Annual Health Sector Performance Report

The Republic of Uganda MINISTRY OF HEALTH Annual Health Sector Performance Report Financial Year 2012 / 2013 Affari Esteri allo Sviluppo Ministero degli [Annual Health Sector Performance Report 2012/13 FY] Printed with the contribution of the Italian Cooperation Page i

Foreword The Annual Health Sector Performance Report for 2012/13 Financial Year provides progress of the annual workplan as well as the overall health sector performance against the set targets for the Financial Year 2012/13 with a comparative analysis of the previous trends and progress towards achieving the HSSIP 2010/11 2014/15 targets. The report shall be discussed at the 19th Annual Health Sector Joint Review Mission and 9th National Health Assembly 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 achieving the National Development Plan targets and Millennium Development Goals. The sector will continue 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 2010/11-2014/15 Mid-Term review. This will further be supported by 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 all Ugandans in the achievement of the progress reported in the sector performance. Improvements in performance were made possible by the multitude of all categories of health workers in the sector, 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, and appeal to them to improve. I wish to thank the HPAC 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 and presented as scheduled. For God and My Country Ruhakana Rugunda (Dr.) MINISTER OF HEALTH [Annual Health Sector Performance Report 2012/13 FY] Page iii

Table of Contents Foreword...iii List of Tables...vii List of Figures...ix Acronyms...x Executive Summary... xiv 1 CHAPTER ONE INTRODUCTION... 1 1.1 Background... 1 1.2 Vision, Mission, Goal and Strategic Objectives during the HSSIP 2010/11 2014/15... 1 1.2.1 Vision... 1 1.2.2 Mission... 1 1.2.3 Goal... 1 1.2.4 Strategic Objectives...1 1.3 Projected Demographics for 2012... 2 1.4 The Annual Health Sector Performance Report FY 2012/13... 2 1.4.1 The drafting process... 3 1.4.2 Overview of the report outline...4 2 O VERALL PROGRESS AND PERFORMANCE AGAINST THE KEY SECTOR OUTPUTS... 5 2.1 Overall Summary Progress towards JAF 5 and HSSIP 2010/11 2014/15 Core Indicators... 5 2.1.1 Health Impact Indicators... 5 2.1.2 Morbidity: Level and Trends...8 2.2 Health Services Coverage... 9 2.3 Coverage with Other Health Determinants...14 2.4 Health Quality and Outputs...16 2.5 Health Investments...23 2.5.1 Summary of the Financial Report 2012/13 FY... 27 2.5.2 Trends of the health sector funding 2000/01-2012/13... 27 2.5.3 Financial Performance for Local Governments (LGs)... 28 2.5.4 Summary for Human Resources for Health (HRH)...30 2.6 Progress in Implementation of the JAF 5 Targets...33 2.7 Implementation of the Ministerial Policy Statement 2012/13 FY...34 2.7.1 Assessment of Performance against Planned Key Outputs for the MoH Headquarters...34 2.8 Global Fund (GF) Supported Interventions 2012/13...56 2.8.1 Global Fund for TB, HIV/AIDS and Malaria...56 2.8.2 Global Alliance for vaccines and Immunization (GAVI)... 57 2.9 Health Partnerships Performance...58 2.10 Public- Private Partnerships...61 2.10.1 Private Not-For Profit (PNFP) Sub-Sector... 61 2.10.2 Private Health Practitioners (PHP) Sub-Sector... 64 2.10.3 PHP Contribution to selected HSSIP 2010/11 2014/15 outputs... 65 2.10.4 Civil Society Organizations... 66 [Annual Health Sector Performance Report 2012/13 FY] Page v

2.11 Local Government Performance...71 2.11.1 District League Table (DLT) Performance...71 2.12 Hospital Performance...76 2.12.1 Regional Referral Hospitals...76 2.12.2 General Hospital Performance...84 2.12.3 Functionality of HC IVs...88 2.12.4 Quality of Care...93 3 ANNEX...95 3.1 Delivery of the Uganda National Minimum Health Care Package (UNMHCP)...97 3.1.1 Cluster 1: Health promotion, disease prevention, and community health initiatives...97 3.1.2 Control of Diarrheal Diseases... 99 3.1.3 Epidemic Disaster Prevention, Preparedness and Response (EDPPR)... 101 3.1.4 Cluster 2: Maternal and Child Health... 103 3.1.5 Prevention and Control of Communicable Diseases... 110 3.1.6 Diseases Targeted for Elimination... 116 3.1.7 Prevention and Control of Non-communicable Conditions... 119 3.2 Integrated Health Sector Support Systems...124 3.2.1 Human Resources for Health... 128 3.2.2 Health Infrastructure Development and Management... 129 3.2.3 Management of Essential Medicines and Supplies... 132 3.2.4 National Medical Stores... 133 3.2.5 National Drug Authority... 134 3.2.6 Information for Decision Making... 135 3.2.7 Quality of Care... 137 3.2.8 Health Policy, Planning and Support Services... 139 3.2.9 Legal and Regulatory Framework... 142 3.2.10 Research... 143 3.2.11 Uganda National Health Research Organisation... 143 3.2.12 Natural Chemotherapeutics Research Institute (NCRI)... 144 3.2.13 Uganda Virus Research Institute (UVRI)... 145 3.2.14 Public Private Partnership for Health... 146 3.3 Monitoring and Evaluation of Implementation of the HSSIP 2010/11 2014/15...146 3.4 League Tables 2012/13 FY...148 vi Page [Annual Health Sector Performance Report 2012/13 FY]

List of Tables Table 1: Demographic Information... 2 Table 2: Comparison of Maternal deaths notified by facilities to those reported through HMIS... 5 Table 3: Trends in IP Mortality (Under 5)... 7 Table 4: Top ten causes of hospital based mortality for all ages in 2012/13... 7 Table 5: Top ten causes of morbidity among all ages from 2008/09 to 2012/13 FY... 8 Table 6: Performance for Health Services Coverage Indicators... 10 Table 7: % of facilities that have tracer items for child immunization services among facilities... 11 Table 8: % of facilities that have tracer items for ARV services among facilities that provide this service... 12 Table 9: % of facilities that have tracer items for malaria services among facilities that provide this service... 12 Table 10: Key outputs of the USF Program 2012/13... 14 Table 11: Performance for coverage for other health determinants and risk factors indicators during 2012/13 FY... 15 Table 12: Waiting time for clients before being attended to and length of the visit... 17 Table 13: % of Health Facilities with No Stockout For the 6 Tracer Medicines 2012/13 FY... 19 Table 14: HC IV Functionality 2011/12 to 2012/13 FY... 20 Table 15: Performance for health system output (availability, access, quality, safety) indicators... 20 Table 16: Summary of HRH status in public health... 23 Table 17: VHT Establishment by June 2013... 24 Table 18: Performance for coverage for health investments and governance indicators... 25 Table 19: Government allocation to the Health Sector 2000/01 to 2011/12... 28 Table 20: Primary Health Care Grants FY 2000/2001-2012/13 in billions of Ug. Shillings... 29 Table 21: Summary of the recruitment rates by cadre... 31 Table 22: Progress in Implementation of JAF 5 Targets... 33 Table 23: Summary of Achievements under Health Systems Development... 34 Table 24: Summary of Achievements under Clinical and Public Health... 37 Table 25: Summary of Achievements under Supervision and Monitoring... 42 Table 26: Summary of Achievements under Research... 43 Table 27: Summary of Achievements under Pharmaceutical and Other Supplies GAVI... 44 Table 28: Summary of Achievements under National Medical Stores... 44 Table 29: Summary of Achievements under Planning, Policy and Support Services... 46 Table 30: Summary of Achievements under Health Service Commission... 48 Table 31: Summary of Achievements under Uganda Cancer Institute... 49 Table 32: Summary of Achievements under Uganda Heart Institute... 50 Table 33: Summary of Achievements under Uganda Blood Transfusion Services... 50 Table 34: Summary of Achievements under Mulago Hospital... 51 Table 35: Summary of Achievements under Butabika Hospital... 52 Table 36: Key Outputs for Regional Referral Hospitals in the MPS 2012/13... 53 Table 37: HPAC Institutional representatives attendance... 58 Table 38: Progress in implementation of the Country Compact during 2012/13 FY... 59 Table 39: Contribution of UPMB Health Facilities to the HSSIP Outputs... 63 Table 40: DHIS2 Registered Health Facilities Categorized by Specified Ownership... 65 Table 41: PHP Maternal and Child Health Outputs... 65 Table 42: District League Table National Averages 2010/11 2012/13 FYs... 74 Table 43: Top 15 performing districts... 74 Table 44: Bottom 15 performing districts... 74 Table 45: District ranking for new districts... 75 Table 46: Staffing levels for top 10 districts Table... 75 Table 47: Staffing levels for Bottom 10 districts... 75 Table 48: Regional Referral Hospital Ownership 2012... 76 [Annual Health Sector Performance Report 2012/13 FY] Page vii

Table 49: Financial Performance for 14 RRHs for FY 2012/13 (UGX Billions)... 76 Table 50: Staffing at the 14 RRHs... 77 Table 51: Positions filled in RRHs and Large PNFPs... 78 Table 52: Key Hospital Outputs and Ranking of RRHs and Large PNFP Hospitals 2012/13 FY... 79 Table 53: Summary of Key Outputs for RRHs and Large PNFPs... 80 Table 54: Summary of Overall performance for the RRHs and Large PNFP Hospitals 2012/13 (N=18)... 81 Table 55: Selected Efficiency Parameters for RRHs and Large PNFP Hospitals 2012/13... 82 Table 56: Selected Quality of Care Parameters for RRHs and Large PNFP Hospitals 2012/1... 83 Table 57: General Hospital Ownership 2012... 84 Table 58: Summary of Outputs from the General Hospitals FY 2012/13 (N=110)... 85 Table 59: The Top 15 Performing Hospitals... 86 Table 60: Selected efficiency parameters for General Hospitals... 87 Table 61: Comparison of Maternal Deaths and Fresh Still Births to Deliveries... 87 Table 62: Positions filled in HC IVs 2012/13... 88 Table 63: Numbers of C/S performed by each HC IV in 2012/13 FY... 90 Table 64: Summary of Outputs from the HC IVs FY 2012/13 (N=193)... 91 Table 65: The Top 15 Performing HC IVs... 92 Table 66: Efficiency & Usage Measurements of HC IVs... 92 Table 67: General Service readiness index and domain scores by facility type, ownership and location... 94 Table 68: District League Table 2012/13 FY... 148 Table 69: General Hospital League Table... 155 Table 70: Risk of Maternal Death Table 71: Risk of a Fresh Still Birth... 158 Table 72: HC IV League Table... 161 viii Page [Annual Health Sector Performance Report 2012/13 FY]

List of Figures Figure 1: Health facility-based maternal deaths in FY 2009/10 and 2012/13... 6 Figure 2: % of facilities that have tracer items for ANC services among facilities that provide this service... 13 Figure 3: Percentage of facilities that have tracer items for FP services among facilities providing FP... 15 Figure 4: Health units reporting stock out overtime... 19 Figure 5: % of facilities that have tracer items for TB services among facilities that provide this service... 22 Figure 6: Trends in PHC Grant Allocations 2000/01 2012/13 FYs... 29 Figure 7: Effect of the recruitment on staffing status on HC IVs & HC IIIs... 31 Figure 8: Trend of % of health workers in post working at the different levels of health facilities... 32 Figure 9: Staffing in UPMB hospitals... 61 Figure 10: SUO in UPMB hospitals Figure 11: Staff productivity in UPMB Hosps. 2012/13... 62 Figure 11: Staff productivity in UPMB Hosps. 2012/13... 62 Figure 12: Trends in income for recurrent operations... 62 Figure 13: Volume of Outputs for RRHs and Large PNFPs 2011/12 2012/13 FYs... 80 Figure 14: Trends in Caesarean Section and Blood transfusion... 89 Figure 15: Trends in Caesarean Sections performed in the SMGL Project Districts... 91 Figure 16: General Service readiness index and domain scores... 93 Figure 17: Blood Collection over the Years... 126 [Annual Health Sector Performance Report 2012/13 FY] Page ix

Acronyms ACT Artemisinin Combination Therapies AHSPR Annual Health Sector Performance Report AIDS Acquired Immuno-Deficiency Syndrome AMREF African Medical and Research Foundation ANC Ante Natal Care ART Anti-retroviral Therapy ARVs Antiretroviral Drugs BFHI Baby Friendly Health Initiative CAO Chief Administrative Officer CB-DOTS Community Based TB Directly Observed Treatment CCM Country Coordinating Mechanism CDC Centres for Disease Control CDD Control of Diarrhoeal Diseases CDP Child Days Plus CDR Case Detection Rate CEmOC Comprehensive Emergency Obstetric Care CPR Contraceptive Prevalence Rate CPT Cotrimoxazole Prophylaxis CSO Civil Society Organization CYP Couple Years of Protection DHO District Health Officer DHMT District Health Management Team DLT District League Table DOTS Directly Observed Treatment, short course (for TB) DPs Development Partners DPT Diphtheria, Pertussis (whooping cough) and Tetanus vaccine EAC East African Community ECSA-HC East Central and Southern Africa - Health Community EID Early Infant Diagnosis EMHS Essential Medicines and Health Supplies EmOC Emergency Obstetric Care FP Family Planning FY Financial Year GAVI Global Alliance for vaccines and Immunization GBV Gender Based Violence GFTAM Global Fund to fight TB, Aids and Malaria GH General Hospital GoU Government of Uganda HC Health Centre x Page [Annual Health Sector Performance Report 2012/13 FY]

HCT HDP HIV HMIS HPAC HRH HSD HSS HSSIP HSSP ICU IDSR IEC IMAM IMCI IPT IRS JAF JBSF JICA JMS JPP JRM KDS LG LLINs MCH MeTA MDGs MDR MIP MMR MoFPED MoGLSD MoH MoLG MoPS MoU MPDR MTEF HIV/AIDS Counselling and Testing Health Development Partners Human Immuno-Deficiency Virus Health Management Information System Health Policy Advisory Committee Human Resources for Health Health Sub-Districts Health Systems Strengthening Health Sector Strategic Investment Plan Health Sector Strategic Plan Intensive Care Unit 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 Joint Assessment Framework Joint Budget Support Framework Japan International Cooperation Agency Joint Medical Stores Joint Program on Population Joint Review Mission Kampala Declaration on Sanitation Local Government Long Lasting Insecticide Treated Nets Maternal and Child Health Medicines Transparency Alliance Millennium Development Goals Multi-drug Resistant Malaria in pregnancy Maternal Mortality Ratio Ministry of Finance, Planning and Economic Development Ministry of Gender, Labour and Social Development Ministry Of Health Ministry of Local Government Ministry of Public Service Memorandum of Understanding Maternal Perinatal Death Review Medium Term Expenditure Framework [Annual Health Sector Performance Report 2012/13 FY] Page xi

MTR NCD NCRI NDA NGOs NHA NHP NMCP NMS NTDs NTLP OPD OPM OPV ORS ORT PHA PHAST PHC PLWHA PMDT PMTCT PNFP PPPH PRDP RH RRH RUTF SGBV SHSSPP SLD SMC SMER SP STI SUO SWAP TB TMC TSR Mid-Term Review Non Communicable Diseases National Chemotherapeutic Research Institute National Drug Authority Non-Governmental Organizations National Health Assembly National Health Policy National Malaria Control Programme National Medical Stores Neglected Tropical Diseases National Tuberculosis and Leprosy Control Program Out Patients Department Office of the Prime Minister Oral Polio Vaccine Oral Rehydration Salt Oral Rehydration Therapy People with HIV/AIDS Participatory Hygiene and Sanitation Transformation Primary Health Care People with HIV/AIDS Programmatic Management of Multi-Drug Resistant TB Prevention of Mother to Child Transmission Private Not for Profit Public Private Partnership for Health Peace Recovery and Development Plan Reproductive Health Regional Referral Hospital Ready to Use Foods Sexual and Gender Based Violence Support to the Health Sector Strategic Plan Project Second Line Drugs Senior Management Committee Supervision, Monitoring, Evaluation and Research Sulfadoxine/Pyrimethamine Sexually Transmitted Infection Standard unit of Output Sector-Wide Approach Tuberculosis Top Management Committee Treatment Success Rate xii Page [Annual Health Sector Performance Report 2012/13 FY]

TT Tetanus Toxoid TWG Technical Working Group UACP Uganda Aids Control Program UBOS Uganda Bureau of Statistics UBTS Uganda Blood Transfusion Services UCI Uganda Cancer Institute UDHS Uganda Demographic and Health Survey UGFATM Uganda Global Fund for AIDS, TB and Malaria UHSSP Uganda Health Systems Strengthening Project UHI Uganda Heart Institute UNEPI Uganda Expanded Programme on Immunization UNFPA United Nations Fund for Population Activities UNHCO Uganda Health Users/Consumers Organization UNHRO Uganda National Health Research Organisation UNICEF United Nations Children s Fund UNMHCP Uganda National Minimum Health Care Package USF Uganda Sanitation Fund UVRI Uganda Virus Research Institute VHRC Voices for Health Rights Coalition VHT Village Health Team WASH Water and Sanitation Hygiene WHO World Health Organisation WVU World Vision Uganda [Annual Health Sector Performance Report 2012/13 FY] Page xiii

Executive Summary Background The annual sector performance report is an institutional requirement produced to highlight progress, challenges, lessons learnt and propose ways of moving the sector forward. The Annual Health Sector Performance Report (AHSPR) 2012/13 Financial Year (FY) is the third annual report for the Health Sector Strategic and Investment Plan (HSSIP) 2010/11-2014/15. The report mainly focuses on the progress of the annual workplan as well as overall sector performance against the targets set for the FY 2012/13 as well as trends in performance for selected indicators over the previous FYs. The development process of the AHSPR 2012/13 was widely consultative with stakeholders from all departments of the Ministry of Health (MoH), Development Partners (DPs), Bilateral Agencies, Implementing Partners (IPs) and Civil Society Organizations (CSOs). The overall coordination and technical support was provided by the MoH AHSPR Task Force. Data The report focuses on the core indicators of the Monitoring and Evaluation (M&E) Plan for Implementation of the HSSIP, 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 Health Management Information System (HMIS), administrative sources and programme data, including both quantitative and qualitative data. Coverage estimates based on the HMIS data use the UBOS mid-year population projections to estimate the target populations and should be considered as only indicative as the last census was conducted in 2002. National progress and performance Inputs and Processes: Money, Policies and Workforce The amounts of investments (human resources and finances) for health from GOU continue to be below the HSSIP targets which were already below the globally recommended targets. Financial investment in health by GOU shows a further decline over the years from 9.6% in 2009/10 to 7.4% in 2012/13. The percentage of approved posts filled by health workers (Public facilities) increased from 58% in 2011/12 to 63% in 2012/13. Assessment of availability of existing human resource (absenteeism monitoring) through the National Panel Surveys does not provide timely information for decision making towards improvement of the existing workforce. The VHT concept is promoted through training of VHTs of which 75% have been established and only 55% villages have trained VHTs. In 2012/13 FY not a single district/vht was trained on the VHT Strategy. [Annual Health Sector Performance Report 2012/13 FY] Page xi xiv Page [Annual Health Sector Performance Report 2012/13 FY]

Service Outputs The health sector achieved the HSSIP targets for 3 out of the 5 indicators determining availability, access, quality and safety of health services. The stabilization of per capita OPD utilization above 1 i.e. 1.2 in 2011/12 and 1.1 in 2012/13 could be related to the progressive improvement in medicines availability in both public and private health facilities. Such positive changes in service utilization and availability of medicines could be verified further through client feedback mechanisms e.g. timely and regular client satisfaction surveys. Project and institutional specific client satisfaction studies conducted for projects evaluation or institutional assessments generally indicate that the general level of client satisfaction is improving over the years. The availability of the 6 tracer medicines (first line antimalarials (ACTs), Depoprovera, Sulphadoxine / Pyrimethamine, measles vaccine, ORS and Cotrimoxazole) in both public and private health facilities has continued to improve over the last four years with the percentage of facilities without stock out of any of the 6 tracer medicines increasing from 21% in 2009/10 to 48% in 2011/12 and is now 53% in 2012/13. This is a positive trend though below the HSSIP target of 60% for 2012/13. There was remarkable improvement in the functionality of HC IVs from 25% in 2011/12 to 36% HC IV performing C/S in 2012/13. There was also a slight increase in the percentage of HC IVs providing blood transfusion services from 26% in 2011/12 to 27% in 2012/13. One of the factors that could be contributing to the remarkable increase in the indicator for % of HC IVs performing C/S is the improved reporting from 96 to 179 HC IVs in 2011/12 and 2012/13 respectively as a result of using the DHIS-2 system for reporting. Over the years, poor functionality of HC IVs was attributed to inadequate human resource specifically Medical Officers. During 2012/13 FY the MoH undertook major recruitment for all HC IVs and HC IIIs and the effect of this recruitment will be analyzed in the subsequent FY. The MoH needs to carry out further analysis to identify additional factors affecting functionality of HC IVs. TB Case Detection Rate declined from 57% to 55% whereas TB Treatment Success Rate which is a quality indicator increased from 71.1% in 2011/12 to 79% in 2012/13. Service Coverage and Determinants The health sector realized improvement in 6 out of the 8 core indicators for health service coverage with two of health service coverage indicators above the HSSIP target for 2012/13. The percentage of children under one year immunized with DPT 3 was 87% (1,319,860 out of 1,520,347 children of whom 85% were males & 88% females). The DPT 3 coverage achieved is [Annual Health Sector Performance Report 2012/13 FY] Page xii [Annual Health Sector Performance Report 2012/13 FY] Page xv

above the HSSIP target (83%) for the year. The percentage of one year old children immunized against measles was 85% (1,285,020 out of 1,520,347 children) a decline from 89% in 2011/12. The sector achieved the measles immunization coverage target (85%) for the year. The health sector also maintained a positive trend in performance for the HIV/AIDS prevention, care and treatment services. The percentage of children exposed to HIV from their mothers accessing HIV testing within 12 months increased from 32% in 2011/12 to 46% (47,444 children) in 2012/13 though still below the HSSIP target (55%) for the year. There was also remarkable improvement in the percentage of eligible persons receiving ARV therapy to 76% (total of 566,444 of whom 524,603 adults and 41,520 children) from 59% in 2011/12. This achievement was also above the HSSIP target (65%) for the year. In FY 2012/13 193,000 new patients were enrolled on the life saving ART against the planned target of 110,000 new patients. This enrolment for the first time exceeded the number of estimated new infections (140,000) over the same period marking a tipping point in the ART programme. This was a result of strengthened programs of; accelerated accreditation of health facilities, scale up of Option B+, Web Based ARV Ordering Systems, supply chain rationalization which strengthened the PSM and improved overall support to health facilities by the MoH and Implementing Partners. The coverages for all RH indicators are still below the HSSIP targets. The percentage of deliveries in health facilities increased slightly from 40% to 41%. The percentage of pregnant women who completed IPT 2 increased from 44% to 47% in 2012/13. Human resource constraints especially skilled health workers and adequate numbers at lower levels was still a challenge during the larger part of 2012/13 FY. The health sector realized significant increase in funding and supply of essential RH medicines and health supplies, and improvement in staffing levels for critical cadres at HC IVs and HC IIIs during 2012/13. These resources are being distributed and are expected to have a positive impact on the outputs of the RH program. The community needs to be mobilized to maximize use of the interventions and availability of RH supplies and commodities for the sector to realize improvements in coverage for all RH services. The findings of the UDHS 2011 showed improvement in coverage for 3 out of the 4 other health determinants and risk factors indicators as reported in the AHSPR 2011/12 FY. The Couple Years of Protection (CYP) computed from the HMIS shows a remarkable increase from 1,780,578 in 2011/12 to 3,275,403 in 2012/13 FY. This is mainly due to the FP revitalization strategies implemented during the year, specifically the increased funding for procurement of RH commodities including contraceptives. The latrine coverage (all types) reduced to 68% in 2012/13 from 71% in 2011/12. [Annual Health Sector Performance Report 2012/13 FY] Page xiii xvi Page [Annual Health Sector Performance Report 2012/13 FY]

2011/12 to 3,275,403 in 2012/13 FY. This is mainly due to the FP revitalization strategies implemented during the year, specifically the increased funding for procurement of RH commodities including contraceptives. The latrine coverage (all types) reduced to 68% in 2012/13 from 71% in 2011/12. [Annual Health Impact Health Sector Performance Report 2012/13 FY] Page xiii The MoH recommends implementation of the Child Survival strategy at all levels of care in order to achieve the MDG 4. The UDHS 2011 findings showed improvement in all the newborn and integrated child survival performance indicators in the 5 years prior to the survey. The sector continues providing key interventions like Vitamin A supplementation, ICCM, mass deworming and health education to sustain improvement of the under five nutritional status and reduction of anaemia as demonstrated by the UDHS and HMIS reports. There is need to continue community mobilization and involvement in the new community based interventions. Data from the 2011 AIDS Indicator Survey (AIS) revealed an increase in the HIV prevalence among adults from 6.4% in 2004/05 to 7.3% in 2011. This trend is attributable to both new infections and improved survival as more PLHIV access ART. Access to a comprehensive range of HIV/AIDS care services has been improved through accelerated accreditation of ART sites which increased number of health facilities providing ARVs to 1,160 excluding specialized clinics, research programmes and private clinics. A total of 400,000 out of 1,000,000 (40%) males targeted received Safe Male Circumcision. As of March 2013, the coverage for PMTCT services was 85% of hospitals, 97% of HC IVs, 93% of HC IIIs and 24% of HC IIs providing PMTCT services. Approximately 90% of pregnant women were tested for HIV during ANC. The proportion of pregnant women living with HIV receiving ARVs increased from 50% in 2009 to 96% in 2012. Among 53,451 pregnant women who received ARVs between October 2012 and March 31 st 2013 at 2,087 sites, 33% received PMTCT option A, 38% received option B+ and 29% were already on ART before their first ANC. There was an increase in the number of malaria patients reported in the Outpatients from 13,263,620 in 2011/12 to 15,997,210 in 2012/13. Malaria remained the leading cause of morbidity and mortality among all age groups and accounted for 20.6% (5,079/24,651) of all inpatient deaths in 2012/13. The sector improved malaria case management through increased access to ACTs and use of Rapid Diagnostic Tests at HC IIs and IIIs without microscopes. Indoor Residual Spraying was conducted in the 10 target districts for the last 2 years with up to 92% coverage, protecting more than 2.6 million people. There was remarkable reduction of indoor resting vector population reduction as well as remarkable reduction of malaria prevalence in target districts. A total of 21 million LLINs were procured and distribution to be completed by January 2014. The MoH should conduct the Malaria Indicator Survey to provide up to date data on performance against the National Malaria Control Program lead indicators. Community utilization of the malaria interventions e.g. sleeping under LLINs, and uptake of IPT 2 are still very low. Prompt treatment of malaria is also still low. There is need to strengthen community response in utilization of the malaria interventions like sleeping under LLINs and uptake of IPT [Annual Health Sector Performance Report 2012/13 FY] Page xiv in the country. Overall there is positive progress in the TB program lead indicators although this is slow for core Page xvii indicator TB Case Detection [Annual Rate. Health TB Sector Treatment Performance Success Report Rate 2012/13 increased FY] from 71.1% in 2011/12 to 79% in 2012/13. There was an increase in the proportion of TB patients tested for HIV to 89% from 80% (above HSSIP target of 80% for the year). ART uptake for TB/HIV co-infected patients also increased to 57% from 48% though still below the HSSIP target (60%) for the year. DOTS

response in utilization of the malaria interventions like sleeping under LLINs and uptake of IPT in the country. Overall there is positive progress in the TB program lead indicators although this is slow for core indicator TB Case Detection Rate. TB Treatment Success Rate increased from 71.1% in 2011/12 to 79% in 2012/13. There was an increase in the proportion of TB patients tested for HIV to 89% from 80% (above HSSIP target of 80% for the year). ART uptake for TB/HIV co-infected patients also increased to 57% from 48% though still below the HSSIP target (60%) for the year. DOTS coverage increased from 47% in 2011/12 to 55% in 2012/13. There is need for further integration of TB/HIV services at health facility level. To improve TB treatment outcomes there is need to tap into the trained VHTs who will increase community participation in supporting patients to complete treatment. Monitoring Implementation of the Ministerial Policy Statement During 2012/13 FY the MoH planned for a number of significant infrastructure development projects focusing on rehabilitation and equipping hospitals and HC IVs. Largely most of the planned outputs under health systems development (infrastructure) from GoU and support from various DPs were achieved. The sector should plan and allocate sufficient resources for operation and maintenance of both medical equipment and infrastructure including vehicles. Two new vaccines (PCV and HPV) were launched; scale up is ongoing with training of health workers and distribution of vaccines. EmONC equipment was procured and distributed under the UHSSP. However, technical support supervision remains inadequate and interventions like MPDR have not been embraced positively by health workers resulting in low reporting and review of maternal and perinatal deaths compared to those reported under the HMIS. There was timely and coordinated response to disease outbreaks in the country largely due to an efficient surveillance system. The various health research institutions undertook research activities focusing on malaria, other outbreaks due to highly pathogenic viruses and other endemic diseases e.g. plague yellow fever. The NMS continued supplying medicines and health supplies to public health facilities and achieved several of the planned outputs. Notably there was increased access to maama kits to 82% of mothers delivering in public health facilities. During the year NMS commenced supply of medicines and health supplies to all health facilities in the UPDF, Police Force and Prison services. A total of 45,350 uniforms were procured for all cadres and will be distributed during 2013/14 FY. All the semi-autonomous institutions including; Mulago National Referral Hospital, Butabika [Annual National Health Referral Sector Mental Performance Hospital, Report Regional 2012/13 Referral FY] Hospitals, Uganda Cancer Institute, Uganda Page xv Heart Institute, Uganda Blood Transfusion Services showed improvement in provision of secondary and tertiary referral services and specialized services and infrastructure development. The major challenge was inadequate resources (financial and human). Monitoring Implementation of the Country Compact The sector performed fairly well in implementation of the compact. There was compliance with 10 out of the 16 measurement indicators. All the 3 performance indicators under its key xviii functions Page of policy guidance [Annual and monitoring Health Sector were Performance achieved Report through 2012/13 attendance FY] of most of the planned meetings for the governance structures. The sector was complaint against 5 out of the 8 indicators for monitoring programme

National Referral Mental Hospital, Regional Referral Hospitals, Uganda Cancer Institute, Uganda Heart Institute, Uganda Blood Transfusion Services showed improvement in provision of secondary and tertiary referral services and specialized services and infrastructure development. The major challenge was inadequate resources (financial and human). Monitoring Implementation of the Country Compact The sector performed fairly well in implementation of the compact. There was compliance with 10 out of the 16 measurement indicators. All the 3 performance indicators under its key functions of policy guidance and monitoring were achieved through attendance of most of the planned meetings for the governance structures. The sector was complaint against 5 out of the 8 indicators for monitoring programme implementation and performance especially through quarterly performance reviews, annual sector performance review and reporting, and is on track regarding the MTR of the HSSIP. However, failure by the MoH to conduct regular supervision and monitoring of programme implementation in the districts was a big setback in realization of the mandate of the centre. Only two out of the five indicators measuring performance of the planning and budgeting processes were achieved. There was slow progress in achieving the remaining 3 outputs due to leadership and governance issues. Public Private Partnership for Health The health sector benefits from the partnerships with the private sector in form of the Private Health Providers, PNFP and CSO arms. There was contribution in form of advocacy, supporting and monitoring service delivery from all these stakeholders in the sector performance discussed above. In this annual report the contribution from some of the PHP and CSOs has been documented. The major challenges faced include inability to generate comprehensive reports from the private sector. This is largely due to lack of HMIS tools, capacity gaps on utilization of HMIS tools, lack of feedback on reported data, failure to appreciate the need to report, and failure to transmit filled HMIS data sets with most PHP facilities lacking required human resource, equipment and infrastructure to effectively report. Local Government Performance Local Government performance assessment was done using an improved set of 11 indicators (three management and nine access/quality/coverage indicators) for the 111 districts. There is an improvement in the DLT national average performance from 57% in 2011/12 to 63% in 2012/13. The improvement in performance was observed for almost all indicators with the [Annual Health Sector Performance Report 2012/13 FY] Page xvi exception of ANC 4 th visit and completeness of monthly reports. The top ten districts in 2012/13 were; Gulu, Kabarole, Nwoya, Masaka, Kyegegwa, Bushenyi, Abim, Jinja, Luwero and Kyenjojo. The lowest performance levels were noted in Kaabong and Amudat. Hospital Performance Hospital outputs were assessed using the Standard Unit of Output (SUO). The 14 RRHs and 4 large PNFPs hospitals (Lacor, Nsambya, Mengo and Lubaga) attended to a total of; 2,537,666 outpatients; 89,626 deliveries and 339,670 admissions among other outputs. On average each hospital attends to; 140,981 outpatients, conducted 4,979 deliveries and 19,981 admissions. The SUO for these hospitals increased from 5,361,005 in 2011/12 to 8,189,908 in 2012/13. Average staff productivity [Annual increased Health Sector to 2,724 Performance from 1,534 Report SUO/Staff 2012/13 FY] in 2011/12. Mbale Page RRH and xix Masaka RRH had the highest SUOs of 858,116 and 792,551 respectively. A total of 110 hospitals offering general hospital services and reporting through the DHIS2 were

in 2012/13. The improvement in performance was observed for almost all indicators with the exception of ANC 4 th visit and completeness of monthly reports. The top ten districts in 2012/13 were; Gulu, Kabarole, Nwoya, Masaka, Kyegegwa, Bushenyi, Abim, Jinja, Luwero and Kyenjojo. The lowest performance levels were noted in Kaabong and Amudat. Hospital Performance Hospital outputs were assessed using the Standard Unit of Output (SUO). The 14 RRHs and 4 large PNFPs hospitals (Lacor, Nsambya, Mengo and Lubaga) attended to a total of; 2,537,666 outpatients; 89,626 deliveries and 339,670 admissions among other outputs. On average each hospital attends to; 140,981 outpatients, conducted 4,979 deliveries and 19,981 admissions. The SUO for these hospitals increased from 5,361,005 in 2011/12 to 8,189,908 in 2012/13. Average staff productivity increased to 2,724 from 1,534 SUO/Staff in 2011/12. Mbale RRH and Masaka RRH had the highest SUOs of 858,116 and 792,551 respectively. A total of 110 hospitals offering general hospital services and reporting through the DHIS2 were assessed. They collectively attended to a total of; 3,754,144 outpatients; conducted 150,276 deliveries and 690,621 admissions among other outputs. On average each hospital attends to; 35,080 outpatients, 1,392 deliveries and 6,412 admissions. The total SUO for GHs has increased from 10,506,636 in 2011/12 to 15,129,354 in 2012/13 with notable increase in performance for admissions, outpatient attendances and deliveries. The minimum SUO for GHs was 2,529 and maximum 523,549. There was a decline in the immunization contacts at the GHs. The 5 top performing hospitals were Iganga, Busolwe, Bwera, Mityana and Pallisa GHs respectively. In addition to performing Caesarean Sections, 193 HC IVs were also assessed using the SUO. In total HC IVs attended to 4,473,744 outpatients; conducted 123,610 deliveries; and admitted 395,898 patients. The mean outpatient attended to was 23,468, mean deliveries 661 and mean admission 2,234. The total SUO for HC IVs was 11,413,220 with a maximum of 304,048 and minimum of 4,148. The minimum SUO for HC IV level is higher than the minimum (2,529) SUO for GHs. The 5 top performing HC IVs in 2012/13 were Bugobero HC IV, Kawempe HC IV, Mukono Town Council HC IV, Serere HC IV and Luwero HC IV. The Service Availability and Readiness Assessment survey conducted in June 2013 showed that the general service readiness index was 61% with the availability of standard precautions for infection prevention at 83%, basic equipment at 79% and basic amenities at 62%. Service availability was highest in the referral hospitals and progressively decreased by level of care. There were also higher levels of service availability in private facilities compared to public and similarly higher for urban compared to rural facilities. [Annual The sector Health should Sector focus Performance on interventions Report 2012/13 geared FY] at improving service delivery at the Page primary xvii care level specifically through improving the existing health infrastructure, provision of basic equipment, dissemination of guidelines for standard precautions and infection prevention and control, providing appropriate diagnostic facilities and essential medicines by level of care. All this should be augmented with provider training to enhance their knowledge and skills. xx Page [Annual Health Sector Performance Report 2012/13 FY]

1 CHAPTER ONE INTRODUCTION 1.1 Background The Annual Health Sector Performance Report (AHSPR) is an institutional requirement compiled to highlight progress, challenges, lessons learnt and propose ways of moving the health sector forward in relation to the National Development Plan (NDP), National Health Policy, the Sector Strategic Plan and annual workplans. The AHSPR 2012/13 FY is the thirteen annual report produced by the Ministry of Health (MoH). This report is the third annual report for the Health Sector Strategic and Investment Plan (HSSIP) 2010/11-2014/15. The report mainly focuses on the progress of the annual workplan as well as overall health sector performance against the targets set for the FY 2012/13. The report takes into consideration the annual performance in terms of: 1) the effectiveness, responsiveness and equity in the health care delivery system. 2) How well the integrated support systems have been strengthened as well as the status of programme implementation and overall development mechanisms. The sector performance will be deliberated upon during the 19 th Joint Review Mission (JRM) and 9 th National health Assembly (NHA), September 23 rd to 26 th, 2013. The outcomes of the sector performance review are expected to guide future planning and programming. 1.2 Vision, Mission, Goal and Strategic Objectives during the HSSIP 2010/11 2014/15 1.2.1 Vision A healthy and productive population that contributes to socio-economic growth and national development. 1.2.2 Mission To provide the highest possible level of health services to all people in Uganda through delivery of promotive, preventive, curative, palliative and rehabilitative health services at all levels. 1.2.3 Goal The overall goal for the Health Sector during HSSIP 2010/11 2014/15 is To attain a good standard of health for all people in Uganda in order to promote a healthy and productive life 1.2.4 Strategic Objectives To achieve this goal, the health sector shall focus on achieving universal coverage with quality health, and health related services through addressing the following strategic objectives. [Annual Health Sector Performance Report 2012/13] Page 1 [Annual Health Sector Performance Report 2012/13 FY] Page 1

1. Scale up critical interventions for health, and health related services, with emphasis on vulnerable populations. 2. Improve the levels, and equity in access and demand to defined services needed for health. 3. Accelerate quality and safety improvements for health and health services through implementation of identified interventions. 4. Improve on the efficiency, and effectiveness of resource management for service delivery in the sector. 5. Deepen stewardship of the health agenda, by the MoH. 1.3 Projected Demographics for 2012 The projected population demographics for the period under review have been calculated basing on the annual population projection of 35,356,900 reported in the State of Uganda Population Report 2012 by Uganda Bureau of Statistics (UBOS). Table 1: Demographic Information Demographic Variables Proportion Population Total Population 100% 35,356,900 Children below 18 years 56% 19,799,864 Adolescents and youth (young people) (10 24 years) 34.7% 12,268,844 Orphans (for children below 18 years) 10.9% 3,853,902 Infants below one year 4.3% 1,520,347 Children below 5 years 19.5% 6,894,596 Women of reproductive age (15 49 years) 23% 8,132,087 Expected number of pregnancies 5% 1,767,845 UBOS 2012 Midyear Projection 1.4 The Annual Health Sector Performance Report FY 2012/13 The objective of the AHSPR 2012/13 is to review the performance of the sector for the FY 2012/13 against target for the HSSIP 2010/11 2014/15 core indicators, actions and indicators set out in the Ministerial Policy Statement (MPS) 2012/13 FY, Joint Assessment Framework (JAF) 5 under the Joint Budget Support Framework (JBSF). The report provides an assessment of what has been achieved and what has not, and explains some of the reasons for the level of [Annual Health Sector Performance Report 2012/13] Page 2 2 Page [Annual Health Sector Performance Report 2012/13 FY]

performance. This report provides the health sector performance against selected indicators for the last FY with comparison of performance over the previous four FYs. Thus, the report provides progress on: i) Sector performance based on the JAF 5 indicators and HSSIP 2010/11 2014/15 indicators for the FY 2012/13 ii) Financial Report for the FY 2012/13 including a donor-expenditure analysis iii) Overall health service coverage levels iv) Status of implementation of the key sector outputs as outlined in the MPS 2012/13 and the Compact for Implementation of the HSSIP 2010/11 2014/15 v) Local Government (District) performance using the League Table vi) The individual and collective contribution of the National, Regional Referral Hospitals (RRHs) and General Hospitals (GHs) as well as the Private Not-For Profit (PNFP) hospitals at similar levels vii) Implementation progress on the delivery of the Uganda National Minimum Health Care Package (UNMHCP) and health support systems 1.4.1 The drafting process The development process of the AHSPR 2012/13 was widely consultative with stakeholders from all departments of the MoH, Health Development Partners (HDPs), Bilateral Agencies, Implementing Partners and Civil Society Organizations (CSOs). The Health Policy Advisory Committee (HPAC) and Senior Management Committee (SMC) provided guidance and monitored progress in the entire process. The overall coordination and technical support to Technical Working Groups (TWGs), and Departments was provided by the MoH AHSPR Task Force. The composition of the Task Force was drawn from all departments of MoH, CSOs and HDPs. Regular meetings were held with various TWGs, to assess progress in development of the AHSPR. The information used in compiling the AHSPR 2012/13 is both quantitative and qualitative. This AHSPR uses the HMIS aggregated monthly reports from the District Health Information Software (DHIS)-2 for the entire FY. Other key sources of information included: i. HSSIP 2010/11 2014/15 ii. Ministerial Policy Statement (MPS) 2012/13 iii. MoH activity plan 2012/13 iv. Biannual sector performance review reports (Q1 & 2 and Q3 & 4) 2012/13 v. MoH programmes and other central level institutions reports [Annual Health Sector Performance Report 2012/13] Page 3 [Annual Health Sector Performance Report 2012/13 FY] Page 3

vi. Output Budgeting Tool (OBT) reports to the Ministry of Finance, Planning and Economic Development (MoFPED) vii. Annual Health Sector Performance Reports 2011/12 FY viii. Uganda Demographic Health Survey (UDHS) reports ix. Service Availability and Readiness Assessment Reports (SARA) 2012 and 2013 1.4.2 Overview of the report outline The AHSPR 2012/13 FY is divided into three sections as follows; Section 1 is an introduction that covers the background to the AHSPR 2012/13 FY in relation to the framework for achieving the HSSIP 2010/11 2014/15 goals, drafting process and sources of information. Section 2 provides an overview of the sector performance for FY 2012/13 and includes the overall performance of the sector against the HSSIP 2010/11 2014/15 core indicators; an assessment of central level performance against planned key outputs from the MPS 2012/13; contribution of the private sector; progress towards global partnerships; assessment of district performance using the District League Table (DLT); assessment of hospital performance and the functionality of HC IVs. Section 3 is an annex to the report detailing the specific component/ program lead indicators and targets and the progress in implementation of priority activities during 2012/13 FY based on the UNMHCP as well as the health service support system. [Annual Health Sector Performance Report 2012/13] Page 4 4 Page [Annual Health Sector Performance Report 2012/13 FY]

2 OVERALL PROGRESS AND PERFORMANCE AGAINST THE KEY SECTOR 2 OVERALL OUTPUTS PROGRESS AND PERFORMANCE AGAINST THE KEY SECTOR OUTPUTS This chapter presents an overview of the overall progress and trends in health sector This chapter performance presents for FY an 2012/13. overview It of therefore overall includes progress an assessment and trends of performance in health sector of the sector performance using the for HSSIP FY 2012/13. 2010/11 It therefore 2014/15 includes core indicators an assessment and marking of performance progress of towards the sector achievement using of the the HSSIP JAF 2010/11 5, MPS and 2014/15 MoH Activity core indicators Plan targets and marking for 2012/13 progress FY. towards achievement of the JAF 5, MPS and MoH Activity Plan targets for 2012/13 FY. 2.1 Overall Summary Progress towards JAF 5 and HSSIP 2010/11 2014/15 2.1 Overall Core Summary Indicators Progress towards JAF 5 and HSSIP 2010/11 2014/15 Core Indicators 2.1.1 Health Impact Indicators 2.1.1 The Health four Impact impact Indicators indicators (Maternal Mortality Ratio [(MMR), Neonatal Mortality Rate (NMR), The four impact indicators (Maternal Mortality Ratio [(MMR), Neonatal Mortality Rate (NMR), Infant Mortality Rate (IMR), and Under 5 Mortality Rate] used to assess the analysis of impact Infant Mortality Rate (IMR), and Under 5 Mortality Rate] used to assess the analysis of impact of health service delivery were assessed in the UDHS 2011 and trends analyzed in the AHSPR of health service delivery were assessed in the UDHS 2011 and trends analyzed in the AHSPR 2011/12. 2011/12. The fifth, proportion of household experiencing catastrophic payments, measures financial risk The fifth, proportion of household experiencing catastrophic payments, measures financial risk (protection) was 43% for FY 2009/10 (National Health Accounts (NHA) Report, 2013). The target (protection) was 43% for FY 2009/10 (National Health Accounts (NHA) Report, 2013). The target for 2012/13 for 2012/13 FY was FY 19%. was The 19%. NHA The for NHA 2010/11, for 2010/11, 2011/12 2011/12 and 2012/13 and 2012/13 are yet to are be done. yet to be done. Notification Notification of maternal of maternal deaths deaths is mandatory is mandatory but very but few very deaths few were deaths notified were i.e. notified 0.6%, 3.6%, i.e. 0.6%, 3.6%, 7% and 7% 11% and of 11% the of deaths the deaths reported reported in HMIS in were HMIS notified were notified in 2009, in 2010, 2009, 2011 2010, and 2011 2012 and 2012 respectively. respectively. Notification Notification of maternal of maternal deaths is deaths mandatory is mandatory but has improved but has improved slightly over slightly the over the years. years. Table 2: Table Comparison 2: Comparison of Maternal of Maternal deaths notified deaths by notified facilities by to facilities those reported to those through reported HMIS through HMIS Item Item 2009 20092010 2010 2011 20112012 2012 Total number Total number of deaths of notified deaths notified 13 13 45 45129 129125 125 Total number Total number of deaths of reported deaths reported in HMIS in HMIS 1,143 1,143 1,005 1,005 1,844 1,844 1,160 1,160 % of HMIS % of reported HMIS reported deaths notified deaths notified 0.6% 0.6% 3.6% 3.6% 7.0% 7.0% 11% 11% Source: HMIS, MPDR Report 2009 11, 2012 Source: HMIS, MPDR Report 2009 11, 2012 [Annual Health Sector Performance Report 2012/13] Page 5 [Annual Health Sector Performance Report 2012/13] Page 5 [Annual Health Sector Performance Report 2012/13 FY] Page 5