywide compared 1,365 annual planned output target. - Conducted and concluded 10 disciplinary investigations for negligence, misconduct or malpractice and 5 cases are ongoing. - Supported professional Career development in 17 professional Associations compared to 20 professional associations Annual planned output target. - An up-to-date register of allied health professionals was gazetted and 200 copies distributed to relevant stakeholders. - Supervisory authorities at all Regional and National Referral Hospitals were appointed and oriented. Uganda Nurses and Midwives Council Achievements during the period under review - 5,518 registered and enrolled of 5,472 registered on first attempt and 46 went through attachment. - Registration of Nurses/midwives trained outside Uganda were 43 applied but 35 registered and 8 are undergoing orientation. The applicant were from German, India, Serbia, Britain, Korea, Netherland, USA, Tanzania, Italy, Philippine, Pakistan, Canada & Japan. - Establishment and renewal of private maternity homes, domiciliary and clinics the total was 400 facilities of which 50 were new and 350 were renewals i.e. 386 midwives, 37 new and 349 renewals. - Establishment and renewal of private general clinics of 100 facilities i.e. 30 were new while 70 were renewal i.e. 93 nurses, 26 new,67 renewals. - Conducted Technical support in 2 regions: Central (Mukono, Buikwe, Nakaseke, ) and near East (Jinja, Kamuli and Iganga. Institutions visited: Mukono Diocese NTS, Mukono HC IV, Mukono COU Hospital, Lugazi NTS, Kawolo Hospital, Kiwoko hospital & Kiwoko NTS; Jinja NTS, Jinja Hospital,International Institute of Health Sciences, St. Joseph Hospital Kamuli, Buwenge HC IV. - Inspection of health units in Eastern Region Jinja, Iganga, Mbale and Soroti districts by the 4 health professional councils. - 8 schools were inspected to assess suitability to commence training for nurses and midwives at St. Johnas International School Buikwe; Mityana Institute NTS Mityana; St. 82

107 Joseph Hospital School of N&M Kitgum; Uganda Martys Institute, Luuka;, Access school of Nursing Nakaseka; NESDA Sch of Comprehensive Nursing Bugiri; Bweyale NTS Bweyale; Maracha NTS Maracha. (only 2 accredited). - Schools intending to start new N&M programmes 4 schools visited: Kamuli NTS, Nkumba University, Gulu University School of Nursing, Iganga School of Nursing, Ibanda NTS, Lacor school of Nursing, and Rakai Comp. school of Nursing (none accredited). - schools inspected provisionally licensed schools to ascertain sustainability for full registration: Lira Constituent College; Florence Nightingale; Kampala University; Kyetume school of Nursing; St. Johns NTS, Rwashamire; and Ntungamo Health Training Institute; Alice Anume NTS. - Establishment and operationalization of the DHSAs for improving the quality of health service provision 7 districts sensitized and 7 DHSAs established. - Conducted CPD in Moroto, Mbarara, Hoima, Fort Portal, Arua & Soroti RRHs, Princess Diana HCIV, Iriri HCIV and Matany Hospital. - 2 quarterly committee meetings held to review council performances. 02 Disciplinary hearings conducted and cases concluded. 46 DC cases were handled Way forward and recommendations To strengthen collaboration with key stakeholders Recruitment of staff to run the regional satellite centers Mobilize more resources to effectively carry out regulatory mandate 83

108 3.1.8 PNFP Sub-Sector Uganda Catholic Medical Bureau (UCMB) performance The UCMB is a health department of the Catholic Church in Uganda coordinates, represents, and supports 281 accredited health facilities and 13 heath training institutions. The health facilities comprise of 32 hospitals, 5 HC IVs, 169 HC IIIs, and 75 HC IIs. The total workforce in the UCMB network as at June 30 th 2015 was 8,566 as compared to 8,422 as at June 30 th 2014 reflecting a 1.7 increase in total staffing from last FY in the network health facilities. In the last 5 years there has been progressive increase in total staffing of health facilities in the UCMB network with remarkable increases for LLHFs. The increase is partly due to PEPFAR support for HRH in the PNFP health facilities. TABLE 42: UCMB FACILITY STAFFING Years 2010/ / / / /15 HOSPITALS 5,068 5,355 5,435 5,502 5,618 LLUs 2,522 2,688 2,790 2,920 2,948 Total 7,590 8,043 8,225 8,422 8,566 Source: UCMB Facility Annual Staffing Report Over the last years the MoH or District LGs have supported UCMB health facilities with health workers. In 2014/15, GoU seconded 9 of the qualified clinical health workers to UCMB health facilities. PEPFAR through the USAID/Strengthening Decentralization for Sustainability (SDS) and CDC/Mildmay HRH projects are implementing an HRH partnership project with UCMB in Uganda and they support 5 of the qualified clinical staffing (i.e. 230 health workers) of the entire UCMB network health workforce. The two projects are supporting 89 UCMB health facilities in 92 districts of Uganda with key cadres including Medical Officers, Medical Clinical Officers, Midwives, Nurses, Laboratory Personnel, Anesthetic Assistants, Anesthetic Officers, Pharmacy Assistants and Technicians. This has significantly contributed to health workforce stability, availability of qualified health personnel in hard-to-reach areas and improved staffing levels of mainly rural health facilities. The religious organisations contributed 12 of the clinical health workforce and 2 were expatriate clinicians. Overall, one in three (28) clinically qualified health workers in UCMB health facilities are supported from partners Government, Religious organisations and Donors while the bulk (72) are locally remunerated from internally generated resources. The labour turnover in UCMB health facilities and generally in the PNFP health sub-sector remains high though there has been stability in LLHFs and decreases in hospitals in the last 3 years. In FY 2014/15, average staff turnover in UCMB health facilities was 23--Medical 84

109 Officers and Nurses topping the departing HRH for hospitals and lower level facilities respectively. Specifically, in the year under review, HRH turnover in UCMB-affiliated hospitals was 15 while in LLHFs was 31. The major reasons for staff turnover in 2014/15 were better Remuneration jobs (25), Disciplinary/Contract termination (22) followed by recruitment by Government and further studies respectively. The outputs from the UCMB hospitals and Lower Levels depict the performance on the most important health indicators used for monitoring the HSSIP III performance for the FY 2014/2015. There are indicators of progressively increased contribution to national outputs. OPD services: New and Re-attendance for Outpatients increased slightly by 1 from 3,074,691 in FY 2013/14 to 3,103,926 in FY 2014/15. Maternity services: Total number of deliveries increased by 3 from 91,238 in FY 2013/14 to 94,356 in FY 2014/15. Child care: The number of immunizations increased by 3 from 1,969,794 in FY 2013/14 to 2,028,888 in in FY 2014/15. In-Patient services: Total number of Admissions in UCMB Facilities decreased by 3 from 449,934 in FY 2013/14 to 436,506 in FY 2014/15. In the a 10-year period, Total OPD attendances in UCMB Hospitals and LLHFs has increased from 1 million to 3 million contacts in a year, maternal deliveries have increased by 36.3, Total Immunisations have increased by 17.8 while Total Admissions have slightly decreased by 1.7 in the same period. The SUO in UCMB Hospitals has decreased by 5 in the last one year while for LLUs has decreased by 8. Over the last 5 years, the SUO has been either stagnant or decreasing. This is due to various factors including general improvements in health service delivery in the country particularly public health facilities. TABLE 43: FAMILY PLANNING SERVICES IN UCMB HEALTH FACILITIES UCMB Hospitals 2010/ / / / /15 Natural Family Planning Contacts 3,250 7,390 5,806 5,684 9,315 UCMB Lower Level Health Units 2010/ / / / /15 Natural Family Planning Contacts 23,648 14,966 12,979 1,659 12,700 Family Planning service delivery in the UCMB Hospitals has increased in the last 5 years while there has been a decline in the Lower Level Health facilities. The factors for reduction in the contacts for Natural Family Planning services in LLUs is mainly due to HRH capacity technical & skill, as well as limitations in reporting of these activities in the HMIS. 85

110 FIGURE 20: NATURAL FAMILY PLANNING CONTACTS IN UCMB HOSPITALS IN 5 YEARS The significant (64) increase in Natural Family Planning contacts in the Hospitals in the year under review is attributable to the 18-month Natural Plan Project run by CRS/UCMB with support from Georgetown University, USA in 3 Hospitals that was aimed at increasing availability, and accessibility of Natural Methods of Family Planning which included Capacity building, Demand creation and a community involvement approach to service delivery. NFP uptake increased significantly during project period. TABLE 44: UCMB FACILITIES PERFORMANCE IN KEY HIV INDICATORS IN FY 2014/15 Category HCT Number of individuals counseled and tested for HIV and given their results at UCMB facilities during the year. HIV/ART Number of new patients enrolled in HIV care at UCMB facilities during the year. Cumulative Number of individuals on ART ever enrolled in HIV care at UCMB facilities this year. Number of HIV positive patients active on pre-art Care at UCMB facilities. Number of HIV positive cases who received CPT at last visit in the year at UCMB facilities. Number of new patients started on ART at UCMB facilities during the year. Total Number of individuals CURRENT on ART in UCMB facilities. TOTAL NUMBER OF HIV INDIVIDUALS CURRENT IN HIV CHRONIC CARE. Children <15 Years 15 Years and above Total 53, , ,415 1,088 15,315 16,403 6,061 72,530 78, ,016 10,728 5,756 75,868 81,624 1,663 15,304 16,967 5,757 74,715 80,472 6,469 84,731 91,200 The number of persons who underwent HIV counseling, testing and receipt of results in UCMB health facilities in 2014/15 was 668,415 an increase by 27.4 from 2013/14. The improvement was mainly due to increased accessibility to HCT services by children (15 years and below) 86

111 who increased by 40 in one year. In FY 2014/15, 16,967 new patients were initiated on ART in UCMB health facilities, an increase from 2013/14 by The total number of HIV individuals currently in HIV Chronic Care in UCMB health facilities has reduced in the last one year by 42.4 (due to revisions of guidance on initiation based on CD4 count) and a decrease of individuals currently on ART by 14.7 in the same period mainly due to improvement in ART services through accreditation of most HCIII of the public health sector which resulted into more transfer outs, hence the reduction observed. There was an 83 reduction in the number of HIV positive patients active on pre-art Care in UCMB health facilities during the FY 2014/2015 and this was due to the roll out of new HIV clinical guidelines with cut off CD4 increased to 500 from 350 CD4 and it resulted into more enrollment on ART hence reducing the pre-art patient pool. The AIDS Care and Treatment (ACT) Project, is a USG-funded project implemented by the Registered Trustees of the Uganda Episcopal Conference (UEC) through the Uganda Catholic Medical Bureau (UCMB). The project provides comprehensive HIV/AIDS Prevention, Care, and Treatment Services, and strengthens existing health systems in 19 UCMB facilities (Lacor, Aber, Kalongo, St. Joseph's Kitgum, Angal, Nyenga, St. Anthony Tororo, Naggalama, Nsambya, Kisubi, Lubaga, Virika, Bishop Asili, Villa Maria, Comboni Kyamuhunga, Kitovu, Nkozi, Kasanga PHC III and Kamwokya Christian Caring Community). The project health facilities together with satellite health facilities collectively serve a catchment area spanning more than 30 districts, with rural, hard to reach, poor and disadvantaged clients. A total of 160,019 patients were counseled, tested and received HIV test results in FY 2014/15 accounting for 24 of the entire UCMB health facility network for HCT services, 9,648 (6) patients were identified as positive and 6,148 (64) of the HIV positive patients were linked in care. There was an increase by 4 of persons accessing HIV counseling and testing services at the project sites in the last 1 year. Health Financing in the UCMB Network: FY 2014/15 The financial contribution from UCMB health facilities amounted to billion shillings in the FY 2014/2015 a 0.5 increase from last FY. The increase in total income was attributed mainly to a 12 increase in User fees collections. GoU subsidies including the PHC conditional grant to UCMB facilities and the MOH- DP Bursary funds for UCMB Health Training Institutions increased to UGX Billion in FY 2014/15 from UGX.12.9 Billion in FY 2013/14 a 7 increase in Government subsidies in the FY 2014/15. This accounted for 11 of the income for UCMB Health Facilities in the FY. In the same period Donor funding reduced by 13. User fees 87

112 Annual Health Sector Performance Report for Financial Year 2014/15 account for 51 of the Total Income for recurrent operations for UCMB health facilities in FY 2014/15 and Donations accounted for 38. TABLE 45: 5-YEAR TREND OF UCMB HEALTH FACILITIES AVERAGE COST/SUO AND AVERAGE USER FEES/SUO UCMB Hospitals 2010/ / / / /15 Average Cost per SUO 10,254 12,298 14,432 17,544 22,361 Average User Fees per SUO 3,636 5,123 6,169 6,854 10,764 UCMB LLUs 2010/ / / / /15 Average Cost per SUO 2,412 3,224 3,399 3,357 7,280 Average User Fees per SUO 4,653 5,992 5,567 6,308 4,411 User fee collections in Hospitals account for 40 of the recurrent expenditure while in LLHFs support from GoU subsidies PHC-CG contribute significantly to recurrent expenditure which partly explains the decrease in user fee/suo while the cost/suo is high. UCMB LLHFs have been gradually reducing nominal user fee charges through flat-rate user fee charging in some facilities; the level of budget support from government always influences this effort. The external donation both in kind and in cash for recurrent operations slightly decreased in absolute and relative terms of contributions to the UCMB budget by 2 and 3 respectively. TABLE 46: TRENDS IN INCOME FOR RECURRENT COST IN UCMB NETWORK (HOSPITALS + LLHFS) 150,000,000,000 Trends in Income for Recurrent Operations in UCMB Facilities 130,000,000, ,000,000, ,000,000,000 70,000,000,000 50,000,000,000 30,000,000,000 10,000,000,000 (10,000,000,000) Aid User Fees Govt. Subsidies (money and drugs) Source: Bureaux databases 88

113 In FY 2014/15, the Total Expenditure for UCMB health facilities (Hospitals & LLUs) was UGX. 138 Billion-- an increase by 2.7 from the year 2013/14. UCMB health facilities spent UGX Billion on Medicines & Supplies, an increase by 11.7 from FY 2013/14. Hospitals account for majority (82.9) of this expenditure. A third (34.7) of the Medicines & Supplies procurements were from Joint Medical Store (JMS) which offers affordable financing terms including 3-month credit facilities and last-mile distribution to ensure ready availability of medicines & supplies to health facilities. UCMB Health Facility procurements from JMS have increased by in the last one year to UGX.12.9 Billion in FY 2014/15, and efforts are underway to further improve JMS procurements Uganda Protestant Medical Bureau (UPMB) performance during the FY 2014/15 UPMB is one of the three religious medical bureau networks in Uganda. The bureau is the health technical arm of the Church of Uganda (CoU) and the Seventh Day Adventist Church (SDA). By the end of the FY 2014/15, the Bureau had a network of 283 health units scattered across Uganda Figure 21: Staffing in UPMB hospitals, HC IVs and LLUs UPMB is committed to ensuring that member health facilities meet the recommended staffing numbers across all levels of care. A total of 88 health workers were recruited with support from the Strengthening Decentralization for Sustainability HRH Project and MildMay Uganda to address the challenge (72 and 11 HWs recruited by SDS and MildMay respectively). The staff are distributed across 38 health facilities across the network (31 SDS and 7 Mild May). There is however a sustainability gap anticipated as the Projects support winds up in Dec 2015 and March 2016 respectively. Over the previous three FYs, statistics show an increasing trend in the number of clients seeking outpatient services in UPMB hospitals and HC IVs. The FY registered close to 20 increase in outpatient contacts. Other indicators showing an increasing trend include Antenatal care and Family planning services as well as hospital bed capacities. Immunization and deliveries across UPMB hospitals and HC IVs continued to show a downward. 89

114 In-patient summary statistics UPMB Hospitals and HC IVs In-patient episodes continued to show a decreasing trend the total number of clients admitted during the FY fell by 9.5 compared to admission in the FY 2013/14. The ALOS approximately remained at 4 days. The BOR slightly reduced from 35.5 in 2013/14 to 33.4 in 2014/15. FY Total bed capacity OPD attendance Admissions Deliveries ANC and FP Immunization , , ,838 27, , , , , ,179 34, , , , , ,282 32, , , ,755 55,099 44,203 84, ,770 FIGURE 22: STANDARD UNIT OF OUTPUT IN UPMB HOSPITALS The indicator Staff productivity (Staff SUO) is obtained by computing the SUO for each facility and dividing it by the total number of staff available for the period under review implying the staff SUO has a direct relationship with the hospital SUO and an inverse relationship with the total number of staff at the facility. Figure 27 shows the total SUO for UPMB hospitals for the FY to FY The primary vertical axis represents the SUO for the four FYs while the secondary vertical axis represents the staff SUO. UPMB hospitals registered a decline in the total SUO and staff productivity during the FY. Pictorial for infrastructure support to some member health facilities in Busoga Diocese Bunyiro HC II Before After 90

115 UGANDA MUSLIM MEDICAL BUREAU The Bureau coordinates the activities of all member health facilities and is the main link between these facilities (Muslim-Founded PNFPs), the government and other stakeholders. Currently the bureau membership consists of 5 hospitals, 2 HC IVs, 24 HC IIIs and 23 HC IIs and totaling to 54 PNFP facilities. The main achievements in the reporting period are summarized in the table below showing key indicators. TABLE 47: KEY OUTPUTS FOR THE UMMB FACILITIES Output No of patients Total OPD attendance 275,868 Total ANC 21,916 ANC 1st Visits 10,304 Total Admissions 31,161 Mothers Tested 10,304 Option B+ mothers tested positive 369 Total HCT 72,248 Deliveries 5,629 HIV+ Deliveries 245 Tested HCT clients tested positive to HIV 2,363 Total HIV/AIDs Pre ART 3,869 Total ART 3,303 Total Immunization: children immunised 153,129 Total Malaria Tests 124,966 Total number of clients received FP 30,924 Deductions ANC services; 47 of total ANC are first visits, 100 of ANC first visits were tested for HIV of which 3 were HIV+ on first ANC visit. All the 3 (100) were initiated on option B+ and in chronic HIV/AIDs care and management at the respective facilities. Maternity: 4 of total deliveries were positive. This service is particularly still under performing due to lack of equipment especially in the lower level facilities. HIV/AIDs management: a total of 72,248 were counseled and tested for HIV of which 2,363 were positive representing 4 prevalence rate far below the national rate of

116 A total of 3,869 clients were in care for all network facilities by end of June The total number of ART clients is 3,303 among network facilities. Training of staff was conducted in the network facilities. In partnership with different organizations we carried out the trainings as shown in the table below. TABLE 48: STAFF TRAINING IN UMMB FACILITIES Topic Organising Institution Number of Participants Health Management Information System (HMIS) TASO UGANDA 21 District Information system II (DHIS 2) TASO UGANDA 10 Elimination of Mother To Child HIV Transmission UMMB / MILDMAY 32 Integrated Human Resources Information system (I-HRIS) Intrahealth 31 Founder bodies and HUMC leadership workshop UMMB / MILDMAY 42 Total Trained (July 14 /June15)

117 District (112 Districts) Total Population (UBOS Aug 2014) Monthly reports sent on time (3) Completeness monthly reports (2) Completeness facility reporting (3) Completeness of the annual report (2) Total DPT3 Coverage Deliveries in govt and PNFP facilities OPD Per Capita HIV testing in children born to HIV positive women Latrine coverage in households IPT2 ANC4 TB success rate Approved posts that are filled HMIS reporting completeness and timeliness Medicine orders submitted timely Annual Health Sector Performance Report for Financial Year 2014/15 4 Annex TABLE 49: DLT RANKING FOR THE 112 DISTRICTS 2014/15 FY Coverage and quality of care (75) Management (25) GULU KAMPALA KABAROLE JINJA RUKUNGIRI BUTAMBALA LIRA LAMWO MITYANA LYANTONDE SERERE MBALE BUSHENYI MASAKA LUWERO AGAGO SOROTI NEBBI KATAKWI HOIMA KABERAMAIDO OYAM DOKOLO MUKONO NWOYA NATIONAL AVERAGE KUMI KITGUM KIBOGA

118 District (112 Districts) Total Population (UBOS Aug 2014) Monthly reports sent on time (3) Completeness monthly reports (2) Completeness facility reporting (3) Completeness of the annual report (2) Total DPT3 Coverage Deliveries in govt and PNFP facilities OPD Per Capita HIV testing in children born to HIV positive women Latrine coverage in households IPT2 ANC4 TB success rate Approved posts that are filled HMIS reporting completeness and timeliness Medicine orders submitted timely Annual Health Sector Performance Report for Financial Year 2014/15 Coverage and quality of care (75) Management (25) ISINGIRO IGANGA KANUNGU AMOLATAR MPIGI TORORO KYENJOJO KAMWENGE NAKASEKE KIRUHURA RAKAI OTUKE KABALE KYEGEGWA AMURIA APAC KAMULI MBARARA KAYUNGA BUIKWE KOBOKO NGORA KALUNGU BUNDIBUGYO ARUA SHEEMA NTUNGAMO NAMUTUMBA AMURU MUBENDE BUSIA MASINDI KIBAALE KALANGALA NAKASONGOLA KISORO

119 District (112 Districts) Total Population (UBOS Aug 2014) Monthly reports sent on time (3) Completeness monthly reports (2) Completeness facility reporting (3) Completeness of the annual report (2) Total DPT3 Coverage Deliveries in govt and PNFP facilities OPD Per Capita HIV testing in children born to HIV positive women Latrine coverage in households IPT2 ANC4 TB success rate Approved posts that are filled HMIS reporting completeness and timeliness Medicine orders submitted timely Annual Health Sector Performance Report for Financial Year 2014/15 Coverage and quality of care (75) Management (25) KASESE ABIM BUGIRI KIRYANDONGO BUKOMANSIMBI PADER PALLISA BUDAKA ADJUMANI SIRONKO IBANDA NAMAYINGO ALEBTONG BUKEDEA LWENGO KAPCHORWA BULIISA GOMBA MITOOMA BUDUDA RUBIRIZI NTOROKO ZOMBO BUKWO BUTALEJA MARACHA LUUKA NAPAK KOLE MOYO KYANKWANZI KALIRO MAYUGE MANAFWA WAKISO KIBUKU

120 District (112 Districts) Total Population (UBOS Aug 2014) Monthly reports sent on time (3) Completeness monthly reports (2) Completeness facility reporting (3) Completeness of the annual report (2) Total DPT3 Coverage Deliveries in govt and PNFP facilities OPD Per Capita HIV testing in children born to HIV positive women Latrine coverage in households IPT2 ANC4 TB success rate Approved posts that are filled HMIS reporting completeness and timeliness Medicine orders submitted timely Annual Health Sector Performance Report for Financial Year 2014/15 Coverage and quality of care (75) Management (25) YUMBE SEMBABULE BUYENDE KWEEN KAABONG BUHWEJU MOROTO NAKAPIRIPIRIT KOTIDO BUVUMA BULAMBULI AMUDAT

121 District Total Population (UBOS Aug 2014) Monthly reports sent on time (3) Completeness monthly reports (2) Completeness facility reporting (3) Completeness of the annual report (2) DPT3 Coverage Deliveries in govt and PNFP facilities OPD Per Capita HIV testing in children born to HIV positive women Latrine coverage in households IPT2 ANC4 TB success rate Approved posts that are filled HMIS reporting completeness and timeliness Medicine orders submitted timely Total Rank Annual Health Sector Performance Report for Financial Year 2014/15 TABLE 50: DLT RANKING FOR THE 14 DISTRICTS 2014/15 FY WITH REFERRAL HOSPITALS Coverage and quality of care (75) Management (25) GULU 443, KAMPALA 1,516, KABAROLE 474, JINJA 468, LIRA 410, MBALE 492, MASAKA 296, SOROTI 252, HOIMA 573, KABALE 534, MBARARA 474, ARUA 785, MUBENDE 688, MOROTO 104, Average 7,516, NATIONAL 34,844,

122 Total Population (UBOS Aug 2014) Monthly reports sent on time (3) Completeness monthly reports (2) Completeness facility reporting (3) Completeness of the annual report (2) Total DPT3 Coverage Deliveries in govt and PNFP facilities OPD Per Capita HIV testing in children born to HIV+ women Latrine coverage IPT2 ANC4 TB success rate Approved posts that are filled HMIS reporting completeness and timeliness Medicine orders submitted timely Annual Health Sector Performance Report for Financial Year 2014/15 TABLE 51: RANKING OF THE 31 NEW DISTRICTS 2014/15 FY Coverage and quality of care (75) Management (25) District BUTAMBALA LAMWO SERERE AGAGO NWOYA NATIONAL OTUKE KYEGEGWA BUIKWE NGORA KALUNGU SHEEMA KIRYANDONGO

123 Total Population (UBOS Aug 2014) Monthly reports sent on time (3) Completeness monthly reports (2) Completeness facility reporting (3) Completeness of the annual report (2) Total DPT3 Coverage Deliveries in govt and PNFP facilities OPD Per Capita HIV testing in children born to HIV+ women Latrine coverage IPT2 ANC4 TB success rate Approved posts that are filled HMIS reporting completeness and timeliness Medicine orders submitted timely Annual Health Sector Performance Report for Financial Year 2014/15 Coverage and quality of care (75) Management (25) District BUKOMANSIMBI NAMAYINGO LWENGO GOMBA MITOOMA RUBIRIZI NTOROKO ZOMBO LUUKA NAPAK KOLE KYANKWANZI KIBUKU BUYENDE KWEEN BUHWEJU

124 h d i s tr i c t s Total ) Popul ation (UBO S Aug 2014) N a T ti o o t n a a l l S R c a o n r k e Monthly reports sent on time (3) Completeness monthly reports (2) Completeness facility reporting (3) Completeness of the annual report (2) Total Total Population (UBOS Aug 2014) DPT3 Coverage Deliveries in govt and PNFP facilities OPD Per Capita HIV testing in children born to HIV+ women Latrine coverage IPT2 ANC4 TB success rate Approved posts that are filled HMIS reporting completeness and timeliness Medicine orders submitted timely Annual Health Sector Performance Report for Financial Year 2014/15 Coverage and quality of care (75) Management (25) District BUVUMA BULAMBULI AMUDAT TABLE 52: LEAGUE TABLE FOR HARD TO REACH DISTRICTS Coverage and quality of care (75) Management (25) 100

125 Monthly reports sent on time (3) Completeness monthly reports (2) Completeness facility reporting (3) Completeness of the annual report (2) DPT3 Coverage Deliveries in govt and PNFP facilities OPD Per Capita HIV testing in children born to HIV positive women Latrine coverage in households IPT2 ANC4 TB success rate Approved posts that are filled HMIS reporting completeness and timeliness Medicine orders submitted timely Annual Health Sector Performance Report for Financial Year 2014/ GULU 443, LAMWO 134, AGAGO 227, MUKONO 599, NWOYA 128, KITGUM 204, KANUNGU 252, BUNDIBUGY O 224, AMURU 190, KALANGALA 53, KISORO 287, ABIM 109, BUGIRI 390, PADER 183, ADJUMANI 232, NAMAYINGO 223, NTOROKO 66, BUKWO 89, NAPAK 145,

126 (26 hard to Reach districts) Total Population (UBOS Aug 2014) Monthly reports sent on time (3) Completeness monthly reports (2) Completeness facility reporting (3) Completeness of the annual report (2) DPT3 Coverage Deliveries in govt and PNFP facilities OPD Per Capita HIV testing in children born to HIV positive women Latrine coverage in households IPT2 ANC4 TB success rate Approved posts that are filled HMIS reporting completeness and timeliness Medicine orders submitted timely Total Rank National Rank Annual Health Sector Performance Report for Financial Year 2014/15 Coverage and quality of care (75) Management (25) MAYUGE 479, KAABONG 169, MOROTO 104, NAKAPIRIPIRI T 169, KOTIDO 178, BUVUMA 89, AMUDAT 111, Average 5,487, NATIONAL 34,844,

127 Total Population (UBOS Aug 2014) Monthly reports sent on time (3) Completeness monthly reports (2) Completeness facility reporting (3) Completeness of the annual report (2) DPT3 Coverage Deliveries in govt and PNFP facilities OPD Per Capita HIV testing in children born to HIV positive women Latrine coverage in households IPT2 ANC4 TB success rate Approved posts that are filled HMIS reporting completeness and timeliness Medicine orders submitted timely Total Annual Health Sector Performance Report for Financial Year 2014/15 TABLE 53: REGIONAL RANKING 2014/15 Coverage and quality of care (75) Management (25) District NEBBI KOBOKO ARUA ADJUMANI ZOMBO MARACHA MOYO YUMBE Arua-Region KAMPALA BUTAMBALA MITYANA LUWERO MUKONO

128 Total Population (UBOS Aug 2014) Monthly reports sent on time (3) Completeness monthly reports (2) Completeness facility reporting (3) Completeness of the annual report (2) DPT3 Coverage Deliveries in govt and PNFP facilities OPD Per Capita HIV testing in children born to HIV positive women Latrine coverage in households IPT2 ANC4 TB success rate Approved posts that are filled HMIS reporting completeness and timeliness Medicine orders submitted timely Total Annual Health Sector Performance Report for Financial Year 2014/15 Coverage and quality of care (75) Management (25) District MPIGI NAKASEKE KAYUNGA BUIKWE MUBENDE NAKASONGOLA GOMBA WAKISO BUVUMA Central-Region KABAROLE KYENJOJO KAMWENGE KYEGEGWA BUNDIBUGYO

129 Total Population (UBOS Aug 2014) Monthly reports sent on time (3) Completeness monthly reports (2) Completeness facility reporting (3) Completeness of the annual report (2) DPT3 Coverage Deliveries in govt and PNFP facilities OPD Per Capita HIV testing in children born to HIV positive women Latrine coverage in households IPT2 ANC4 TB success rate Approved posts that are filled HMIS reporting completeness and timeliness Medicine orders submitted timely Total Annual Health Sector Performance Report for Financial Year 2014/15 Coverage and quality of care (75) Management (25) District KASESE NTOROKO Fort Portal-Region GULU LAMWO AGAGO NWOYA KITGUM AMURU PADER Gulu-Region HOIMA KIBOGA MASINDI

130 Total Population (UBOS Aug 2014) Monthly reports sent on time (3) Completeness monthly reports (2) Completeness facility reporting (3) Completeness of the annual report (2) DPT3 Coverage Deliveries in govt and PNFP facilities OPD Per Capita HIV testing in children born to HIV positive women Latrine coverage in households IPT2 ANC4 TB success rate Approved posts that are filled HMIS reporting completeness and timeliness Medicine orders submitted timely Total Annual Health Sector Performance Report for Financial Year 2014/15 Coverage and quality of care (75) Management (25) District KIBAALE KIRYANDONGO BULIISA KYANKWANZI Hoima-Region JINJA IGANGA KAMULI NAMUTUMBA BUGIRI NAMAYINGO LUUKA KALIRO MAYUGE BUYENDE

131 Total Population (UBOS Aug 2014) Monthly reports sent on time (3) Completeness monthly reports (2) Completeness facility reporting (3) Completeness of the annual report (2) DPT3 Coverage Deliveries in govt and PNFP facilities OPD Per Capita HIV testing in children born to HIV positive women Latrine coverage in households IPT2 ANC4 TB success rate Approved posts that are filled HMIS reporting completeness and timeliness Medicine orders submitted timely Total Annual Health Sector Performance Report for Financial Year 2014/15 Coverage and quality of care (75) Management (25) District Jinja-Region LIRA OYAM DOKOLO AMOLATAR OTUKE APAC ALEBTONG KOLE Lira-Region LYANTONDE MASAKA RAKAI KALUNGU

132 Total Population (UBOS Aug 2014) Monthly reports sent on time (3) Completeness monthly reports (2) Completeness facility reporting (3) Completeness of the annual report (2) DPT3 Coverage Deliveries in govt and PNFP facilities OPD Per Capita HIV testing in children born to HIV positive women Latrine coverage in households IPT2 ANC4 TB success rate Approved posts that are filled HMIS reporting completeness and timeliness Medicine orders submitted timely Total Annual Health Sector Performance Report for Financial Year 2014/15 Coverage and quality of care (75) Management (25) District KALANGALA BUKOMANSIMBI LWENGO SEMBABULE Masaka-Region MBALE TORORO BUSIA PALLISA BUDAKA SIRONKO KAPCHORWA BUDUDA BUKWO BUTALEJA

133 Total Population (UBOS Aug 2014) Monthly reports sent on time (3) Completeness monthly reports (2) Completeness facility reporting (3) Completeness of the annual report (2) DPT3 Coverage Deliveries in govt and PNFP facilities OPD Per Capita HIV testing in children born to HIV positive women Latrine coverage in households IPT2 ANC4 TB success rate Approved posts that are filled HMIS reporting completeness and timeliness Medicine orders submitted timely Total Annual Health Sector Performance Report for Financial Year 2014/15 Coverage and quality of care (75) Management (25) District MANAFWA KIBUKU KWEEN BULAMBULI Mbale-Region RUKUNGIRI BUSHENYI ISINGIRO KANUNGU KIRUHURA KABALE MBARARA SHEEMA NTUNGAMO KISORO

134 Total Population (UBOS Aug 2014) Monthly reports sent on time (3) Completeness monthly reports (2) Completeness facility reporting (3) Completeness of the annual report (2) DPT3 Coverage Deliveries in govt and PNFP facilities OPD Per Capita HIV testing in children born to HIV positive women Latrine coverage in households IPT2 ANC4 TB success rate Approved posts that are filled HMIS reporting completeness and timeliness Medicine orders submitted timely Total Annual Health Sector Performance Report for Financial Year 2014/15 Coverage and quality of care (75) Management (25) District IBANDA MITOOMA RUBIRIZI BUHWEJU Mbarara-Region ABIM NAPAK KAABONG MOROTO NAKAPIRIPIRIT KOTIDO AMUDAT Moroto-Region

135 Total Population (UBOS Aug 2014) Monthly reports sent on time (3) Completeness monthly reports (2) Completeness facility reporting (3) Completeness of the annual report (2) DPT3 Coverage Deliveries in govt and PNFP facilities OPD Per Capita HIV testing in children born to HIV positive women Latrine coverage in households IPT2 ANC4 TB success rate Approved posts that are filled HMIS reporting completeness and timeliness Medicine orders submitted timely Total Annual Health Sector Performance Report for Financial Year 2014/15 Coverage and quality of care (75) Management (25) District SERERE SOROTI KATAKWI KABERAMAIDO KUMI AMURIA NGORA BUKEDEA Soroti-Region NATIONAL TABLE 54: GENERAL HOSPITAL PERFORMANCE 111

136 Facility Admissions Patient Days Beds Total OPD Deliveries Total ANC Postnatal Attendances FP Immunization Caesarian Sections Major operations IPD Deaths Fresh Still births Maternal deaths BOR ALOS Maternal Death Risk FSB Risk SUO 2014/15 Annual Health Sector Performance Report for Financial Year 2014/15 Iganga 23,624 62, ,381 6,481 7,303 2,349 1,122 12,922 1,735 3, ,117 Busolwe 13,427 22, ,082 1,896 2, , ,312 Kitgum 15,186 66, ,480 2,770 2, , ,107 Mityana 14,533 69, ,275 5,763 6,431 1,971 1,221 7,685 1,474 2, ,434 Tororo General 14,083 58, ,432 5,158 6,040 2, , , ,433 Bwera 14,360 56, ,258 4,318 7, ,054 15,831 1,183 1, ,386 Pallisa 14,458 57, ,445 3,626 3,928 3,240 1,135 8, ,364 Kawolo 11,704 31, ,820 3,764 5, ,828 9, , ,614 Apac 14,121 44, ,355 2,222 4, , , ,592 Angal St. Luke 15,142 98, ,231 2,537 2, , , ,797 Atutur 11,543 31, ,229 1,737 2, , , ,162 Ibanda 15,078 37, ,862 2,447 1, , , ,438 Kayunga 11,319 33, ,930 3,045 3, , , ,679 Kagadi 14,134 44, ,917 3,729 4, , , ,236 Nebbi 12,667 42, ,810 2,367 3, , ,728 Yumbe 11,716 46, ,264 2,480 2, , ,934 Lyantonde 9,759 25, ,797 2,087 4, , ,186 Kalongo Ambrosoli Memorial 12,799 66, ,526 3,247 3, ,199 6, , ,527 Adjumani 10,436 49, ,515 1,840 2, , , ,987 Kamuli 10, , ,015 1,968 3,555 2, , ,757 Entebbe 8,268 20, ,246 5,158 8,738 1, ,732 1,219 1, , ,146 Katakwi General 10,683 36, ,795 1,535 2, , ,490 Kilembe 12,031 53, ,589 2,368 1, , , ,152 Bugiri 9,634 39, ,514 2,623 4, , , ,

137 Kitagata 8,226 31, ,581 2,088 2, , , ,146 Bududa 9,519 29, ,931 1,246 1, , ,047 Itojo 10,074 41, ,609 2,198 1,605 1, , ,200 Gombe 9,930 34, ,141 2,889 3, , ,441 Kiryandongo 10,253 36, ,146 2,019 4, , ,959 Masafu General 8,619 23, ,782 1,679 2, , ,171 Kiboga 9,319 30, ,527 3,096 3,988 1, , ,213 Masindi 9,188 27, ,649 3,744 6, , , ,402 Kisoro 8,318 44, ,867 2,805 3, , , ,833 Kaabong 9,113 33, ,318 1,258 1, , ,062 Aber Ngo 9,088 44, ,433 2,145 3, , ,977 Matany 9,404 76, ,307 1,005 2, , ,304 Kiu Teaching 10,104 33, ,921 1,329 1, , ,104 1, ,927 Bombo General Military 8,341 38, ,901 2,063 2, ,018 4, , ,940 Kisiizi NGO 8,152 53, ,317 2,152 3, , , ,112 Mutolere (St. Francis) 9,089 52, ,856 2,139 2, , , , ,551 Kumi NGO 7,194 44, ,510 1,494 1, , , , ,496 Ishaka Adventist 9,182 21, ,604 2,568 2,737 1,186 7,133 1,024 1, ,562 St. Joseph'S Kitgum 9,056 66, ,467 1,708 2,249 1,394 7, ,174 Kalisizo 6,742 19, ,936 2,340 3, , , ,052 Nakaseke 6,594 33, ,126 2,309 2, , , , ,714 Koboko 8,452 21, ,378 1,953 3, , ,387 Kagando 8,658 46, ,703 1,541 2, ,119 6, , ,095 Kapchorwa 6,887 28, ,940 1,865 2, ,215 4, ,291 Kiwoko 7,486 37, ,989 2,098 2, , , ,942 Kyenjojo 6,933 15, ,938 2,241 2,849 1,262 1,517 8, , ,567 Bundibugyo 6,029 34, ,930 1,670 2, , ,598 Kamuli Mission 6,778 18, ,210 1,960 3,855 5, , ,

138 Nakasero 5,845 21, ,393 1, , , ,957 Rakai 5,220 11, ,068 1,517 1, , ,696 Murchison Bay 1,628 5, , , , ,758 Anaka 6,415 23, ,664 1,178 2,283 1, , , ,489 St. Karolii Lwanga Nyakibale 7,066 24, ,635 1,679 1, , , ,092 Moyo 4,456 18, , , ,989 St. Francis Naggalama 4,854 16, ,248 1,469 2, , ,721 Nkozi 4,839 15, ,749 1,615 1,791 1, , ,191 Kibuli 3,959 8, ,000 1,714 2, , ,021 St. Joseph Kitovu 5,510 24, ,289 1,338 1, , , ,900 International Kampala 1,769 7, ,117 1,165 2, , , ,654 Kuluva 5,763 36, ,564 1,224 2, , ,518 Buluba 4,479 16, ,533 1, , ,409 Kisubi 3,600 11, ,122 1,404 2, , , ,556 Virika 5,223 13, , , , , ,257 Kambuga 4,158 13, ,682 1,076 1, ,221 2, ,510 Comboni 4,125 10, , , , ,405 Kakira Worker's 3,196 7, , , ,868 Ruharo Mission 4,169 15, , , ,443 Abim 3,431 13, , , ,434 Nyapea 4,703 10, ,873 1,358 1, , ,540 Maracha 4,687 37, , , ,414 Kabarole 4,341 7, , , , ,274 Holy Innocents Children's 4,129 9, , , ,167 Mildmay Uganda 193 1, , ,540 Villa Maria 4,148 17, ,108 1,199 1, , ,430 Rubongi Military 2,444 9, , , ,760 Bwindi Community 3,291 14, ,769 1,374 1, , ,

139 Buikwe St. Charles Lwanga 4,067 12, ,886 1,007 1, , ,379 Rugarama 3,524 18, , , , ,794 Amudat 4,133 13, , , ,453 Lugazi Scoul 2,955 6, , ,863 2, ,881 Kanginima 4,065 11, , , ,134 St. Francis Nyenga 3,129 11, , , , ,195 Dabani 3,824 7, , , ,350 Benedictine Eye 2,768 7, , , ,661 Lwala 3,165 17, , , , ,496 Bukwo General 1,809 4, , , , ,117 St. Anthony's Tororo 3,216 14, , , ,870 Ngora Ngo 2,548 12, , , ,171 Rushere Community 2,539 8, , , , ,296 Nakasongola Military 1,381 11, , ,532 Novik 0 41, , ,159 Namungoona Orthodox 1, , , , ,255 Mukwaya General 753 1, , , ,436 Nkokonjeru 1,758 4, , , , ,673 UPDF 2nd Div , , ,851 St. Catherine 0 34, ,884 Gulu Military 1,203 9, , , ,778 Mount Elgon 972 2, , , ,167 Amai Community 1,498 7, , , ,087 Buwenge NGO 1,100 3, , , , ,802 Pioneer 1,256 3, , ,687 5th Military Division 774 3, , ,413 Mayanja Memorial 1,004 2, , , ,070 Mbarara Community 1,094 1, , , ,

140 Gulu Independent 708 2, , , ,058 Paragon Kampala , , ,935 Galilee Community General , , ,671 Oriajini 1,016 2, , , ,536 Cure Children's 949 5, , ,671 Uganda Martyrs , , ,589 Saidina Abubakar Islamic , , ,298 Kida 898 1, , , ,175 Senta Medicare Clinic , , ,850 Kololo 0 10, , ,175 Kabasa Memorial 661 2, , , ,564 Buliisa , ,296 Bamu , ,621 Old Kampala , , ,594 Tumu , ,308 Ruth Gaylord , ,514 Bethany Women and Family 0 4, ,228 Divine Mercy , ,455 JCRC Clinic Mengo 0 1, , ,619 Kitintale 0 1, ,817 Ntinda ,274 Middle East Bugolobi 0 1, ,117 Family Care Kigezi Health Care Foundation III

141 Summary Admissions Patient Days Beds Total OPD Deliveries Total ANC Postnatal Attendances FP Immunization Caesarian Sections Major operations IPD Deaths Fresh Still births Maternal deaths BOR ALOS Maternal Death Risk FSB Risk SUO 2014/15 Annual Health Sector Performance Report for Financial Year 2014/15 TABLE 55: SUMMARY OF GENERAL HOSPITAL PERFORMANCE Minimum Maximum 23,624 98, ,381 6,481 8,738 5,469 8,863 27,121 1,735 3,208 1, , ,117 Total 730,313 2,776,176 15,235 4,125, , ,578 63,521 54, ,209 40,093 73,180 18,476 3, ,811 8,185 16,256,818 # of hospitals reporting Valid Average 5, , ,493 1,364 1, , ,158 TABLE 56: OUTPUTS AND RANKING OF HC IVS 2014/15 117

142 Facility Admiss ions Patient Days Beds Total OPD Deliveri es Total ANC Postnat al Attenda nces Family Plannin g Immuni zation Caesari an Section s Major operati ons Blood transfu sion units IPD Deaths Fresh Stillbirt hs Materna l deaths SUO Rank MukonoT.C. HC IV ,837 1 Luwero HC IV ,578 2 Serere HC IV ,613 3 Kitebi HC III ,405 4 Kumi HC IV ,033 5 Amuria HC IV ,613 6 Kakuuto HC IV ,736 7 Budaka HC IV ,810 8 Pakwach HC IV ,421 9 Busia HC IV , Budadiri HC IV , Kasangati HC IV , Mpigi HC IV , Kibuku HC IV , Kabuyanda HC IV , Kaberamaido HC IV , Azur HC III , Nyahuka HC IV ,

143 Facility Admiss ions Patient Days Beds Total OPD Deliveri es Total ANC Postnat al Attenda nces Family Plannin g Immuni zation Caesari an Section s Major operati ons Blood transfu sion units IPD Deaths Fresh Stillbirt hs Materna l deaths SUO Rank Nankandulo HC IV , Dokolo HC IV , Buyinja HC IV , Kibaale HC IV , Namwendwa HC IV , Magale HC IV , Buwenge HC IV , Omugo HC IV , Tokora HC IV , Wakiso HC IV , Butebo HC IV , Kitwe HC IV , PAG Mission HC IV , Kyangwali HC IV , Kabwohe HC IV , Mulanda HC IV , Rukunyu HC IV , Midigo HC IV ,

144 Facility Admiss ions Patient Days Beds Total OPD Deliveri es Total ANC Postnat al Attenda nces Family Plannin g Immuni zation Caesari an Section s Major operati ons Blood transfu sion units IPD Deaths Fresh Stillbirt hs Materna l deaths SUO Rank Anyeke HC IV , Bumanya HC IV , Kangulumira HC IV , Mukono Co UHC IV , Kibiito HC IV , Rubaare HC IV , River Oli HC IV , Kidera HC IV , Ogur HC IV , Bukomero HC IV , Bukedea HC IV , Mungula HC IV , Ishongororo HC IV , Nankoma HC IV , Princes Diana HC IV , Kyabugimbi HC IV , Nagongera HC IV , Kigorobya HC IV ,

145 Facility Admiss ions Patient Days Beds Total OPD Deliveri es Total ANC Postnat al Attenda nces Family Plannin g Immuni zation Caesari an Section s Major operati ons Blood transfu sion units IPD Deaths Fresh Stillbirt hs Materna l deaths SUO Rank Ntwetwe HC IV , Semuto HC IV , Kiganda HC IV , Lalogi HC IV , Rugazi HC IV , Kotido HC IV , Rwashamaire HC IV , Mitooma HC IV , Naam Okora HC IV , Amolatar HC IV , Bufumbo HC IV , Bishop Asili Ceaser HC IV , Aduku HC IV , Ruhoko HC IV , Kyegegwa HC IV , ATIRIR HC IV , Muyembe HC IV , Mukuju HC IV ,

146 Facility Admiss ions Patient Days Beds Total OPD Deliveri es Total ANC Postnat al Attenda nces Family Plannin g Immuni zation Caesari an Section s Major operati ons Blood transfu sion units IPD Deaths Fresh Stillbirt hs Materna l deaths SUO Rank Karenga HC IV , Apapai HC IV , Alebtong HC IV , Busiu HC IV , Aboke HC IV , Bwizibwera HC IV , Kinoni HC IV , Nsinze HC IV , Amach HC IV , Rwekubo HC IV , Kihiihi HC IV , Bugobero HC IV , Busesa HC IV , Kyarusozi HC IV , Nakasongola HC IV , Nabilatuk HC IV , Kebisoni HC IV , Obongi HC IV ,

147 Facility Admiss ions Patient Days Beds Total OPD Deliveri es Total ANC Postnat al Attenda nces Family Plannin g Immuni zation Caesari an Section s Major operati ons Blood transfu sion units IPD Deaths Fresh Stillbirt hs Materna l deaths SUO Rank Kiyunga HC IV , Namayumba HC IV , Bbaale HC IV , Bugono HC IV , Ndejje HC IV , Kakindo HC IV , Karugutu HC IV , Kapelebyong HC IV , Bubulo HC IV , Kakumiro HC IV , Buliisa HC IV , Bugangari HC IV , Pajule HC IV , Orum HC IV , Ngora Gvt HC IV , Benedict Medical centre HC IV , Rhino Camp HC IV , Mpumudde HC IV ,

148 Facility Admiss ions Patient Days Beds Total OPD Deliveri es Total ANC Postnat al Attenda nces Family Plannin g Immuni zation Caesari an Section s Major operati ons Blood transfu sion units IPD Deaths Fresh Stillbirt hs Materna l deaths SUO Rank Kiwangala HC IV , Awach HC IV , Kityerera HC IV , Shuuku HC IV , Kanungu HC IV , Kigandalo HC IV , Padibe HC IV , Madi-Opei HC IV , Busaru HC IV , Bukuku HC IV , Chahafi HC IV , Bukulula HC IV , Bugembe HC IV , Kiruhura HC IV , Kassanda HC IV , Patongo HC III , Muko HC IV , Kazo HC IV ,

149 Facility Admiss ions Patient Days Beds Total OPD Deliveri es Total ANC Postnat al Attenda nces Family Plannin g Immuni zation Caesari an Section s Major operati ons Blood transfu sion units IPD Deaths Fresh Stillbirt hs Materna l deaths SUO Rank St.Paul HC IV , Budondo HC IV , Adumi HC IV , Ntara HC IV , Kyazanga HC IV , Rubuguri HC IV , Bwijanga HC IV , Nyimbwa HC IV , Namatala HC IV , Atiak HC IV , Nyamuyanja HC IV , Toroma HC IV , Kaproron HC IV , Rwesande HC IV , Wagagai HC IV , Rugaaga HC IV , Lwengo HC IV , Nsiika HC IV ,

150 Facility Admiss ions Patient Days Beds Total OPD Deliveri es Total ANC Postnat al Attenda nces Family Plannin g Immuni zation Caesari an Section s Major operati ons Blood transfu sion units IPD Deaths Fresh Stillbirt hs Materna l deaths SUO Rank Ssekanyonyi HC IV , Maddu HC IV , Hamurwa HC IV , Ssembabule HC IV , Kikyo HC IV , Rubaya HC IV , Mparo HC IV , Kamwezi HC IV , Buhunga HC IV , Kyannamukaaka HC IV , St. Joseph G.S. Kyamulibwa Ngo HC IV , Kalagala HC IV , Walukuba HC IV , Kalangala HC IV , Bukwa HC IV , St. Ambrose Charity HC IV , Kojja HC IV , ASTU HC IV ,

151 Facility Admiss ions Patient Days Beds Total OPD Deliveri es Total ANC Postnat al Attenda nces Family Plannin g Immuni zation Caesari an Section s Major operati ons Blood transfu sion units IPD Deaths Fresh Stillbirt hs Materna l deaths SUO Rank Kikuube HC IV , Buwasa HC IV , Buvuma HC IV , Bushenyi HC IV , Buwambo HC IV , Bishop Masereka CF HC IV , Butenga HC IV , Maziba Gvt HC IV , Kamukira HC IV , Masindi Military HC IV , Kiyumba HC IV , Kyantungo HC IV , SAS Clinic, Bombo Road , Mwera HC IV , Kampala Hospital , Bugamba HC IV , Busanza HC IV , Ngoma HC IV ,

152 Facility Admiss ions Patient Days Beds Total OPD Deliveri es Total ANC Postnat al Attenda nces Family Plannin g Immuni zation Caesari an Section s Major operati ons Blood transfu sion units IPD Deaths Fresh Stillbirt hs Materna l deaths SUO Rank Butiru HC III , Mbarara Municipal Council HC IV , Ntungamo HC IV , Luwunga Barracks HC IV , Bukasa HC IV , Makonge HC III , North Kigezi HC IV , Kataraka HC IV , St. Franciscan HC IV , Ntuusi HC IV , Nyamirami HC IV , Women's Hospital, FC-Bukoto , HiimaIaa (Uci) HC IV , Pearl Medical Center HC IV , Kawempe HC IV , Ayira Health Services

153 Facility Admiss ions Patient Days Beds Total OPD Deliveri es Total ANC Postnat al Attenda nces Family Plannin g Immuni zation Caesari an Section s Major operati ons Blood transfu sion units IPD Deaths Fresh Stillbirt hs Materna l deaths SUO Rank Mbarara Municipal HC IV

154 MINISTRY OF HEALTH P. O. Box 7272 Kampala Uganda Plot 6 Lourdel Rd, Nakasero General Telephone: / /9 Permanent Secretary's Office: Fax: info@health.go.ug