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ANNUAL REPORT 2013 1

MEDICINES AND HEALTH SERVICE DELIVERY MONITORING UNIT

ANNUAL REPORT 2013

MEDICINES AND HEALTH

SERVICE DELIVERY MONITORING UNIT

“Raising the bar in healthcare”

REPUBLIC OF UGANDA

ANNUAL REPORT 20132


Contact Us:MEDICINES AND HEALTH SERVICE DELIVERY MONITORING UNITPlot 21, Naguru Drive, NaguruP.O. Box 25497, Kampala - UgandaTel: +256 414 288 442/5Toll Free: 0800 100 447Email: [email protected]: www.mhu.go.ug

©Copyright, MHSDMU 2014All rights reserved. Permission should be sought to reproduce or use part of or the whole of the content contained herein.




Acknowledgement

The Medicines and Health Service Delivery Monitoring Unit would like to appreciate partners that have played a very important collaborative role to enhance the performance of the Unit improving health service delivery for the population of Uganda. These include Ministry of Health, National Medical Stores, Professional Regulatory councils, Development partners, Uganda Police Force, Directorate of Public Prosecution, Internal Security Organization, District Local Governments, National Drug Authority, Media, Ministry of Education, Judiciary, Inspector General of Government, Ministry of Finance, Parliament, and Ministry of Public Service among others. The Unit especially wants to thank communities and the general public who have been our main stakeholders in identifying and addressing health sector challenges.

ANNUAL REPORT 20132


I am happy to present to you MHSDMU’s 4th Annual Report.

The approach to monitoring this last year has been focused on improved data collection and detailed analysis of findings thus arriving at more statistically relevant conclusions.

Although we note an improvement generally in service delivery, it is limited in scope and the challenge remains scalability and sustainability of successes. Many recommendations have been derived from a combination of field findings and strategic discussion but the turn-around time is less than desirable.

One of the biggest challenges in the health sector is being able to work with other stakeholders without duplicating each other’s roles, but rather complementing and supporting one another.

I call upon the implementers of health programs to re-examine the approach and implementation methods that have not yielded results.

In the coming year, our emphasis will be to critically engage policy makers and those planning for the health sector to cause some operational reforms that will bring about the improvement of service delivery. I call upon all stakeholders to work with us to ensure that health service delivery is improved.

For God and my Country

Dr. Diana Atwine Kanzira

Director – MHSDMU

Director’s Foreword



Content Page

1.0 About MHSDMU 4

1.1 An Overview of MHSDMU’s Achievements 5

Part A

2.0 Introduction 9

2.1 Heath Workforce 10

3.0 Heath Service Delivery 17

4.0 Medical Products, Vaccines and Technology 23

5.0 Health Financing 28

6.0 Leadership, Stewardship and Governance 32

7.0 Health Information Systems 36

8.0 MHSDMU’s Upcoming Activities 38

Part B: District Findings

9.1 Adjumani District 39

9.2 Buvuma District 42

9.3 Hoima District 47

9.4 Jinja District 55

9.5 Kalangala District 58

9.6 Yumbe District 62

9.7 Kiryandongo District 66

9.8 Arua District 70

9.9 Sheema District 74

9.10 Kibaale District 78

9.11 Moyo District 81

Appendices

Appendix 1: Court Cases 85

Appendix 2: Radio Shows 90

ANNUAL REPORT 20134


1.0 About MHSDMU

The Medicines and Health Service Delivery Monitoring Unit (MHSDMU), also called The Unit, is a department set up in 2009 by a presidential instrument to improve health service delivery. Its mission is to monitor and support an efficient and accountable national health care system which provides affordable quality services to the Ugandan population.

MHSDMU’s vision is that of a healthy and socio- economically productive Ugandan population supported by an effective and responsive health care system. MHSDMU’s hallmark is its commitment to the double- edged principle of both monitoring and strengthening the health system to achieve positive sustainable health sector results.

MHSDMU’s Strategic Objectives

1 2 3Monitor health care service delivery in

Uganda

Strengthen the Ugandan health system

Improve citizen ownership of health

services

The Unit strongly believes in the notion of collaborative partnership working with existing structures to register health gains for the Ugandan population. MHSDMU’s collaborators include: The Ministry of Health, Local Governments, Health Professional Councils, the Judiciary, Uganda Police Force, World Health Organization (WHO), United Nations Children’s Fund (UNICEF), DFID, Inspectorate of Government and Makerere Medical School among others.

MHSDMU’s work is multi-disciplinary and evidence-based, and information is the backbone for the success of its operations. Information sources include but are not limited to mTrac, the toll free line, partners like MoH, ISO and Police, politicians, health workers, public complaints and whistle blowers.



1.1 An Overview of MHSDMU’s Achievements

In 2013, MHSDMU…

Monitored

• 239healthfacilities,including12hospitals,in13districts

Conducted

• FinancialauditswhichunearthedmismanagementofShs.8,076,823,197UGX

• Human resource audits and enabled 369 health workers to access thepayroll

• Research on the HMIS capacity, specifically computer inventory, in 85districts

• 10communitydialogueandsensitisationcampaigns

Recovered

• Shs.873,220,000UGXthroughrefundsandcourtcases

• StolenequipmentandkitsworthShs.148,000,000UGX

Generated

• 67criminalcasesandsecured20convictions

Trained

• Sixdistrictsinpropermedicinesmanagement

Closed

• OneIllegaltrainingschoolfornurses

Exposed and Halted

• Shoddyworknotdemonstratingvalueformoney

• Fourunqualifiedpersonnelimpersonatingashealthworkers

ANNUAL REPORT 20136


MH

SDM

U A

CHIE

VEM

ENTS

IN F

Y 20

12-2

013

The

Tabl

e be

low

sum

mar

izes

MH

SDM

U’S

ach

ieve

men

ts.

HEAL

TH S

YSTE

M

BLO

CKM

HSDM

U 20

13

ACTI

VITY

ACHI

EVEM

ENT

Serv

ice D

elive

ryM

onito

ring

and

supe

rvisi

on o

f fac

ilitie

sM

onito

ring

activ

ities

were

car

ried

out i

n 1

2 di

stric

ts o

f whi

ch 1

3 ho

spita

ls an

d 23

9 he

alth

cen

ters

wer

e vis

ited.

Pr

omot

ing

Patie

nt

Safe

ty a

nd A

dher

ence

to

Qua

lity P

roce

dure

s

Vario

us c

ases

of m

edica

l neg

ligen

ce (c

rimin

al o

r adm

inist

rativ

e) w

ere

rece

ived

and

forw

arde

d fo

r act

ion

to th

e re

spec

tive

offic

es lik

e th

e Ug

anda

Med

ical C

ounc

il an

d th

e Po

lice.

Unea

rthin

g &

Stop

ping

Unq

ualifi

ed P

erso

nnel

/ qua

cks:

M

HSDM

U in

vest

igat

ed a

cas

e re

gard

ing

an M

oH o

fficia

l who

was

impe

rson

atin

g as

an

engi

neer

. The

per

son

had

been

em

ploy

ed b

y M

OH

as a

Prin

cipal

en

gine

er th

e ca

se is

bef

ore

cour

t.

An

indi

vidua

l was

arre

sted

in Y

umbe

for c

arry

ing

out o

pera

tions

beh

ind

his

drug

sho

p, a

nd y

et h

e is

not a

qua

lified

hea

lth w

orke

r.

One

suc

h op

erat

ion

led

to th

e de

ath

of a

wom

an. H

e wa

s fin

ed 5

,000

,000

/=.

'

'Dr''

Kish

Kay

angw

e a

form

er in

-cha

rge

Kitw

e HC

IV w

as a

lso a

rrest

ed fo

r im

pers

onat

ion

as a

med

ical d

octo

r and

was

con

victe

d.

Ano

ther

qua

ck w

as a

rrest

ed tr

eatin

g pa

tient

s in

thei

r hom

es a

nd th

e m

atte

r is

in c

ourt.

Mos

quito

Net

Dist

ribut

ion

MHS

DMU

is de

eply

invo

lved

in th

e pl

anni

ng o

f the

nat

iona

l (m

ass)

mos

quito

net

dist

ribut

ion

exer

cise.

Our

role

is th

at o

f mon

itorin

g th

e ex

ercis

e an

d su

ppor

ting

othe

r sta

keho

lder

s to

ens

ure

trans

pare

ncy

and

equi

tabl

e di

strib

utio

n.

Med

icine

s, Va

ccin

es&

Tech

nolo

gies

Man

agem

ent o

f M

edici

nes

& re

late

d Su

pplie

s

M

HSDM

U wo

rked

with

Blo

od B

ank

to s

ecur

e re

leas

e of

blo

od te

stin

g kit

s th

at w

ere

stuc

k at

Cus

tom

s of

fice

in U

RA

Rec

over

ed H

IV te

stin

g kit

s wo

rth 2

0,00

0,00

0/=

in T

oror

o CR

B 12

16/2

012.

One

of t

he s

uspe

cts

plea

ded

guilty

and

was

fine

d 2,

000,

000/

= wh

ile th

e re

st a

re s

till

unde

rgoi

ng tr

ial in

Tor

oro

mag

istra

te c

ourt.

R

ecov

ered

an

asso

rtmen

t of l

abor

ator

y kit

s wo

rth 3

6,00

0,00

0/=

from

MED

TEC

H (E

.A) L

TD. T

he s

uspe

cts

were

cha

rged

in M

akin

dye

cour

t.

Rec

over

ed a

n as

sortm

ent o

f lab

orat

ory

kits

and

HIV

test

ing

kits

worth

70,

000,

000/

= fro

m a

sch

ool la

b sh

op a

long

Willi

am s

treet

.

Hel

ped

redu

ce s

tock

out

s: T

he in

ciden

ce o

f dru

g st

ock

outs

has

dec

reas

ed d

ue to

con

tinuo

us e

ngag

emen

t of N

MS

in s

tream

linin

g its

ope

ratio

ns. A

ll hea

lth

cent

res

visite

d in

201

3 ha

d m

ost o

f the

ess

entia

l med

icine

s in

sto

ck.

P

rovid

ed tr

aini

ng in

dru

g m

anag

emen

t: M

HSDM

U’s

drug

aud

its in

sev

eral

hea

lth fa

cilitie

s an

d ho

spita

ls ha

ve le

d to

disc

over

y of

poo

r dru

g m

anag

emen

ts

syst

ems

and

reco

mm

enda

tions

hav

e be

en m

ade

to th

e co

ncer

ned

offic

ials.

The

se in

clude

hea

lth c

ente

r In-

Char

ges,

sto

re m

anag

ers,

hos

pita

l dire

ctor

s an

d di

stric

t hea

lth o

ffice

rs. T

he M

HSDM

U te

am id

entif

ies

the

prob

lem

s bu

t mos

t im

porta

ntly

cond

ucts

ons

ite te

achi

ng in

dru

g in

vent

ory,

requ

isitio

n an

d iss

ue

form

ats

and

disp

ensin

g lo

gs. F

ollo

w-up

has

sho

wn th

at th

ere

has

been

impr

ovem

ent i

n dr

ug m

anag

emen

t in

the

area

s vis

ited.

I

nter

cept

ed a

con

signm

ent o

f 500

0 do

ses

of F

luco

nazo

le e

xpire

d m

edici

nes

that

had

bee

n cle

ared

by

URA

onto

the

mar

ket d

espi

te re

ject

ion

by N

DA.

R

ecov

ered

4 s

olar

pan

els

that

had

bee

n st

olen

from

Kiry

ando

ngo

Hosp

ital.

R

ecov

ered

all t

he th

eatre

equ

ipm

ent t

hat h

ad g

one

miss

ing

in B

ukas

a HC

IV in

Kal

anga

la D

istric

t.

Rec

over

ed a

n X-

ray

mac

hine

wor

th 2

0,00

0,00

0/=

sto

len

from

Atu

tur H

ospi

tal in

Kum

i dist

rict a

nd ta

ken

to a

priv

ate

clini

c ca

lled

Awoj

a M

edica

l Cen

tre. T

wo

heal

th w

orke

rs a

re o

n in

terd

ictio

n an

d th

e ca

se is

bef

ore

DPP.

R

ecov

ered

a d

oubl

e ca

bin

that

was

sto

len

from

Kap

chor

wa d

istric

t and

foun

d in

gar

age

in M

bale

.

Rec

over

ed tw

o m

otor

cycle

s an

d tw

o so

lar p

anel

s be

long

ing

to K

apoc

horw

a he

alth

dep

artm

ent.

T

aske

d th

e Si

ronk

o di

stric

t lea

ders

hip

to re

turn

the

doub

le c

abin

they

had

take

n fro

m th

e DH

Os

offic

e.



HEAL

TH S

YSTE

M

BLO

CKM

HSDM

U 20

13

ACTI

VITY

ACHI

EVEM

ENT

Hum

an

Reso

urce

s fo

r He

alth

Heal

th W

orke

rAu

dits

H

ealth

wor

ker a

udits

wer

e do

ne in

hea

lth fa

cilitie

s vis

ited

usin

g se

lf-ad

min

ister

ed h

ead

coun

t too

ls. H

ealth

wor

kers

who

had

pay

roll r

elat

ed is

sues

wer

e he

lped

by

forw

ardi

ng th

eir c

ompl

aint

s to

the

conc

erne

d of

fices

like

the

CAO

and

Min

istry

of P

ublic

Ser

vice.

I

n Si

ronk

o di

stric

t, 33

hea

lth w

orke

rs w

ere

help

ed to

acc

ess

the

payr

oll,

while

in M

asak

a th

e nu

mbe

r was

65

Kab

ale

186

and

Arua

85.

Unifo

rm D

rive

On

beha

lf of

MoH

, MHS

DMU

colle

cted

per

sona

l dat

a fo

r all g

over

nmen

t hea

lth w

orke

rs in

the

coun

try fo

r the

pur

pose

s of

mak

ing

unifo

rms.

Thi

s da

ta h

as b

een

subm

itted

to N

MS

and

unifo

rms

are

bein

g m

ade.

Lead

ersh

ip,

Stew

ards

hip

and

Gov

erna

nce

Syst

ems

Stre

ngth

enin

g an

d In

stitu

tiona

l Ca

pacit

y Bu

ildin

g

M

HSDM

U to

geth

er w

ith M

OH

and

Mul

ago

hosp

ital h

ave

agre

ed to

form

mon

thly

roun

d ta

ble

disc

ussio

ns to

spe

cifica

lly re

view

and

addr

ess

the

prob

lem

s of

M

ulag

o ho

spita

l.

MHS

DMU

has

been

inst

rum

enta

l in c

oord

inat

ing

mee

tings

with

regu

lato

rs in

the

heal

th s

ecto

r like

Uga

nda

Nurs

es a

nd M

idwi

fery

Cou

ncil a

nd M

inist

ry o

f Ed

ucat

ion

to s

tream

line

licen

sure

of n

urse

s/m

idwi

ves

and

train

ing

inst

itutio

ns.

P

rese

ntat

ions

of t

he fi

ndin

gs in

the

heal

th fa

cilitie

s, b

est m

edica

l pra

ctice

s an

d m

edico

lega

l issu

es w

ere

mad

e to

foru

ms

of h

ealth

wor

kers

’ Jin

ja S

choo

l of

Nurs

ing

and

Mid

wife

ry, H

oim

a, A

rua,

and

Jin

ja R

egio

nal R

efer

ral h

ospi

tals,

Mity

ana,

Adj

uman

i, Ka

gadi

, Moy

o, K

obok

o, K

iryan

dong

o an

d Yu

mbe

hos

pita

ls,

dist

ricts

offi

cials-

: Jin

ja, A

rua,

Yum

be, A

djum

ani,

Kala

ngal

a, B

uvum

a, H

oim

a, K

ibaa

le, K

iryan

dong

o, M

oyo,

and

Mity

ana.

Org

anisi

ng

Com

mun

ity D

ialo

gue

Se

ssio

ns

I

n re

spon

se to

com

plai

nts

rece

ived

a te

am w

as s

ent t

o Ly

anto

nde

dist

rict f

ollo

wing

a p

etitio

n by

the

com

mun

ity. M

any

alle

gatio

ns o

f med

ical n

eglig

ence

we

re le

vied

agai

nst a

one

Dr.

Kizz

a, b

oth

sides

wer

e gi

ven

an o

ppor

tuni

ty to

pre

sent

and

in th

e en

d th

e do

ctor

apo

logi

zed

to th

e co

mm

unity

. In

one

parti

cula

r cas

e, h

e pr

omise

d to

han

dle

it in

divid

ually

with

the

com

plai

nant

. The

com

mun

ity a

ccep

ted

his

apol

ogy

and

forg

ave

him

.

In

Kaba

role

dist

rict,

ther

e we

re a

llega

tions

of e

xtor

tion

and

paym

ent f

or X

-ray

serv

ices

at th

e ho

spita

l. A

mee

ting

was

held

bet

ween

hea

lth w

orke

rs a

nd th

e co

mm

unity

and

cur

rent

ly th

ere

are

no lo

nger

com

plai

nts

in th

is re

gard

.

Oth

er is

sues

wer

e re

solve

d th

roug

h th

e sa

me

appr

oach

in K

aliro

, Kita

gata

, Kas

ese

and

Kaba

le.

Heal

th

Man

agem

ent

Info

rmat

ion

Syst

ems

Gho

st H

ealth

ce

nter

sM

HSDM

U co

llabo

rate

d wi

th o

ther

hea

lth s

take

hold

ers

to c

lean

up

the

heal

th c

entre

inve

ntor

y to

wee

d ou

t all t

he g

host

facil

ities

in th

eco

untry

.

Equi

pmen

tin

vent

ory

I

nven

tory

of e

quip

men

t in

vario

us h

ealth

facil

ities

has

been

con

duct

ed a

nd th

e cu

lture

of p

erio

dic

inve

ntor

y ha

s be

en in

culca

ted

i

nto

all t

he h

ealth

cen

ters

and

hos

pita

ls vis

ited.

A

t the

new

ly co

nstru

cted

Chi

na-U

gand

a Fr

iend

ship

Hos

pita

l in N

agur

u, in

vent

ory

of th

e al

l the

equ

ipm

ent w

as d

one

by M

HSDM

U to

geth

er w

ith th

e ho

spita

l st

aff.

Ther

e is

a lis

t the

y ca

n no

w re

fer t

o pe

riodi

cally

.

Heal

th F

inan

cing

Fina

ncia

l Aud

iting

F

inan

cial a

udits

hav

e be

en c

ondu

cted

in 1

2 di

stric

ts, 1

3 ho

spita

ls an

d 23

9 he

alth

cen

tres.

W

e ha

ve a

lso e

nabl

ed p

eopl

e to

stre

amlin

e th

e fin

ancia

l sys

tem

s an

d re

fund

mon

ies

prev

ious

ly m

isman

aged

.

ANNUAL REPORT 20138




PART A: THEMATIC FINDINGS2.0 INTRODUCTION

In 2013 MHSDMU undertook comprehensive monitoring for 239 health facilities in 13 districts. Our aim was not only to monitor but also contribute to system strengthening. This report adopts the WHO (2007) definition of a health system as “all organisations, people and actions whose primary intent is to promote, restore or maintain health”. A health system is more than government hospitals or heath centres, and this report will show that MHSDMU’s work is not limited to public facilities.

In terms of structuring, this report will draw from a universally acceptable health system model. The WHO, World Bank and various governments around the world have a common understanding of key elements of a health system known as “building blocks”. “Building blocks” are the aims and desirable characteristics any health system should have; some would describe them as critical success factors that are essential to a health system’s survival (Johnson & Stoskopf, 20101). Health system “building blocks” are six in number and are listed below:

1. Service delivery2. Medical Technology3. Health workforce4. Health Financing5. Health information6. Leadership and governance

The findings of this report will be arranged according to the building blocks listed above.

A total of 239 health facilities were visited including 12 hospitals, 16 HCIVs, 87 HCIIIs and 124 HCIIs. Table 1 below shows the districts and health facilities where comprehensive monitoring was undertaken by MHSDMU.

Table 1: Health facilities visited in 2013

District HCII HCIII HCIV Hospital AllKoboko 0 0 1 0 1Moyo 0 0 0 1 1Sheema 0 0 2 1 3Buvuma 4 3 1 0 8Kalangala 3 6 1 0 10Kiryandongo 12 5 0 1 18Yumbe 12 7 1 1 21Mityana 19 1 2 1 23Arua 3 17 3 1 24Adjumani 18 6 0 1 25Kibaale 10 14 3 1 28Hoima 15 19 2 1 37Jinja 28 9 1 2 40

All 124 87 17 11 239

The next section shows MHSDMU’s assessment of these health facilities according to the six health system blocks. Although this section presents thematic findings irrespective of districts to give the national picture, the latter part of this report (PART B) will present district-specific findings.

1 Johnson, J.A. and Stoskopf, C.H. (2010) Comparative Health Systems: Global Perspectives. Jones & Bartlett Publishers.

ANNUAL REPORT 201310


2.1 Health WorkforceA well-performing health workforce is one that works in ways that are responsive, fair and efficient to achieve the best health outcomes possible, given available resources and circumstances (i.e. there are sufficient staff, fairly distributed; they are competent, responsive and productive).

It is well documented that Uganda faces a human resources for health (HRH) crisis and the 13 districts visited were no exception but rather lent credence to the fact that the few HRH are almost incapable of achieving the best health outcomes for Uganda’s population. Figure 1 below shows the magnitude of under-staffing in the health facilities visited:

Figure 1: Positions filled Vis-a-vis number approved from HCII's to Hospitals.

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Non-Clinical Type of Sta� Clinic

Positions FilledSta� Present

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3

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1412

10 10

3137

26 25

153

119

9197

32

30

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8

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24

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As Figure 1 shows, not only was the health workforce less than required but it was also found to be unevenly distributed across clinical and non-clinical cardres. Moreover it was also evident that proper planning on how best to optimize the limited HRH was lacking, for example critical staff taking leave or attending workshops without consideration of how this would affect health facility functioning. The limited HRH and lack of proper HR management practices has far-reaching consequences for service delivery and also negatively impacts on all the other health system blocks as will be seen in the latter sections. Tables 2 – 5 overleaf show a more detailed picture of the human resource structure at the different levels of health facilities.



Table 2: Human resource structure at HCIIs

Staff category Number recommended by MoH Average staffing levels at the facility

Positions filled On duty Currently

presentOn official

leave

Clinical Staff** 05 04 04 03 01 - - -

Non-Clinical Staff*** 04 02 02 02 - - - -

All staff 09 05 06 05 01 - - -

** Clinical Staff include Enrolled midwife, Enrolled Nurse, Health assistant, Nursing assistant

*** Non-clinical staff include Askari and Porter

Table 3: Human resource structure at HCIIIs

Staff category Number recommended by MoH Average staffing levels at the facility

Positions filled On duty Currently

presentOn official

leave

Clinical Staff** 12 11 09 07 -

Non-clinical Staff*** 07 06 05 04 -

All staff 18 17 14 11 -

** Clinical Staff include: Clinical Officer, Enrolled Midwife, Enrolled Nurse, Health Assistant, Nursing Assistant, Nursing Officer

*** Non-clinical staff include: Askari, Health information assistant, Laboratory Assistant, Laboratory Technician and Porter

Table 4: Human resource structure at HCIVs

Staff category Number recommended by MoH Mean staffing levels at the facility

Positions filled

On duty

Currently present

On official leave

Clinical Staff** 31 28 24 24 02Non-clinical Staff*** 16 14 12 12 01All staff 47 42 36 36 03

** Clinical Staff include: Anesthetic Attendant, Anesthetic Officer, Assistant Entomological officer, Assistant Health Educator, Clinical Officer, Enrolled Midwife, Enrolled Nurse, Enrolled Psychiatric Nurse, Health Assistant, Nursing Officer, Ophthalmic Clinical Officer, Public Health Dental Officer, Public Health Dental Officer, Senior Medical Officer, Senior Nursing Officer, Theater Assistant

*** Non-clinical staff include: Accounts Assistant, Askari, Cold Chain Assistant, Driver, Health Inspector, Health Information Assistant, Laboratory Assistant, Laboratory Technician, Officer Typist, Porter, Stores Assistant



Table 5: Human resource structure at Hospitals

Staff category Number recommended by MoH Mean staffing levels at the facility

Positions filled

On duty

Currently present

On Annual leave

Taking further studies

On Sick Leave

Attending workshop

Clinical Staff** 145 113 91 84 04 15 02 02Non-clinical Staff*** 39 43 32 32 01

All staff 184 156 123 126 04 15 02 03

** Clinical Staff include: Anesthetic Attendant, Anesthetic Officer, Assistant Entomological officer, Assistant Health Educator, Clinical Officer, Dental Attendant, Dental Surgeon, Enrolled Midwife, Enrolled Nurse, Enrolled Psychiatric Nurse, Health Educator, Medical Officer, Medical Social Worker, Nursing Assistant, Nursing Officer, Ophthalmic Clinical Officer, Orthopedic Officer, Principal Medical Officer, Principal Nursing Officer, Public Health Dental Officer, Public Health Dental Officer, Senior Medical Officer, Senior Nursing Officer, Senior Clinical Officer

*** Non-clinical staff include: Accounts Assistant, Artisans’ Mate, Askari, Cook, Dark room Attendant, Driver, Health Inspector, Health Information Assistant, Hospital Administrator, Laboratory Assistant, Laboratory Technician, Mortuary Attendant, Nutritionist, Personnel Officer, Pharmacist, Physiogtherapist, Radiographer, Records Assistant, Senior Accounts Assistant, Senior Hospital Administrator, Senior Laboratory Technologist, Officer Typist, Stenographer Secretary, Porter, Stores Assistant, Occupation Therapist, Supplies Officer

2.2 Absenteeism of Health Facility Heads

Faced with the problem of understaffing, absenteeism also negatively affects the functionality of health facilities at all levels. This is worsened when the absent staff are the ones expected to provide leadership to the smooth running of the health facility. It is hard to operate effectively without leadership or robust management structures in place. The absence of health facility in-charges not only demotivates other workers but also makes the health facility lose credibility among its clients and community.

Furthermore, absenteeism puts people in a precarious position where they are left without choices for healthcare and leads to complication of certain health conditions and unnecessarily deaths. A case in point is Lewa HCII in Adjumani district which was found closed and without any form of communication from the In-Charge regarding his whereabouts. Patients, some in critical condition, were found waiting outside and MHSDMU had to transport them to Aliwara HCIII for treatment as shown in picture below:

Lewa HCII in Adjumani District closed with patients waiting that were later taken to Aliwara HCIII for treatment

Patients and other community members reported that it was not the first time they had come to a closed facility; infact the In-Charge at Lewa HCII was found to have been present at the facility for a total of less than 21 days in the previous two months. This scenario at Lewa HCII is no different from many other health facilities that MHSDMU has visited.



2.2.1 Reasons for Absenteeism

The reasons given for absenteeism of health workers, particularly In- Charges, are even more disturbing; the majority of them were found to be absent on official duty which included attending legit workshops or training to build their capacity, while others were undertaking private engagements or merely absconded from duty without giving any reason as shown in Figure 2 below:

Figure 2: Reasons given for Absenteeism of health facility In-Charges

It is therefore not surprising that, with the absence of many health facility heads and lack of HR systems in place to effectively manage existing staff, adherence to the attendance policy by other staff was also found to be poor. Generally, the expected attendance monitors for staff such as register books or leave forms were found to be weakly enforced and nearly non-existence and this could partly explain the high levels of absenteeism among other staff members at health facilities as Table 6 below illustrates:

Table 6: Staff Attendance Monitoring

HCII HCIII HCIV/Hosp All

Facility has a functional register book 54 (45%) 54 (68%) 23 (88%) 131 (58%)

Facility has a system of granting leave 42 (76%) 40 (80%) 15 (88%) 97 (80%)

On-the spot presence of the facility in-charge 44 (52%) 34 (57%) 14 (88%) 92 (58%)

Average days the in-charge was present in last 2months 25 23 15 22

2.2.2 The Role of Community & Health Management Committees

Ideally the local community should play a monitoring role and hold their service providers (in this case, health workers) accountable. However as seen in the case of the waiting patients found at Lewa, the community continues to be made powerless and resigned about the nature of services they receive. In addition to the community, all health facilities are expected to have Health Management Committees (HMC) which meet periodically to oversee service delivery. Except for a few, the majority (93.7%) of 239 facilities visited were found to have HMCs in place. It is commendable that a large number of HMCs (92%) met quarterly and only a few (6%) met only when necessary. However the nature and perceived seriousness of HMC meetings as well as the power they wield over health facilities was found to be largely questionable. Furthermore, it was found that some HMC meetings



tended to operate in an informal way and with no specific agenda or records (for example minutes) of what was discussed. Such weak management structures could partly explain the dysfunction of many health facilities.

What also becomes clear is that the Health System Blocks introduced in section 1.0 of this report are interrelated and falling short of one automatically has a negative impact on another. For example in this case the absence of strong leadership and management structures can be correlated with absenteeism of health workers which ultimately leads to poor service delivery. This is an argument which will continue to be developed throughout this report, and MHSDMU believes that there is no single magic bullet to tackle health system issues but rather approach and address them in a holistic manner.

2.3 Health Worker Uniforms

MHSDMU’s previous reports (2011 and 2012) have shown that many health workers do not have uniforms and how this has been detrimental in various ways including disrespect to the health profession and contributing to the high cases of impersonation by unscrupulous people. MHSDMU has often made a case for why health workers should be dressed in uniform. The evidence shows that attire has a direct impact on patient reactions. Some research shows that an appropriately dressed health worker gives the impression that patient contact is an important event and that it takes time to prepare for it, whereas the unkempt health worker can be perceived as unskilled and uncaring

2.

Patients all over the world have been noted to favor health workers in professional attire. Wearing professional dress while providing patient care favorably influences trust and confidence-building in the medical encounter (Rehman Etal, 2005)3.

Moyo hospital staff in theatre and OPD dressed in their uniform

In March 2013, MHSDMU was tasked by the Ministry of Health to compile the uniform specifications of all health workers serving in public health facilities in Uganda. The uniform kit for nurses also included white shoes. The cadres included nurses, doctors and allied health professions. This was primarily aimed at providing the health workers with their standard professional dress code but also for easy identification by patients, protection from infectious material and as a deterrent of masquerading ‘health workers’ that have infiltrated these health facilities.

2 Brase, G.L. and Richmond, J. (2010) The White-Coat Effect: Physician Attire and Perceived Authority, Friendliness and Attractiveness.

3 Rehman S.U., Nietert, P.J., Cope, D.W. and Kilpatrick, A.O. (2005) What to wear today? Effect of doctor's attire on the trust and confidence of patients. Am J Med. 2005 Nov;118 (11):1279-86.



Ministry of Health (MoH) provided a standard template for the specifics to be captured. MHSDMU’s role was to collect this information and pass it on to NMS whose role was to procure the uniforms. A standard for the uniforms had earlier been agreed on earlier by MoH. This included embroidery of the health workers name and the Uganda flag.

The National Medical Stores (NMS) run an advert in three local dailies to relay this information to all District Health Officers and Chief Administrative officers. Lists from health facilities across the country including Mulago National Referral hospital were received by MHSDMU and forwarded to NMS. Some districts have already started receiving consignments of the uniforms.

Newly-made uniform with health worker’s name tag and the flag of Uganda

2.4 Staff Accommodation

Table 6 shows that in all the 239 health facilities monitored in 13 districts, 178 had staff houses whereas only 43 facilities did not. 18 health facilities were found closed and abandoned and MHSDMU could not gather this data. In all the 178 facilities found with good staff houses (for example Hoima RRH as shown overleaf ). 176 staff houses / quarters were being utilised by the health workers and two staff quarters were found unutilised. The lack of staff accommodation was noted to be severe in the Island districts of Buvuma and Kalangala where only two HCIVs had staff houses that were dilapidated. The rest of the district did not have accommodation for health workers as shown below.

Table 7: Presence and status of staff houses at the facility

HCII HCIII HCIV/Hsp All

Facility has staff housesNo 40 (34%) 3 (4%) 0 43 (19%)Yes 79 (66%) 74 (96%) 25 (100%) 178 (81%)

Number of occupied staff Houses

None 25 (32%) 29 (40%) 6 (24%) 60 (34%)One house 25 (32%) 7 (10%) 2 (8%) 34 (19%)Two houses 13 (17%) 16 (22%) 1 (4%) 30 (17%)Three houses 11 (14%) 8 (11%) 0 19 (11%)Four + Houses 4 (5%) 13 (18%) 16 (64%) 33 (19%)

Table 7 also shows that 34% of the staff houses provided by the government were unoccupied by the time of the visit, with HC IIIs the most affected (40%). This finding is worrying, especially considering



the fact that government invests lots of money in their construction. Observational findings during the field visits revealed that some health workers hire out their officially allocated staff houses as a way of earning extra income.

The newly-built staff houses in Hoima Regional Referral Hospital



3.0 Health Service DeliveryGood health services are those that deliver effective, safe, quality personal and non-personal health interventions to those who need them, when and where needed, with minimum waste of resources.

Service delivery has been defined as “the way inputs are combined to allow the delivery of a series of interventions or health actions” (WHO 2001) and it is the main function the health system needs to perform (WHO, 2000). The service provision function of the health system is the most familiar; infact the entire health system is often identified with just service delivery.

MHSDMU focused on not only the presence of various services in health facilities but also whether they are functioning or not. For example the existence of a theatre does not always mean that theatre services are actually being offered at that facility; and the reason could be lack of skilled personnel or tools to use. Below is data on some of the existing services including Out Patient Department (OPD), maternity and antenatal care among others.

3.1 Functionality of Out-Patient Departments

Most OPDs visited were found to be functional, adhering to basic standards in hygiene and attending to patients as expected. The average attendance level at most OPDs was found to be decent and within expected range as shown in Figure 3 below:

Figure 3: Numbers of patience loads at the out-patient department

The majority of OPDs also had observation (88%) and emergency (80%) rooms as shown in Table 8 below:

Table 8: Functionality of the Out-patients' Department (OPD)


Status of the facility’s OPD Clean/tidy 108 (93%) 56 (79%) 24 (92%) 188 (88%)

Dirty/unkempt 8 (7%) 15 (21%) 2 (8%) 25 (12%)

OPD has an observational room 82 (85%) 49 (91%) 23 (92%) 154 (88%)

OPD has an emergency room 58 (84%) 42 (72%) 15 (88%) 115 (80%)

OPD register book is present and functional 63 (59%) 57 (83%) 18 (69%) 138 (69%)



What was missing, however, was proper record keeping in a substantial proportion (31% average) OPDs. As Table 8 above shows facilities these did not have register books in OPD; moreover it was mostly HCIIs (at 41%) without this information yet the bulk of their work is in OPD. The lack of this critical information, also a building block of health systems (HMIS), presents challenges to the nature and impact of service delivery.

3.2 Presence and Functionality of In-Patients Department

Uganda’s health system is organised in such a way that all facilities from Health Centre III should provide admission services to patients. However this is not the case in many HCIIIs as MHSDMU’s previous reports have shown. MHSDMU’s 2013 monitoring in the 13 districts found that the same problem existed and admission services are lacking at many health facilities, especially at HCIIIs. Generally, HCIII’s have lower volumes of admissions across districts; and Hoima’s admission levels are notably high due to support from the Infectious Diseases Institute (IDI). Figure 4 below gives a cross-sectional representation of admission volumes at various facilities in the previous month.

Figure 4: Average number of patients admitted during the previous month of visit by district.

From Figure 4 above it can be argued that, whereas there may be other factors to consider (for example geographical context, season of the year, area population and location), the key issue that stands out is that there are very low levels of admissions and the reasons for this range from lack of infrastructure, space or even personnel to provide the required services. So again the health system blocks of service delivery, financing and workforce intersect with all the others. Table 9 below provides further illustration:



Table 9: Presence and functionality of in-patients departments

HCIII HCIV Hospital All

Facility admits 39 (55%) 19 (95%) 5 (100%) 63 (66%)

Functional children wards available Mean 1 1 2 1

Functional adult wards available Mean 2 2 6 3

Children beds available Mean 8 10 44 14

Children beds currently occupied Mean 5 9 43 11

Adult beds available Mean 12 22 142 28

Adult beds occupied Mean 4 16 130 14

Beds have clean mattresses 25 (86%) 8 (80%) 3 (100%) 36 (86%)

Beds have clean sheets 11 (39%) 2 (20%) 1 (33%) 14 (34%)

Wards have duty rosters 22 (54%) 9 (56%) 4 (100%) 35 (57%)

Wards have patient registers 29 (78%) 9 (82%) 3 (100%) 41 (80%)

As Table 9 above shows, almost half (45%) of the HCIIIs visited did not have a functional In-Patient Department as expected and whereas many HCIVs and hospitals did offer admissions and had beds, the majority of them (66%) were found not to have clean beddings. This problem was especially noticed at HCIVs with 77% of the visited facilities not having clean sheets. Furthermore, almost (44%) of all the health facilities visited did not have visible duty rosters on the wards and it was impossible to tell which health worker was on duty, especially those found off-station as shown below.

3.3 Presence and Functionality of Maternity / Antenatal Services:

Maternal health is a global health priority that Uganda as a nation also subscribes to. The commitment of government and her partners towards preventing maternal deaths and providing the best services can be seen in the improvements made, although there is still a long way to go. The majority of health facilities visited, including HCIIs, were found to provide antenatal (73%), maternity (77%) and PMTCT (96%) services. Unlike what was found in most OPD sections, the levels of record keeping for maternity services was impressive at 94%. Table 10 presents this information.

Table 10: Presence and functionality of maternity / antenatal services


Facility provides antenatal services 70 (96%) 19 (100%) 5 (100%) 94 (97%)

Average visits made last month 96 173 293 122

Facility provides PMTCT services 62 (95%) 13 (100%) 4 (100%) 79 (96%)

Facility provides maternity services 61 (95%) 13 (100%) 4 (100%) 78 (96%)

Maternity has patient registers 59 (97%) 16 (100%) 4 (100%) 79 (98%)

Average deliveries made last month 21 61 126 35

3.4 Presence and Functionality of Theatres

Fully functional theatre services are expected from HCIVs upwards, while HCIIIs should be in a position to handle minor surgical procedures. However this was not found to be the case, beginning with the fact that only 36% of facilities from HCIVs had theatres in place. A positive finding though is that, for those HCIVs and hospitals which had theatres, both major and minor surgeries were available to the



population. It is also worth noting here that there were variations for facilities with theatres in terms of infrastructure, equipment and personnel as shown below:

The well-equipped & functional theatre at Moyo Hospital

Table 11 below shows the nature of services as far as theatres are concerned.

HCIV (n=5) Hospitals (n=5) All (n=10)

Theatre present at the facility 5 (100%) 5 (100%) 10 (100%)

Average surgeries performed last month Major surgeries 23 49 40

Minor surgeries 49 151 110

Both major and minor - 98 98

Generally theatre services were found to be at an all-time low in most districts. A good example is Jinja district which, by the time of MHSDMU visit, did not have a functional theater in all its HCIVs. The theatre at Bugembe HCIV had been turned into store while other districts like Kalangala had totally abandoned their theatres.

3.5 Presence and Functionality of LaboratoriesApart from HCIIs of which only 10% had laboratories, the majority of the higher-level health facilities had functional and well-kept laboratories performing the core tests like malaria and HIV. A key challenge with these laboratories across all levels is that they experienced stock-outs of re-agents which becomes disruptive in their bid to provide accurate and real-time clinical tests. Table 12 below shows the state of laboratories:

Table 12: Presence and functionality of laboratory services at facilities


Facility has a functional laboratory 59 (87%) 14 (100%) 4 (100%) 77 (90%)

Status of the laboratory Clean/tidy 46 (84%) 14 (100%) 4 (100%) 64 (88%)

Dirty/unkempt 9 (16%) - - 9 (12%)

Laboratory performs HIV tests 67 (94%) 20 (91%) 5 (100%) 92 (94%)HIV tests performed during the past one month Mean 217 430 1358 300

Laboratory performs malaria tests 67 (94%) 20 (91%) 5 (100%) 92 (94%)Malaria tests performed during the past one month Mean 402 639 859 484

Laboratory has ever experienced a stock-out of reagents 32 (64%) 7 (54%) 3 (75%) 42 (63%)



3.6 Infection Control at Health Facilities

As part of ensuring patient safety and avoiding infections, the need for proper waste management at health facilities cannot be over-emphasised. A number of facilities visited had incinerators, appropriate rubbish bins and protective gear for health workers. 86% of the facilities visited used gloves for infection control. Table 13 below shows infection control practices in the facilities visited.

Table 13: Presence and functionality of laboratory services at the facility

HCIII HCIV Hospital AllWritten guidelines and protocols 48 (61%) 15 (68%) 2 (40%) 65 (61%)Functional hand-washing equipment 61 (77%) 16 (73%) 3 (60%) 80 (75%)Soap 65 (82%) 16 (73%) 4 (80%) 85 (80%)Disinfectants 66 (84%) 14 (64%) 3 (60%) 83 (78%)Functional sterilizing equipment 31 (39%) 12 (55%) 2 (40%) 45 (42%)Gloves 72 (91%) 17 (77%) 4 (80%) 93 (88%)Protective gear / Uniforms 47 (68%) 10 (71%) 2 (50%) 59 (68%)Sharps Disposal 67 (85%) 18 (82%) 4 (80%) 89 (84%)

Infection control bins at Moyo hospital

3.7 Utilities

3.7.1 Power

The main source of power in all the 13 district health facilities visited was solar which was found installed in 95.2% of the 239 health centres. No major complaints were raised except for thefts of solar panels in some places.

Figure 5: Presence and functionality of power facilities



3.7.2 Water:

The main water source was the water harvesting system; however, functional water tanks were found in less than half (48%) of health facilities visited. Water supply is still a challenge at many health facilities, only 14% of the facilities had piped water while 32% had functional bore holes.

Figure 6: Status of water services at the facilities visited.

3.8 Ambulances and Transport Facilities

Most hospitals and HCIVs were found with one (1) functional ambulance during MHSDMU’s visit in the 13 districts as shown below.

Table 14: Average number of transportation facilities at the facility


Ambulances Functional 0 1 1 1Non-functional 0 1 1 1

Bicycles Functional 1 2 2 2Non-functional 1 2 5 2

Motor bikes Functional 1 2 2 2Non-functional 1 1 2 1

Other official cars Functional 0 0 2 2Non-functional 0 1 0 1

It was found that only 51.2% of the facilities visited had a transport / ambulance maintenance budget. Furthermore, only 21.5% of the 239 facilities had an ambulance fuel budget whereas in 60.9% of the health facilities MHSDMU established that it is routine for patients to contribute fuel for ambulance usage.

Figure 7: Functionality of transportation facilities at the facility



4.0 Medical Products, Vaccines and Technologies

A well-functioning health system ensures equitable access to essential medical products, drugs, vaccines and technologies assured of quality safety, efficacy and cost-effectiveness, and their scientifically sound and cost-effective use.

Generally the distribution process and availability for medicines, vaccines and technologies was reported to have improved significantly over the last few years. More streamlined processes and structures were found to be in place and delivery schedules had been adhered to a large extent. There was relatively more accountability and improved record keeping for medical products shown through health facility records.

We found that most essential medicines and other supplies had been made available in the last delivery and majority (average 93%) of the health facilities visited had delivery notes confirming this. Table 15 below shows the medical supplies chain.

Table 15: Medical supplies to the facility

HCII HCIII HCIV/Hosp AllNMS delivery notes present 68 (90.67%) 66 (95.65%) 20 (95.24%) 154 (93.33%)At least one person signs on deliveries 52 (92.86%) 50 (92.59%) 14 (93.33%) 116 (92.8%)Makes reports after any deliveries 12 (18.75%) 13 (20.63%) 3 (21.43%) 28 (19.86%)Report makes financial budget of NMS 6 (14.29%) 4 (10.53%) 5 (45.45%) 15 (16.48%)Supplied kit contains most essential medicines and supplies 42 (73.68%) 50 (80.65%) 4 (66.67%) 96 (76.8%)

Kit contains some non-relevant supplies 19 (39.58%) 32 (61.54%) 2 (40%) 53 (50.48%)

Commendable levels of accountability can also be seen whereby at least one local person signs the deliveries and there were also signatures which demonstrated community accountability for medicines. Stake holders who witness delivery of medical supplies include the in-Charge, facility stores manager, LC Officials and Members of the Health Management Committee (HMC).

4.1 Expiry of Medical Supplies

Expired medicines is still a big challenge especially at the large facilities like the hospitals and HCIVs. This may be attributed to the absence of proper store management skills at these facilities and hence greater expiries. It is therefore not surprising when high volumes of expired drugs and other supplies are reported as shown in Figure 8 below:

Figure 8: Experiences with medicine expiries at the visited facilities



From the figure above, t is worth noting that HCIV’s and hospitals which make orders for their drugs show more expiries than HCIIs and HCIIIs which follow the PUSH system. It is possible that this finding could be a result of pooling of these medicines from HCIIIs and HCIIs.

Expired drugs at Aliwara HCII and Biira HCIII in Adjumani District

A plethora of explanations exists for expired medicines at higher-level health facilities which use the ‘pull’ system and these include limited absorption capacity brought about for example by understaffing as well poor storage facilities and procedures.

4.2 Storage

Most health facilities had decent storage facilities, many supported by the SURE project through USAID. Figure 9 below shows the nature and suitability of drug stores of the health facilities visited.

The relevant documentation showing accountability of the medicines was also found in nearly all (92%) facilities visited. A notable gap though was in the area of communication and feedback mechanisms between health facilities and critical bodies such as NMS as shown in Table 16 below:

Table 16: Presence and characteristics of the visited health facility stores

HCII HCIII HCIV/Hosp AllFacility has a drug store 66 (93%) 57 (90%) 15 (100%) 138 (93%)Stock / bin cards present in stores 69 (97%) 70 (99%) 22 (100%) 161 (98%)Requisition orders present in stores 54 (79%) 59 (81%) 20 (95%) 133 (82%)Vouchers present in stores 32 (65%) 31 (67%) 16 (94%) 79 (70%)Dispensing records well maintained 69 (93%) 65 (92%) 21 (91%) 155 (92%)



In terms of neatness and proper organisation of medicines stores, the scenarios were different. While some health facilities, for example Diima HCIII in Kiryandongo district, had well-organised stores; other stores were disorganized (for example Hoima RRH) with items just piled on top of others and without labels as shown in the pictures below.

Disorganised store at Hoima RRH A well-organised store At Diima HCIII

Disorganised stores make it impossible to properly account for incoming and outgoing items. Furthermore, it becomes difficult to manage expiries using the recommended FEFO method of medicines management. As part of MHSDMU’s monitoring and capacity-building strand, health facilities have been mentored in proper medicine’s management. MHSDMU has even gone ahead, when there is need, to help some health facilities (e.g Arua RRH) to organise their storage facilities as shown in the picture below.

Medicines store at Arua RRH

4.3 Management of Medical Supplies

The 1995 Constitution of Uganda gives the National Medical Stores (NMS) the mandate to procure, store and distribute medical supplies to all public facilities. Government through the Ministry of Health (MoH) operates another policy to enhance health service delivery in the private sector through an MoU with private-not-for-profit (PNFP) facilities. It allocates to various facilities through Joint Medical Stores (JMS). The mandate to ensure availability of quality, safe and efficacious cost effective medical supplies lies with the National Drug Authority (NDA). Through MoH a list of essential medicines that constitute a Kit for HCIIs and HCIIIs is made and constantly reviewed and it is this list that NMS uses. Ministry of Health has also developed HMIS tools (stock cards, issue and requisition orders and dispensing logs) on medical supplies chain management and these are distributed to all public facilities on requests made to NMS.



General Findings on Management of Medical Supplies:

• Lackofskilledandadequatehumanresourceinthehealthfacilitiesrequiredintheentireprocessof managing medical supplies. The competence in the medical and pharmaceutical knowledge of most staff members recruited leaves a lot to be desired.

• Infrastructureforstorageofmedicalsuppliesisstillanothergreatchallenge.Mosthealthfacilitieslack stores where medical supplies can be kept in good conditions to maintain the potency.

• Poorrecordkeepinginanumberofhealthfacilitiesvisited.Insomeinstancessomeitsdifficultto find a facility that has all records intact from the time medicines are delivered in the facility (delivery notes, stock cards, issue and requisition and departmental dispensing logs) to the time medicines are received by the end user.

• Poorrecordingpracticesandfalseaccountability,whichiseitherduetoincompetence,deliberateor heavy work load.

• Inafewinstancesmedicinesarestillbeingstolenfromfacilitiesatdifferentlevels(stores,wardsand dispensing centres)

• TherearemanymonitorsanddevelopmentpartnerswhooverloadstaffwithmanyconflictingHMIS tools that are designed to suit their needs and the data that they collect.

• Themajorityoffacilitiesvisiteddidnothaveasystemofaccountingforlaboratoryreagentsandtesting kits. These are grossly mismanaged and are being stolen.

• NearlyallPNFPswhichreceivefundingfromgovernmentdonotaccountforthemedicalsupplies,and they also do not use the HMIS tool as recommended by MoH. Most of the medicines are sold to patients.

• ThePharmacyandDrugsActisveryoldandoutdatedtosupplementtheNDAActinmanagementof medical supplies.

4.4 The Role of Relevant Institutions

4.4.1 National Drug Authority & Quality Control

Apart from a few Anti-malarials, ARV and condoms, NDA no longer conducts mandatory testing but rather relies on Current Good Manufacturing Practice (CGMP) inspections for the quality, safety and efficacy of medical products imported in this country. This presents an opportunity for counterfeits to flood the market with substandard products. ‘Briefcase’ products from around the world have flooded the Ugandan market. This has largely contravened section 8:4 of the NDA Act which allows importation of drugs that do not appear on the national formulary and in emergency situations. This has also been exacerbated by the fact that NDA does not have quality assurance laboratories at border posts.

Furthermore, there is no system in place to carry out surveillance of products and know what quantities have been sold and what are likely to have expired. There still exist several unscrupulous companies that repackage expired medicines and bring them back to the market.

The NDA Act can be assessed as a weak law that does not prescribe deterrent punishments to very serious offences. Whereas some sections of this Act create offences, they do not provide for sanctions.

NDA has also failed to recruit district drug inspectors within its structure and has resorted to local



government employees to supervise medical supplies within the districts. These, in most cases, are not only incompetent in the field but also have a lot of work to do at their own duty stations. As a result many have resorted to extorting and licensing illegal premises hence compromising the quality. In this regard, we recommend that NDA intensifies its quality Assessment effort regarding the quality of the products on the market.

4.4.2 National Medical Stores (NMS)

There is still a challenge of NMS supplying medical supplies with short expiry dates. Furthermore, the paperwork is incongruent with what is being delivered, for example MHSDMU found in a few cases where quantities supplied did not tally with the amounts indicated on delivery notes. The costed amounts of medical supplies on NMS tax invoices was, in some cases, not in agreement with the quantities supplied and whereas discrepancy notes were being made and submitted by the affected in-charges, no response from NMS had been recorded. The Last Mile Delivery (LMD) option lacks technical people who must play a role at the delivery point in verification of products. In most case there is no time for verification because LMD makes late deliveries beyond the stipulated time. Following feedback, this practice is being improved.

4.4.3 Recommendations

1. The NDA ACT and the Pharmacy and Drugs Act need critical amendment to suit the current existing challenges with provisions deterrent enough to stop the rampant crime in the pharmaceutical sector.

2. Government, through MoH, should embark on recruiting or training all recruited staff in the management of medical supplies. This includes use of HMIS tools, record keeping and ethical conduct. Government must also ensure there are adequate, well-furnished structures for medical supplies storage in all facilities. This will reduce on theft and hence prescriptions will be meaningful as the prescribed medicines will still be effective.

3. NDA must resume the mandatory test of all medicines that come in the country. Quality control labs must be constructed on all border posts to check on counterfeit product that enter into this country. NDA must recruit district drug inspectors to effectively and efficiently fulfill its mandate. NDA must direct more of its energy on the quality of the product but not the licensing of premises. NMS must also stop procuring medical supplies with short expiries.

4. On its part the NMS must scrutinize all it out-going orders to ensure that what is recorded on the delivery notes coincides with the quantities packed and the same costed. NMS should also train the Last Mile delivery companies on what should be done and also set deterrent punishments in cases where the norm has been contravened.

5. All monitors and development partners in health must work with the ministry and not distort existing systems/structures. They should also use the existing tools to collect the data required or involve the ministry in cases where specific information or changes are required.

6. The same system that MoH employs/ recommends in the management of medical supplies in its public facilities must be adopted in all PNFP’s for accountability purposes. Furthermore, PNFP’s must stop selling medicines donated to them by government to the public.



5.0 Health Financing

A good health financing system raised adequate funds for health, in ways that ensure people can use needed services and are protected from financial catastrophe or impoverishment associated with having to pay for them. It provides incentives for providers and users to be efficient

It is fair to say that Uganda still has a long way to go in terms of financing universal and quality healthcare. However, significant strides continue being made towards this noble goal and pooling resources to finance the health sector. The removal of user fees increased access to healthcare while teaming up with development partners and on-going budgetary reviews have made resources available for health. However, the challenge within the Ugandan health system has been that of poor accountability of health funds by health workers. The Unit has found that, in spite of the improved accountability, many In-Charges still lack the technical capacity to properly account for funds while others simply do not see the need to. The community on its part is still not knowledgeable and empowered enough to ask for this accountability.

Table 17: Sources of funding to the facility and accountability


Facility receives PHC funds 95 (76%) 59 (73.75%) 18 (69.23%) 172 (74.46%)

Average PHC funds (UGX) received annually 1,007,057 1,053,953 10,600,000 1,677,372

Facility receives development funds - 1 (1.25%) 1 (3.85%) 2 (0.87%)

Staff notified of funds release 50 (64.1%) 30 (63.83%) 13 (81.25%) 93 (65.96%)

Accountability records available 48 (48.98%) 28 (58.33%) 14 (82.35%) 90 (55.21%)

District sends audit reports on receipts 41 (50.62%) 19 (42.22%) 12 (75%) 72 (50.7%)

Accountability displayed for public viewing 28 (33.73%) 16 (33.33%) 4 (23.53%) 48 (32.43%)

Audit and accountability reports copied to HMC 56 (67.47%) 28 (59.57%) 12 (75%) 96 (65.75%)

Accountability agrees with audit 43 (54.43%) 17 (45.95%) 5 (41.67%) 65 (50.78%)

The section below provides more detail on the outcomes of MHSDMU’s financial audits undertaken at the various health facilities where only handful accountabilities were not queried as shown below. As will be shown in Table 18 below, a large amount of money (over 8 billion UGX) was found to have been mismanaged, not accounted for or stolen by the would-be stewards. This has adversely affected health system functioning both directly and indirectly. The table below shows a sample of mismanaged funds at the facilities visited.

Table 18: Mismanaged funds at different health facilities

Summary of audit output for the financial year 2012/13

Period Region Health Facility Details Amount (UGX) Status of case

Jul - Oct

NorthernGulu RRH

Procurement fraud 554,552,965

Case in courtDiverted funds 2,095,729,754Other financial fraud 296,132,339Fraudulent false accounting 3,621,415,000

Western Mubende RRH Financial fraud 360,926,168 Case in court

Eastern Mbale RRH Failure to account for funds 164,571,036 Under Investigation

November Sheema DHO’s office

Allowances paid to staff above the legal rates. This was to mainly the DHO and DHI

7,019,000 Awaiting follow up.



Summary of audit output for the financial year 2012/13

Period Region Health Facility Details Amount (UGX) Status of case

December JinjaRRH

Cash withdrawn by cashierwithout entries into cash book and not accounted for.

60,823,700 Under Investigation

RRH Unaccounted for funds 84,630,800 Awaiting follow up.

Mityana District Hospital

The issues raised were communicated to the Medical Superintendent and he promised to improve. Minor issues raised.

Yumbe DHO’s office Unaccounted for funds 77,647,593 Awaiting follow up.

Missing Vouchers 98,845,027 Awaiting follow up.District Hospital Unaccounted for funds 22,061,750 Awaiting follow up.

Moyo Hospital

The issues raised were communicated to the Medical Superintendent and he promised to improve.

N/A Minor issues raised.

Feb-Apr Northern Arua RRH

Financial fraud-for prosecution 120,616,196

Under investigationFailure to account for funds 63,425,052

Requires further investigation 62,256,101

April KalangalaThe issues raised were communicated to the Medical

Superintendent and he promised to improve. Minor issues raised.

Buvuma DHO’s office no major irregularities found

May

Hoima DHO’s office Accountability Issues 53,902,088 Awaiting follow up.

RRH Misappropriation of funds 275,767,170 Under Investigation

Kampala Naguru H.C Work in Progress

AdjumaniDHO’s office Unaccounted for funds 16,181,000 Awaiting follow up.

Hospital Unaccounted for funds 24,184,200 Awaiting follow up.

June 2013

Western

Kiryandongo District Hospital failure to account for funds 16,136,258

Funds to berecovered byHospital Medical SuperintendentDHO’s office failure to account for funds -

Kibaale DHO’s office Work in Progress

Hospital Work in Progress

5.1 Criminal Investigations and Legal Procedures

As the previous section has demonstrated there is a strong intersection between health and the law. Data presented shows the multi-disciplinary nature of MHSDMU’s work drawing from the disciplines of medicine, law, auditing and police investigation among others. We work closely with the DPP’s office in regards to the cases we find in the field. Table 19 below provides a summary of trends in MHSDMU’s legal work undertaken. A full list of cases and more detailed information can be found in Appendix 1.

Table 19: Trend of legal work undertaken at MHSDM between 2009 and 2013

Convictions Dismissals Acquittals Cases generated

2009-2012 FY 2013 2009-2012 FY 2013 FY 2013 FY 201389 20 36 1 2 67



5.2 Challenges Faced by MHSDMU in Investigation and Prosecution of Cases

A) Investigations

l Restricted timeframes: Difficulty in coping up with the maximum six months period of interdiction (as per standing orders) during which investigations must be completed. Most fraud cases are complicated and require funds and time. Sometimes, delay in completion of investigations is orchestrated by forces beyond MHSDMU e.g. Auditor General’s office delay in furnishing audit reports, delay by banks to provide evidence needed in court etc. In many cases the Unit is put under pressure by responsible authorities e.g. Ministries and government departments to conclude investigations so as to fit within the six months’ interdiction period envisaged by the standing orders lest the interdiction of suspects is lifted – yet to do so would affect progress of investigations and possibly, interference with witnesses.

l Understaffing: Currently there are only nine police detectives are deployed at MHSDMU yet they have to investigate all cases originated throughout the country. They are currently overwhelmed with a backlog of cases.

l Limited Funding: Successful completion of inquiries sometimes requires heavy financial commitments which might not be adequately catered for in the Unit’s budget.

B) Prosecution

l Delayed judgments: Since the start of MHSDMU some judgments have not been handed down. Indeed there is no indication that judgements will be handed down for some cases currently being heard by the relevant judicial officers.

l Lenient sentences: Where judgments are passed some sentences have not been commensurate to the violations. For example the case of Uganda Vs. Nassiwa Christine (Masaka) who was found in possession of stolen drugs. Countless innocent lives had been put at risk because of offender’s actions and a lengthy trial (over 2 years) ensued involving hefty costs of transporting witnesses by the state. The court verdict saw Ms Nassiwa sentenced to just one hour per week of community service for 3 weeks. Court also ordered that the stolen drugs be handed back to the accused! Another case involved Uganda V Pancras (Mayuge); a former hospital porter masquerading as a health worker who started an illegal nursing school, operated for 10 years and ‘graduated’ over 500 students in the process. Court, upon conviction, awarded a paltry fine of Shs. 500,000 UGX after which Mr. Pancras was released back into society despite the grave danger he posed to the public.

l Rampant corruption and professional misconduct, especially among the lower bench characterised by some Magistrates who obtain bribes from suspects to secure bail and dismissal of cases on mere technicalities, even where the evidence is sufficient and overwhelming. There has also been incompetent handling of cases of corruption by some prosecutors due to professional misconduct. Examples include;

i. Cases are not well organized by the prosecution;

ii. The evidence is not presented completely;

iii. Financial evidence is not explained or organized and therefore not understood by the judges/magistrates;



iv. The admissibility of certain types of information is not uniform throughout the judiciary such as: charts and summaries, summary witnesses, circumstantial evidence;

l Weak criminal/penal laws: The NDA Act and certain provisions of the Penal Code are inadequate to cope with the current sophisticated white-collar crimes as they prescribe non-deterrent sentences. For example small fines such the one involving a Mr. Kayangwe - an - imposter who worked in several health facilities exposing his patients at risk was sentenced to a mere fine on his own plea.

l Problems with the adversarial system of justice, for example legal technicalities and unnecessary adjournments leading to lengthy trials; also problems with the improper evaluation of evidence by some judicial officers often leading to acquittal of corrupt officers in the courts.

l Handling and disposal of exhibits by courts, particularly for medicines which sometimes expire while in court custody often due to delayed trials. This leads to waste and also denies the public the opportunity to use and benefit from these essential and often scarce medicines.

The consequences of the shortcomings mentioned above are grave and the possible outcomes are:

i. A breakdown in law and order

ii. Escalation of extra-judicial and unlawful methods of handling suspected criminals by the public e.g. burning of thieves, stoning to death and other forms of mob justice

iii. Demoralised investigating officers and anti-corruption activists

iv. Undermining public confidence in the court system

v. Discouraging public awareness and activism towards medico-legal issues and impunity in the health sector.



6.0 Leadership, Stewardship and Governance

Leadership and governance involves ensuring that strategic policy frameworks exist and are combined with effective oversight, coalition building, regulation, attention to system design and accountability.

6.1 Community Dialogue, Sensitisation and Empowerment (DSE) CampaignsOne of MHSDMU’s strategic objectives is to “improve citizen ownership of health services”. We believe that knowledgeable and empowered communities can play a very critical role in improving and sustaining good quality health services. As part of its routine activities, the Unit has sought to engage communities in knowing their rights, roles and responsibilities so that they can not only hold their service providers accountable but also support them in improving healthcare.

For this reporting period the Unit facilitated ten sessions with community members, health workers and local leaders in the areas visited and a wide range of pertinent issues were discussed. Table 20 shows an example of the districts in which these sessions were held, the content of these discussions and proposed way forward.

Table 20: Community Dialogue Sessions Conducted.

DISTRICT ISSUES DISCUSSED

LyantondeIn collaboration with the Uganda Medical and Dental Practitioners' Council, discussed medical negligence and resolved an imparse between community and health workers. This was in response to a community petition

Kasese Discussed medical negligence and late coming of health workersKaliro Discussed fraud and mismanagement of funds with the district political leaders

Kibaale Held meetings with the district leadership

Kiryandongo Discussed medical negligence and equipment thefts with the district leadership

Arua Discussed equipment mismanagement including ambulances with district leadership.

Sheema Discussed and resolved an imparse between the community members, political heads and health workers after the community had disconnected water supplies to the District Referral Hospital.

Mayuge Discussed and resolved tension between community members who were against the government-led program for mass immunization.

Kabarole Discussed and responded to the community's complaints regarding the escalating user-fees in Buhinga Regional Referral Hospital

Nakaseke Discussed with local leaders, opinion leaders and community members on diverse issues including immunization, VHT complaints and bicycle distribution.

6.2 Standard Guidelines for Licensing and Training of Health Workers

6.2.1 MHSDMU’s role in quality assurance for training institutions

Quality Human Resources for Health (HRH) is one of the most critical factors for quality health service delivery in any country; and its realisation requires rigorous quality assurance mechanisms regarding HRH training. MHSDMU has made significant progress in her efforts to improve quality in the training of health workers since inception. It is common knowledge that most of the health sector problems such as absenteeism, poor work ethic and professional misconduct of health workers are largely a reflection of the quality of training. A lack of proper training of health workers undermines the performance of the health sector.



In the course of routine monitoring, we continue to unearth illegal nursing schools conducting business and thereby releasing unqualified staff. For example in 2013 we closed an unlicensed school of over 200 students in Mukono district; the authorities were arrested and are currently facing several charges including operating an illegal nursing school and obtaining money from students by false pretense.

However, it is apt to note that that some officials on the regulatory side were complicit in this scam. The Unit’s investigations revealed that some government officials continue to extort money from many school proprietors and are charging illegal and often un-receipted fees purportedly for licensing and registration. This abuse of standard processes in licensing, registration and accreditation of nursing schools prompted complaints and disgruntlement by the proprietors. It has also resulted into the operation of many illegal nursing schools.

Confronted with this challenge, the Unit mobilized the key stakeholders to form a multi-sectoral team comprising Ministry of Education and Sports, Ministry of Health, Health Professional Councils and other HRH training stakeholders with a view of enhancing and enforcing compliance to standards in the operations of health training institutions in Uganda. With the Unit as a key player, a revised edition of guidelines for establishing, licensing, registering and accrediting of Health Training Institutions (HTIs) in Uganda has been developed by the relevant stakeholders. These guidelines deal with matters affecting training of nurses in Uganda including licensing, registration and accreditation of nursing institutions, new models for nurses’ education and a national policy to enforce best-practice standards. They also present a harmonised position regarding operation of Nursing Schools, detailed implementation and enforcement procedures, clarified roles of different stakeholders and their coordination mechanisms in line with the national legal framework. The Unit has also launched a strategy in improving and monitoring the nursing healthcare and training.

6.2.2 Challenges faced by professional councils in regulating health training institutions

The enactment of the BITVET Act in 2008 repealed certain provisions in the Nurses and Midwives Act Cap 274 and the Allied Health Professionals Act Cap 268 and removed the powers of these professional councils hitherto exercised such as approval of course programs and Institutions, including accreditation and/or gazetting them. These responsibilities were solely vested in the Ministry of Education and Sports (MoES). The Health Professional Councils’ mandate is now limited to the regulation of enrolment and discipline of their respective professionals, post qualification. Removing these functions from the Ministry of Health (MoH) through its professional councils is unfortunate because of the following reasons:

It is very difficult for the professional councils, which are more technical in this area, to set standards for the training of their own professionals. Given that MoES is already preoccupied with the registration and regulation of Pre-primary, Primary & Post-primary institutions, it might not easily monitor and maintain standards in the training of health workers. This role could have been better carried out by the relevant professional councils under MoH. Indeed, the disempowerment of these councils has culminated in the surge of illegal nursing schools and overall decline in standards.

These two bodies of MoES and National Council for Higher Education (NCHE) are by law given considerable discretionary power in the establishment and regulation of Health Training Institutions. However, having such parallel and overlapping mandates between MoES and NCHE grossly undermines their independence, compromising the efficiency and effectiveness in decision making as well as delaying administrative action. The professional councils assert that they were not even consulted prior to the enactment of the BTVET Act. Indeed many of the flaws in the Act have manifested, for example in the accreditation of irrelevant courses such as Comprehensive Nursing and registration of illegal schools.



6.2.3 Recommendations

It is recommended that the government adopts the following strategies;

1. Create an enabling legal environment to facilitate the involvement of professional bodies.

2. Review all the Acts of Parliament on the education and training of health professionals with a view of harmonizing them, facilitating clear division of roles and responsibilities.

3. Resolving of existing conflicts in related Acts;

4. Re-defining the existing structures to develop and promote education and training of health workers;

5. Re-orientating of existing structures to embrace the demands of Uganda Vision 2040 and the constitution (1995);

6. Developing a comprehensive education and Training Legal framework which defines the roles and responsibilities of all players and stakeholders at all levels; government, parents, community, sponsors and private sector.

7. Providing sanctions against persons and/or bodies and institutions contravening the demands of the laws and regulations such as the current levying of funds to be paid by private institutions, misappropriation of public funds, breach of contract and other forms of unprofessional conduct.

8. Develop a responsive education strategy, implementation plan and financing a framework that would include; developing by statutory instrument regulations concerning fees payment which is currently not only being abused but also forms the major source of conflicts in the licensing and registration of Health Training Institutions.

6.3 Infrastructure and Equipment Management

6.3.1 Value for money

In 2013 MHSDMU found 49 new constructions in the 13 visited districts. Eight out of the 49 new constructions were found in Hospitals and HCIVs, 21 in HC IIIs and the remaining 20 at HCIIs. Of the 49 new constructions, 35 were assessed to be standard works, 5 were ongoing renovations while 9 were shoddy constructions not demonstrating value for money. Seven (7) structures were found to have stalled for more than a year in all the 13 districts visited. There was evidence of a number of dilapidated structures. Table 21 below further illustrates this.

Table 21: Ongoing constructions and renovations at the facility


Facility has ongoing new constructions 20 (18%) 21 (28%) 8 (32%) 49 (23%)

Quality of constructions

Shoddy 5 (28%) 2 (11%) 2 (25%) 9 (20%)

Standard 13 (72%) 16 (89%) 6 (75%) 35 (80%)

Facility has any stalled constructions 5 (29%) 1 (5%) 1 (14%) 7 (16%)

Facility has ongoing renovations 2 (3%) 3 (5%) - 5 (4%)



6.3.2 Inventory Management, Equipment & Infrastructure Maintenance

The state of inventory management was found to be very poor with only 76 (54%) of the 239 facilities visited had updated their equipment inventory books(Table 21). Of the few that had decent records, 24 (41%) updated quarterly (every three months) whereas 35 (59%) updated their records only once a year (annually). Worse still, only 46 facilities out of the 239 had a budget to maintain their equipment as shown below:

Table 22: Equipment maintenance at the facility

HCII HCIII HCIV/Hosp AllFacility has a budget to maintain equipment 21 (40%) 20 (42%) 5 (45%) 46 (41%)Facility has any system to maintain equipment 22 (37%) 22 (44%) 12 (75%) 56 (44%)Facility has an updated equipment inventory book 28 (43%) 35 (60%) 13 (76%) 76 (54%)Frequency of updating equipment inventory bookQuarterly 11 (55%) 10 (34%) 3 (30%) 24 (41%)Annually 9 (45%) 19 (66%) 7 (70%) 35 (59%)



7.0 Health Information Systems

A well-functioning health information system is one that ensures the production, analysis, dissemination and use of reliable and timely information on health determinants, health system performances, and health status.

In section 3.1 this report showed the lack of robust data management systems at some health facilities. Whereas the MoH and her partners have worked hard to improve Health Management Information Systems (HMIS) countrywide, a lot of bottlenecks are still experienced – particularly in the rural areas. In spite of this however the health sector’s HMIS is gradually moving towards better quality and standardized HMIS systems whose data can be used to improve health outcomes. HMIS systems have been greatly enhanced by a number of initiatives – some of which are mentioned below:

7.1 M-Trac

Initiative has been in implementation since December 2011, being sponsored by the World Health Organisation (WHO) and the United Nations Children’s Fund (UNICEF). The initiative operates as a government of Uganda led program with the aim of monitoring disease prevalence and medicine stock- outs in real time. Another aspect of the mTrac implementation is monitoring public user-complaints and comments regarding service delivery within the health sector from the whole country. Here, complaints and/or complements are sent in form of a free anonymous Short-Message (SMS) off the users’ phones to the number 8200. The user-complaints are addressed by one of the three national action centres: National Medical Centre (NMS), Ministry of Health (MoH) and MHSDMU.

Reports that are directed to the attention of MHSDMU are taken up together with the relevant stakeholders such as District Local Government officials, Ministry of Public Service, District Health Teams (DHTs), local police officers, Residential District Commissioners (RDCs), District Internal Security Officers (DISOs), Gombolola Internal Security Officers (GISOs), Local Council (LC) leaders and the communities among others. These are then verified, investigated and offenders prosecuted either through courts of law or administratively.

Between September 2012 and August 2013, a total of 11690 anonymous reports were received, 10675 (91.3%) of which were actionable. Figures 10-13 below show the distribution of the received anonymous reports by action centre, as well as the action taken.





7.2 e-Health

A 2011 baseline survey by UNICEF showed that over 50 eHealth initiatives were being undertaken in the health sector in Uganda. In spite of some success, these were uncoordinated and in many duplicated. Not only were the approval lines unclear but they were also unsustainable and with limited national coverage. The unit participated in raising up this problem and the resulting process of harmonisation. A moratorium was put in place blocking any further roll-out of eHealth while stakeholders worked to streamline policy. As a result, an eHealth Technical Working Group (TWG) has been set up of which the unit is a member. An eHealth policy, technological framework and roadmap have been developed and submitted for approval to relevant authorities. Furthermore, an implementation plan and guidelines are being developed.

7.3 Community awareness and sensitisationIn a bid to connect and engage with the public and critical stakeholders on health matters, MHSDMU conducted 75 radio talk shows in various languages and six Television shows in 2013. Appendix 2 shows details of the radio talk shows but below is a summary:

1st quarter 2nd quarter 3rd quarter 4th quarter

4 television talk shows on Record TV and Top TV 24 Radio talk shows 36 Radio talk shows 4 Radio talk shows Seven Radio talk

shows

MHSDMU website created 3 TV shows 3 TV shows

The topics discussed on each of those shows were diverse and cut across the six health system building blocks. In addition to the talk shows, MHSDMU’s interactive website (http://www.mhu.go.ug) continues to also engage the public on key issues and also give updates on its operations.

8.0 MHSDMU’s Upcoming Activities 8.1 The LLIN Universal Coverage Campaign: Working with Development Partners to

Combat Malaria

The Ministry of Health with support from Global Fund, DFID, PMI and World Vision is undertaking the mass distribution of 21 million LLINs to every two persons in Uganda. Distribution will commence in the Eastern Region and spread countrywide. The Monitoring Unit will participate in monitoring the LLIN distribution exercise to ensure proper accountability and universal coverage. The Unit will also undertake a baseline study on usage of mosquito nets and malaria infection rates at household levels, as a way of evaluating the impact of the LLIN distribution exercise.

8.2 Other Activities

Some of the other upcoming major activities include:Five(5) Year Achievement Report: In September 2014 MHSDMU will make five years since inception.

We shall be outlining the Unit’s achievements over the last five years in a supplementary report.

Five (5) Year Strategic Plan showing the MHSDMU’s focus areas of the next five years.

MHSDMU Re-brands: Look out for our new re-brand ( Name, look and logo) in the media and upcoming publications.



PART B: DISTRICT FINDINGS9.1 ADJUMANI DISTRICT

The Monitoring Unit visited Adjumani district during the weeks of 27th January - 2nd February and 10th – 17th June 2013. The Unit inspected all the 31 government health facilities that include one hospital, one HCIV, seven HCIIIs and 22 HCIIs. In addition, the monitoring team also inspected drug shops and pharmacies in the district.

Findings

9.1.1 Human resources for Health: District staffing was found to be as follows: HCIIIs were fairly staffed with at least 9 out of the 15 (60%) recommended clinical staff. On average, HCIIs were found having 2 technical / health workers out of the recommended 5 staff. Absenteeism still remains a big challenge in Adjumani; out of the 31 health facilities visited, only 7 in-charges (23%) were found at their duty stations. A number of facilities that include Arra, Ogola, and Lewa HCII were found abandoned and closed during working hours. Needless to say, health service delivery in Adjumani was found to be hampered by the absence of the In-Charge in the facilities. However, MHSDMU found some committed health workers for example one at Adjugopi HCII who, amidst infrastructural challenges, was found attending to patients under a tree as shown below:

A health worker at Adjugopi HCII improvises while facility is under repair

The problem of health worker absenteeism was exacerbated by the lack of supervision. For example it was not evident that MOH officials had conducted supervision in the last two years; and sub-county leaders were found not to supervise their local not facilities. The challenge of absenteeism, late coming and neglect of duty was therefore common.

9.1.2 Infrastructure: Adjumani district is commended for fencing off most health facilities and recruiting Askaris to safeguard them. In addition, all facilities in Adjumani, apart from Aliwara HCII, have staff houses which, when compared to the general district staffing levels, should be enough to accommodate all staff especially in the lower health units. Most HCIIs had very good structures but some of these were being underutilised or misused, for example the in-charge of Aliwara HCII who is the only technical staff at the facility was occupying one of facility treatment rooms.



All facilities in Adjumani district were found clean and well-kept except Pachara HCII which was infested with bats and vermin. In the hospital and Mungula HCIV accommodation still remains a big challenge while Adjumani Hospital, Uderu HCII and Mungula HCIV had a number of dilapidated structures. Below is an example:

Cracked walls in the Adjumani Hospital boardroom

The general ward at Arinyapi HCII had never been opened because of shoddy work. Some of the doors were fitted when they were still wet resulting to expansion and so they were unable to close.

In terms of utilities, all health facilities in Adjumani district had functional and well-maintained solar panels and water.

Ambulances in the hospital were grounded as they required repair and maintenance in spite of the fact that funds worth over eight million for repair and maintenance had been released. MHSDMU investigations found that the former hospital administrator had mismanaged these funds and he committed himself to pay back all the misappropriated monies.

9.1.3 Medical Supplies Management: Generally all facilities were found well-stocked with essential medicines and MHSDMU did not get any complaint from the communities concerning medicine stock- outs. However proper medicines management is still necessary because there was a large amount of expired medicines at the majority of the health facilities for example Anomex, Misoprostol, chloram phenicol eye drops and ear drops, condoms and Metronidazole.

9.1.4 Finance and Accountability: Financial accountability in Adjumani district was very poor as shown by the numerous cases of forgery evident in the hospital receipts as seen in the pictures overleaf. In Arere HC II, the health workers were sharing the PHC funds without any form of accountability.



Forged signatures in receipts of Adjumani Hospital

Recommendations:

Adjumani District and other related stakeholders need to look seriously into the issue of health worker absenteeism which was found to be high at 77%. The district and HSD should review and implement their supervision strategy for better results. The MoH should also undertake periodic and purposeful visits aimed at promoting best practices in health worker professionalism and service delivery. Furthermore, local leaders and communities need to also take up their roles and hold health workers to account. Proper medicines management practices need to be emphasised in order to avoid waste and also financial accountability should be demanded by leaders and communities to avoid mismanagement and embezzlement.



9.2 BUVUMA DISTRICT

The Unit visited Buvuma district in April 2013 and conducted site visits of all its health facilities. Buvuma has a total of 11 health facilities scattered on different islands. It is worth noting that Buvuma has no district hospital and critical cases are referred using water transport to the neighbouring Jinja or Mayuge districts. The health centres visited are: Buvuma HC IV, Lwajje HC II, Busamizi HC III, Buwooya HC II, Nkata HC II, Bweema HC III, Lubya HC II, Namiti HC II, Namatale HC II and Bugaya HC III.

Findings

9.2.1 Finance: All health facilities had received PHC funds although feedback got is that this is irregular and insufficient. Buvuma’s DHO reported that despite attaining district status, the money disbursed to the district had not increased and was insufficient to conduct effective service delivery. This was further complicated by lack of proper accountability at most health facilities; PHC accountabilities were not displayed for public viewing and neither did the monitoring team access the accountabilities. The main reason is the fact that In-Charges who were unavailable and seemed not to be transparent about financial matters therefore in their absence no one else could answer any related questions.

9.2.2 Infrastructure: Most of the health centre structures in Buvuma were dilapidated and in need of urgent repairs. There was total lack of or insufficient accommodation for health workers in most facilities and a good example here is Bweema HCII which has a squalid unit for staff housing as shown below.

OPD ceiling in Busamizi HCIII destroyed by bats Picture 24: The only structure in Bweema HCII

The monitoring team found construction works in many health facilities; however the majority of these had stalled while those which were regarded as “complete” had already started depreciating within short periods of time following handover. Cases in point are Nkata HCII where construction of the staff houses had stalled for six years while in Namatele HCII the works were very shoddy and the pit latrine collapsed after less than two years therefore patients had no latrines.



Stalled construction of the staff quarters in Nkata HCIII Namatale HCII 9: Collapsed pit latrine in Namatale

Poor infrastructural management was evident as most facilities, including Buvuma HC IV, were found heavily infested with bats, termites, birds and snakes. Roofs had been destroyed by the bats while termites had eaten doors and windows.

The sanitation and hygiene was found to be extremely poor in many facilities with animals having free access to facility premises resulting in droppings and dung being strewn all over the facility. Also on the Island generally, sanitation is poor; the houses are made of mud and wattle and are clustered making spread of diseases easy. The Toilet/Latrine to Person ratio is very low and none of the facility latrines had hand washing facilities.

Animal droppings in the corridor and compound at Lwajje HCII

Shanty housing with no sanitation facilities in Buvuma Island



9.2.3 Human Resource: Buvuma district faces a challenge of inadequate human resource in terms of both numbers and cadre type. The district has failed to attract and retain critical health workers which can partly be attributed to its ‘Hard to Reach’ status. In some health centres, the monitoring team observed that the staff were fresh from school and had not been given thorough orientation prior to deployment; therefore the notion of patient safety and effective service delivery continues to elude most health facilities. In some health centre there were also cases of volunteers for whom the administrative arrangement was not clear and thus continue to pose risks not only to themselves but also to the patients for example at Nkata HC II . In Namatale HCIII the monitoring team found an unqualified lady dressed in a nurse’s uniform but doing on- the- job training as a Nursing Assistant. Further inquiries revealed it was a private arrangement between the In- Charge and the mother of the girl. The storekeeper at Buvuma HCIV had no formal or basic training in drug or stores management and MHSDMU spent some time providing this basic training as shown below.

Health worker/ volunteers being taught mTrac & medicines management by MHSDMU

9.2.4 Utilities: Solar lighting/power is still a challenge in the health centres in terms of availability, adequacy and functionality. Some facilities like Bweema HC III had been in total darkness since three years ago when their solar broke down and no action had been taken to repair it. With permission sought from the sub-county chief, the monitoring team transported the inverter to the main island for repair. Although Buvuma HC IV is the largest facility in the district, its solar system was not functioning. There is no lighting at night and health workers on night shift are left in the dark which massively affects admission services at night. The theatre relies on the generator for all surgical procedures which is costly and at times unaffordable.

9.2.5 Transport: Transport in the district is still an issue mainly because Buvuma is an island. As a result supervision, operational support, outreaches and staff movement are mainly on water. Very few of the health centres on the islands have boats or at least engines and they have to rely on hiring which is very expensive. The dedicated transport system in the district affects even basic inland health activities like immunization whose teams often go for outreaches on foot due to lack of a bicycle or motorcycle. The monitoring team found that two facilities (Bweema and Bugaya) had received donations of boat engines from UNICEF but still lacked boats on which to mount those engines.



9.2.6 Medical Supplies Management: Most facilities were found to have essential medicines like antibiotics and anti-malarials although two facilities were not receiving medicines from National Medical Stores and had to request for medicines from Buvuma HC IV. The Medicines Information Systems management was an area of concern. HMIS tools for medicines management were poorly filled and basic concepts like drug requisition and issue vouchers were not well understood amongst health workers. As a result the Issue and Requisition vouchers (HMIS 017) were either not utilised or were poorly filled in. Furthermore the issue of proper storage for medicines to ensure their efficacy was not being taken seriously; in fact some facilities were using medicine storage space inappropriately as shown below:

The pharmacy in Nkata HCIII is also used as a housing and sleeping area

9.2.7 HMIS/ MTrac: Generally it was found that HMIS tools were being poorly filled in except for the OPD register. The HMIS 033B surveillance tool was largely ignored or poorly filled in and even then this data was not submitted regularly to MoH. mTrac, the platform used to transmit weekly data, was not being fully utilised especially the community Anonymous SMS hotline which communities utilise to monitor service delivery. Reports coming through the Dash Board were not being addressed. Following MHSDMU’s visit which included training on various aspects including mTrac, reporting through mTrac improved greatly and Buvuma now acts as a model of good practice with 100% reporting rates and has been listed among best performing districts via reporting. While in the district, the monitoring team also addressed complaints that had previously come through the MHSDMU dashboard.

9.2.8 Recommendations For Buvuma District

• There is need for improvement in the area of drug management. This includes strengthening internal controls at the health centers like audits by the in charges and limiting stores access. All transactions must be recorded to ensure accountability and especially the Requisition and Issue Vouchers should be initiated. Mentoring in medicines management should be practiced during supervision visits.

• Accountability for Primary Health Care funds at all health facilities should be communicated to all staff, HMC and also displayed for public viewing which is a requirement by the Ministry of Finance. Transparency avoids abuse and improves ownership of resources.

• The Health sector budget support by government and partners to Buvuma needs to be increased.



• Accommodation should be prioritized in both the district and county annual work plans especially in the ‘extra’ hard to reach islands.

• There needs to be a motivation strategy to recruit and retain staff in the district.

• Politicians and sub county chiefs should be involved in monitoring of health service delivery.

• The practice of inventory of assets and equipment should be inculcated in health workers by the DHO’s office and should be a part of their appraisal.

• The mTrac program should be embraced because it is a MoH programme and has many benefits for the district for example communication, resolving challenges, information for decision making among others. The Community Anonymous SMS reports should be immediately addressed and these should inform supervision planning. Critical reports should be shared with The RDC, CAO, DHO and other relevant stakeholders.

• Infrastructure that was not properly constructed or that has stalled should be investigated and contractors compelled to rectify work. The supervision role of the district in constructions needs to be strengthened.



9.3 HOIMA DISTRICT

The Unit visited Hoima district between 13th - 24th May 2013. One Regional Referral Hospital and 37 lower units were monitored. The visit was both part of MHSDMU’s routine monitoring visits and a response to complaints raised earlier through Mtrac anonymous SMS and toll free line.

The health facilities visited included; Hoima RRH, Kyangwari HCIII, Nsozi HCII, Kasomoro HCII, Buhuka HCIII, Mparangasi HCIII, Kasonga HCII, Buraru HCIII, Kaseeta HCIII, Kibare HCII and Kigorobya HCIV. Other health facilities visited in Hoima district were Kyangwari HCIII, Nsozi HCII, Buhuka HCIII, Kasonga HCII, Kaseeta HCIII, Sebigoro HCIII, Kyehoro HCII, Kikube HCIV, Mukabara HCIII, Wambabya HCII, Bugambe HCIII, Lucy Bisereko HCII, Buhimba HCII, Kyakapeya HCII, Buseruka HCII, Tonya HCII, Bacayaya HCII, Kihuukya HCII, DHO’S Clinic HCII, Kapapi HCII, Kibiro HCII, Kisabagwa HCII, Kasomoro HCII, Mparangasi HCIII, Buraru HCIII, Kibaire HCII, Kyabasengya HCII, Dwooli HCIII, Karongo HCIII, Mbarara HCII, Kiseke HCII, Kigorobya HCIV, Kabwoya HCIII, Kitole HCII, Bujalya HCIII and Kisiha HCII.

Findings

9.3.1 Hoima Regional Referral Hospital

9.3.1.1 Human resource: The performance of staff members remained unknown because departmental heads and area managers in the facility however did not regularly submit performance reports to the administration. This was most common in the pharmacy, radiology, medicine, nursing and theatre departments. Many staff were absenting themselves from the facility without valid reasons and/or communicating to their immediate supervisors. The daily reporting register was not routinely and appropriately used by most staff. Staff were reporting late and exiting early from their duty stations. In addition, most of the clinical staff were frequently attending workshops which created a vacuum that severely impaired service delivery at the facility.

It was observed that the hospital had a large number of staff (to get the figure from Jjumba) on study leave and this was affecting the operations of the facility. It was not clear whether they were bonded by the hospital and would come back after completion of their studies.

There were 98 staff members in the hospital that were on probation despite working for long periods - this greatly demoralised them and affected service delivery.

In addition, extortion was reported to be a common practice in the radiology (X-ray) department and at the main theatre.

Interns were left to attend to patients without any supervision on the wards, and routine visits made by the monitoring team to the hospital at night during its stay in the district established that health workers were largely absent on night shifts.

9.3.1.2 Infrastructure, Equipment and Utilities: With support from the Japanese Development Agency (JICA), the hospital acquired land to modernise and expand the Regional Referral Hospital. In addition, through the capital development fund, the government has built a state of art staff quarter which is accommodating 45 staff – see picture overleaf;



Newly constructed staff housing units at Hoima RRH

In spite of this however, there was shortage of staff accommodation at the lower health facility workers for example the doctor at Kigolobya HCIV does not reside at the facility because the newly-constructed house had not yet been handed over by the district.

Although the hospital was fairly equipped, it lacked an updated comprehensive inventory list of equipment. It was notable that most of the equipment in the hospital was not engraved including the recently procured ones that were being distributed to user departments. As a result, some of the equipment have been diverted for personal use. For example a new ECG machine, Laboratory Kits, BP machines, office table, mosquito nets and stethoscope were found at the store man’s home.

In terms of infrastructure maintenance, the hospital had many broken beds that only required minor repairs yet many pregnant mothers were sleeping on the floor as shown below. The monitoring team engaged the engineering department which pledged to repair these beds.

The construction works for the hospital medical supplies store had stalled for over a year yet MHSDMU verified with the hospital management that all payments had been made. The team engaged the contractor and committed him in writing to start the work on 31/May/2013 and complete in 1 month. On the last follow up trip in July 2013, this had been completed. In addition the facility was extremely dirty and unkempt despite having a company contracted to clean the hospital.

Hoima RRH does not have a functional mortuary suitable for a Regional Referral Hospital. The existing mortuary is small, lacks fridges and has no access to the road as shown below:

The mortuary at Hoima RRH



The hospital does not have a functional incinerator; the one procured in 2011 had not yet been installed. The hospital claims that it wrote to NEMA seeking its approval but has not yet received a response; however the said communication was not seen.

The Incinerator which has remained un-installed for two years

The hospital’s main gate had broken down creating a security breach thus allowing anyone to access the hospital premises. After the intervention of the Unit, the gate was repaired and as a result the security and regulation of traffic at the hospital has improved.

9.3.4 Medicines Management: At Hoima RRH it was found that the use of Rapid Diagnostic Tools (RDTs) to diagnose malaria had resulted in a reduction of unnecessary prescription of anti-malarials thus improving their availability and stock levels.

However, the HMIS tools - specifically the issuing and requisition books, stock cards, dispensing logs - were not being used which resulted into lack of accountability for medicines in the whole hospital. This lack of documentation also contributed to

Medicines pilferage in the hospital. The storage conditions was not up to required standard, for example at the time of this monitoring visit there were no shelves in the drug store and this affected stock taking, record keeping and medicines life span. The hospital’s medicines store is shown below:

The medicines store at Hoima RRH



9.3.5 Financial Management: The hospital had made a number of fraudulent claims for equipment including cases as listed below.

• An incubator worth 104 million was reported to have been procured but this was verified to be false.

• Accountability for fumigation services was costed at 19 million which was also verified as false.

• Three fridges costing 32 million in total were never supplied yet forged receipts had been availed.

• Furniture including a filling cabinet worth 6 million, an “executive chair” at 2 million and an office desk of 2 million were procured in a rushed manner (2 days) with no contracts committee engagement but have since not been assembled or distributed.

• Non-remittances of Withholding Taxes.

• Micro procurement procedures were used when purchasing spares and stationery even when the amounts were beyond the 2million threshold without the approval of the contracts committee.

• The suppliers’ cheques were being written in the names of the account agent who is the hospital accounts assistant, and he was withdrawing cash on behalf of suppliers.

• There is a tendency by management to pay themselves for workshops that are fully sponsored. It was also noted that whenever officers are invited to Kampala for a workshop as a group, they use different vehicles which gives them the ‘opportunity’ of claiming for fuel separately. This not only hampers services at the hospital but also increases costs to the hospital.

The above scenarios demonstrate that, although there is some funding to facilitate smooth hospital operations, it is often misused.

Findings from Other Health Facilities in Hoima District

9.3.6 Health Service Delivery

Service utilization for healthcare was noted to be good and there was generally a high turn up of patients at a number of facilities such as Kaseta HCIII, Kyangwali HCIII and Kisabagwa HCII. In spite of this, services were not readily available at some of the facilities because of health worker absenteeism for example at Kiseke HCII which was found closed by 4:24pm.

Support by Health Partners : Health partner’s for example Stop Malaria, SURE and IDI have supported the district to renovate the theatre at Kikuube HCIV. They have also supplied kits like RDTs and Determine kits, donation of ambulance, and drug storage shelves among others.

The theatre at Kikuube HCIV renovated by IDI



Shelves provided by SURE at Kigorobya HCIV for storing drugs

9.3.7 Human Resource: The monitoring team noted that the levels of absenteeism and abscondment from duty, especially for the in-Charges was high. For example at Kabaale HCIII, 2 staff out of 11 were found on duty and this was common in other facilities. The In-Charge of Bujugu HCIII absconded from duty and instead works for a private hospital in Hoima town called EDPA. The in-charge of Kiseke HCII had closed the facility by 4:24pm due to drunkenness which the monitoring team witnessed.

Nearly all newly-recruited staff in the health facilities were not yet on the payroll and as such were not receiving salaries. Furthermore, the district lacked porters and askaris in most facilities which has led to theft of government assets and unkemptness at the facilities.

Patients waiting for Health workers at Kigolobya HCIV by 10:24am

There was also the issue of poor human resource management for example granting study leave to critical staff without finding replacements as was the case at Bujugu HCIII where the two midwives went for study leave at the same time and no replacement was made.

Health management committees were non- functional in most of the facilities; they had spent close to a year without meeting. In addition, the DHT was not regularly conducting support supervision to hard-to- reach areas like Kibiro HCII and Kyangwali HCIII.



9.3.8 Infrastructure & Utilities Management: Hoima district is commended for fencing off most of the health facilities. However, most facilities still lacked signposts while and the few which were present were not clear. In addition, most of the medical equipment was not engraved and there was poor inventory management for example a motorcycle at Kikuube HCIV was missing. There were many non-functional water tanks in the district for example at Kigolobya HCIV, Dwoli HCIII and Buhimba HCIII. Most facilities also lacked power which was partly caused by theft of solar panels and existence of nonfunctional batteries. A huge power bill of 13,000,000/= had resulted into disconnection of power at Kikuube HCIV.

The district had old and dilapidated structures for example at Buseruka HCIII, Kabwoya HCIII, Buhimba HCIII and Kitole HCII staff quarter and many facilities were dirty and unkempt. Most HC IIIs and HC IIs lacked placenta pits yet they provide maternity services including delivery of babies. Bats and vermin infestation was very high in almost all health facilities. The appalling state of infrastructure is captured in the picture below:

The staff quarters at Kabwoya HCIII

Apart from the RRH, all the ambulances the district were not functioning – these were at Kigorobya HCIV, Buseruka HCIII, Kabwoya HCIII and Kyangwali HCIII as shown below:

Grounded and non-functional ambulances for Buseruka HCIII and Kigorobya HCIV

Construction and engagement with contractors in Hoima district was found to be disappointing in many cases and there were a number of stalled structures for example the one at Wambabya HC II shown below:



The stalled structure at Wambabya HCII

Furthermore, the structures that had been completed and handed over were classic cases of shoddy work which did not demonstrate value for money. For example a latrine built in 2008 at Kikuube HCIV had major cracks and was falling apart.

The latrine at Kikuube HCIV built in 2008

9.3.9 Medicines Management: Most facilities were found stocked with excess anti-malarials, some of which were expired, or about to expire. There was poor drug management and accountability in most of the facilities for example shown by the lack of drug requisition and issue vouchers as well as the other critical documentation for medicines management.



9.3.10 Finances: Like with medicines management, financial accountability in the district was also found to be generally poor. Apart from only one health facility (Mbarara HCII), all the rest could not provide accountability records for the finances that had been disbursed to them. Another problem found was that some facilities had not received their due financial allocations for example Kiseke HCII which had not received PHC for the last one and a half years.

Recommendations for Hoima District

Hoima district needs to rectify its poor performance in the management of medicines, finances, infrastructure, service delivery and human resources for health.

The chronic absenteeism and absconding of health-workers should be severely dealt with and punitive action taken to discourage the practice. Healthcare’ reasons for being absent and absconding need to be carefully looked at and a solution reached.

For medicines management the district should draw from standard guidelines and best practices in the storage, dispensing and recording of medicines. This will also ensure that there is minimal or no wastage of medicines.

Better stewardship of the district and health facilities resources/assets needs to be emphasized, for example the ambulances and buildings. Immediate attention and action should be given to repair and maintenance of broken-down equipment for example beds. Contractors should be put to task to hand-over work that demonstrates clear value for money and should also ensure that on-going joint supervision done right from the start of the contract period.

Financial accountability needs to be exercised with In-Charges being accountable to Health Management Committees and the community by displaying all financial activities for that period. In relation to that the responsible leaders should follow up with the district to solve the problem of facilities which have not been receiving their PHC funds.



9.4 JINJA DISTRICT

The Unit visited Jinja district between the 3rd to 8th of December 2012. A total of 53 health units were visited including one regional referral hospital, one children’s hospital, five HCIVs, 12 HCIIIs and 34 HCIIs.

Nalufenya Government Hospital:

It is a peadiatric hospital, an annex of Jinja Referral Hospital located in Jinja municipality. It manly serves patients from Jinja, Mayuge, Mukono, Kayunga , Iganga, Buyikwe and Kamuli.

Findings:

9.4.1 Human Resource & Management: Medical doctors were not regularly available in the hospital as they commuted in between Jinja hospital and Nalufenya hospital. The fact that administrative oversight over the doctors is a responsibility of Jinja hospital yet their duty station is Nalufenya hospital has made it hard to monitor staff performance. The bulk of the work was being done by lower cadre staff and in the night there were hardly any health workers available. Generally supervision and monitoring by the district and main hospital leadership was found to be inadequate, non-exhaustive and in most cases no reports or feedback was given.

9.4.2 Infrastructure, Equipment & Utilities: An 80 bed hospital with no land title and Information about the land ownership is unclear. There was a Boda Boda stage inside the hospital which created confusion and posed a serious security concern. The laboratory lacked some basic equipment required to carry out some critical tests and patients have to be referred back to the main hospital. Infection control was poor with no provision for hand washing facilities.

Nalufenya Hospital is over stretched by the existing number of cases. The facility was infested with bats, birds, and vermin. As a result of inadequate support staff, the premises were poorly maintained. The equipment inventory list had taken long without being updated and the equipment is not embossed. By the time of our visit, the hospital also had a challenge of shortage of water in the OPD and private wings. The facility has insufficient transport to facilitate their activities.

9.4.3 Medical supplies Management: The availability of essential medicines was good in terms of stock. However there was poor accountability for medicines, recording and follow up. There was poor documentation and records management in the facility. A private drug shop belonging to a nurse in was found within the hospital premises with the knowledge of the administration. The monitoring team met the hospital management and this drug shop was immediately closed.

Findings from Other Health Facilities in Jinja District

9.4.4 Human resource: The district lacked some high cadre staff which created a vacuum and hampered delivery of certain specialist services. For example at Budondo HCIV, the Medical Officer and Dental Officer had left for further studies and no replacement had been made.

By the time our visit, in-charges of most health facilities were attending workshops and could not be found at their work stations; workshop attendance was reported to be the main cause



of staff absenteeism. A few of the health workers who turned up at some of the facilities were reported to always come late – an allegation that was verified by the monitoring team. For example by the time of our visit, the in-charge of Nabitambali HCIII arrived on duty at 11:00am and despite adequate staff accommodation at the facility, the staff preferred to commute from Bugembe and Jinja town. As mentioned in Part A of this report, it is unfortunate that while some health workers struggle to get decent accommodation within the proximity of their workplace, others with the accommodation have been found to be misusing or under utilising it. At Mpamba HC III, only two out of the twelve health workers were found at the facility. The askari was found to be the one admitting patients, conducting rapid diagnostic tests for malaria and dispensing medicines – roles for which he is unqualified.

At Muwumba HC III, the In-Charge had allowed unqualified volunteers to work in the facility and one of these volunteers was extorting money from patients. Generally the bulk of the work was being abandoned to these unqualified persons and without supervision.

Indiscipline, risky behaviours and a general lack of professionalism among staff members was also observed. For example the ambulance driver of Bugembe HC IV was found drunk while on duty, yet this drunk driver had been given the responsibility of driving two pregnant mothers who had been referred to Jinja Regional Referral Hospital. The monitoring team had to step in to intervene because the lives of the expectant mothers were at risk.

An MHSMDU driver steps in to take patients to Jinja Regional Referral Hospital while the drunk

ambulance driver awaits transportation to the Police Station.

Periodic supervision and monitoring was fairly done by DHTs and other teams, but without an efficient and effective tool.

9.4.6 Sensitisation and Capacity Building at JSNM: In a bid to promote participatory improvement of the health sector, MHSDMU also engages training institutions like nursing and medical schools. The main objective is to showcase some of the challenges facing the health sector and role of these institutions. One such visit was to Jinja School of Nursing and Midwifery (JSNM) where a presentation was made to all the students on ‘‘The Role of Nurses in Health Service Delivery”. This is because the majority of health workers are nurses/midwives and their contribution to health system. The problem and impact of illegal nursing schools and scenarios of unethical behavior of nurses was also highlighted during this presentation. In response to the unit’s findings on illegal nursing schools, students promised to work with authorities in curbing this problem.



9.4.7 Infrastructure and Equipment: Transport in Jinja district was generally not a major challenge because of the availability of ambulances, motorcycles and bicycles in most of the health centres. The health facility buildings were also in fair condition although bats infestation was common in all health centres. There were some other challenges particularly with stewardship of hospital equipment and the functionality of theatres; infact no embossed equipment was found in all the government health facilities in the entire district. All the theatres in the lower-level units were found to be non-functional which explains the higher referral rates to Jinja Regional Referral Hospital. At Budondo HC IV theatre equipment had been donated but the facility lacked a theatre and so the equipment could not be put to use.

In Bugembe HC IV, the theatre is structurally sound but has never been used since its completion. It is only used for minor procedures like medical male circumcision, incision and drainage. The theatre was also being used as a store for equipment and other supplies like the motorcycle, water guard jerrycans and outreach equipment. Theatre equipment at Bugembe HCIV was bought 10 years ago but has never been used. The failure to operationalise the theatre was attributed to poor design of the windows installed which would not give the theatre optimal sterile conditions. This clearly shows that there was lack of routine inspection of the works by district officials before commissioning of the theatre.

9.4.8 Medical Services: All facilities including HCIIs facilities were found offering antenatal/ maternity services. However most of the Laboratories were found closed while some had no personnel.

9.4.9 Medical Supplies Management: A general lack of medicines accountability and documentation was noted in most of the lower health units.

9.4.10 Finance Management: All the In-Charges of health facilities visited were away for workshops and no accountability could be seen except for Ivunamba HCII.

Recommendations for Jinja District

The Jinja district leadership should find a replacement for the staff who are on study leave. A case in point is the Medical Officer and Dental Officer at Budondo HCIV who left for further studies. Related to this, better management of HRH should be undertaken, for example by proper scheduling for leave of all staff.

Professionalism and high standards of discipline among all staff should be enforced, for example, the driver who was found drunk while on duty should be punished.

There is need to improve collaboration between the DHOs office, regional referral hospital and municipal health facilities such as sharing of information and joint planning.

Workshops and trainings should be coordinated, to ensure that facilities and patients are not left unattended to.

The district should prioritise engraving of all equipment in the facilities in order to avoid theft.

The district should endeavor to make all the theatres in HCIVs functional.

The DHO should ensure that medicines accountability and documentation is improved.



9.5 KALANGALA DISTRICT

The Unit carried out a monitoring exercise in Kalangala district from 8th – 12th April 2013. The exercise was prompted by complaints generated through mTrac’s anonymous SMS service and the Unit’s toll free line.

The health facilities visited in Kalangala are shown in the table below: Siaap HC II, Jaana HC II, Mulabana HC II, Mugoye HC III, Lulamba HC III, Bubeke HC III, Bufumira HC III, Mazinga HC III, Bwendero HC III Kalangala HC IV, Bukasa HC IV. The Unit appreciates the services of all the health workers who work in these hard-to-reach area, and especially staff of Mazinga HCIII and Jaana HCIII.

Findings

9.5.1 Human resource: The Unit discovered there was a total lack of supervision by DHO’s office in the entire district. As a result many staff recruited had never reported to their duty stations and people only depended on the good will of dedicated workers who can function even without supervision. Most health centers lacked daily staff reporting registers and for the few that had them, health workers did not adhere to them while others misused them. Lack of staff uniforms and the shortage of staff accommodation was also noted in all health centres.

For instance the staff at Mugoye HC III had a forged staff attendance register to show their attendance yet they were absent for most of the time. Late coming and absenteeism was found to be common for many of the staff, including the leadership. For example the in-charges of Mugoye HCIII, Kalangala HC IV and the staff of Bwendero HC IV exhibited very high absenteeism levels. The challenges facing HRH in Kalangala need to be put into context. Despite Kalangala being a hard-to-reach place, the staff are not getting hard-to-reach allowance. In addition, newly recruited staff were not yet on payroll and needless to say this makes their survival difficult.

9.5.2 Finance and administration:

9.5.2.1 The DHO’s Office: It was noted that the DHO’s office operated five account accounts namely:

i. The district Health account- For managing PHC and Development funds

ii. The DHS account - Global Fund account

iii. The PMTCT account - Support from PREFA,

iv. The HBVCT Account – Projects account.

v. The KCPHSP account - The donor funded project for HIV AIDS activities.

The District Health Account: A financial audit was undertaken for the financial years 2011/12 and 2012/13. It found that the district receives approximately 73M UGX for its PHC activities. This amount was discovered to be too little to handle all district’s activities, bearing in mind the hard-to-reach nature of the district. The accountabilities looked at, for the financial year 2011/12 (PHC) were acceptable, although the audit was limited in scope since most of the documents were said to have been taken by the Auditor General’s office. In addition, there were also no cash book and bank statements for the said financial year.



PMTCT account: This is support that the district gets from PREFA, and the budget for the project was about Shs. 292M. The accountabilities looked at were satisfactory.

KCPHSP: This project is funded by USAID, has its own office and staff, although some existing government health workers are involved and get paid from it. The district also supplements its meager budget from this project.

9.5.2.2 Accountability within Health Centres: Accountability for HCIVs was fair, although it was noted that they receive insufficient PHC funding of only 1,800,000/= per quarter, which is not enough to run a HCIV. There was generally poor record keeping in all the health facilities in the district. The team noted missing and poor accountability in the lower health centers visited.

9.5.3 Infrastructure and Equipment: Our findings showed that most facilities in Kalangala had dilapidated structures, some of which are hazardous. For example, a newly recruited Lab Assistant was hit by debris from her old house in the staff quarters of Bwendero HCIII while the staff quarters of Kalangala HCIV were in an appalling state as shown in the picture below.

The dilapidated staff quarters at Kalangala HCIV

Generally there was poor maintenance of the district’s infrastructure and the monitoring team found very unkempt and dirty facilities for example Mugoye HCIII, Bwendero HCIII and most health centers visited were infested with bats and vermins. Also poor stewardship of essential equipment and other assets was noted for example the bicycle and motorcycle given to Mulabana HC II were found missing and no one could give an explanation. Moreover no inventory management was found in the entire district and all the equipment in the district was not engraved which this results in the loss of government property. All health centres in the district were not fenced and lacked land titles; this has led to the land being encroached on other illegitimate users. For example Wamala supermarket was built on land rightfully belonging to Kalangala HC IV.

Wamala Supermarket built on Kalangala HCIV land



Despite recruitment of doctors at Kalangala HCIV, the theatre was found performing only minor surgeries. At Bukasa HCIV, the theatre was found abandoned with all the doors and windows eaten up by termites and the structure was being used to provide shelter to chicken and goats. The pictures below illustrate this:

The abandoned theatre at Bukasa HCIV with equipment which had been stolen, but recovered by MHSDMU

9.5.4 Health Service Delivery: Our findings revealed that health service delivery in the district was unsatisfactory. For example Bukasa HCIV was under-performing because the services offered are similar to those of a HC II, in spite of the infrastructure and equipment in place. Few or no deliveries were being done in some of the HCIIIs. For example, in Bwendero HCIII there were no deliveries for the entire month of February while in Lulamba HCIII the mid-wife had deliberately refused to attend to mothers. The lack of placenta pits was noted in most health centers, most nottable in Bukasa HCIV.

9.5.5 Medical Supplies: There was lack of proper medicines management in most health centers as shown by poor compliance to using HMIS tools, especially those used in medicines management. Furthermore, a lot of anti-malarials were found expiring in health centers, for example at Bwendero HCII, Mulabana HCII, Bafumira HCIII and Bukasa HCIV. The excessive medicines found in these health facilities were mostly paracetamol, IV fluids and eardrops of gentamycin and chloramphenicol. There was a general lack of records, and therefore the drug audit could not be undertaken by the monitoring team to establish the gaps.



Some of the expired drugs found at Kalangala HCIV

Storage of medicines was also found to be poor with drugs mixed up irrespective of type or expiry dates. Shelving and clear labeling of drugs was non-existent despite being a basic requirement of drug storage. The monitoring team worked together with local staff at some of the health facilities to organise their medicines stores as shown below:

The Unit's Pharmacy Team helped arrange the drug store of Kalangala HCIV

Snapshot of some Health Facilities in Kalangala District

Saipi HC II originally a community based facility was handed over to government. However it was established that they were not getting PHC funds and drugs from NMS despite government seconding two health workers to this facility. It lacked a Health Management Committee, and it was relying a few drug supplies from Bugoye HCIII.

Mugoye HC III had a new clinical officer, but the health centre was very unkempt and dirty especially in the labour ward which doubled as a store. The In-charge was staying in Kampala and was never at the facility while other staff forged attendance due to lack of supervision. The facility had no power, with an improvised laboratory space and had one microscope. Their drug management system was fine at the time of our visit despite absenteeism and late coming.



9.6 YUMBE DISTRICTThe MHSDMU team visited Yumbe district for routine monitoring of health services from the 24 January to 9 February 2013. Yumbe district had a total of 25 government health facilities of which one is a general hospital, one HCIV and the rest are lower level health units.

The health facilities visited include: Yumbe Hospital, Abiriamajo HC II, Dramba HC II, Locombogo HCII, Okuyo HCII, Aliapi HCII, Kei HC II, Lodonga HC III, Yoyo HC II, Ambelechu HC II, Kerwa HCII, Lokpe HCII, Yumbe HCIII, Apo HCII, Kochi HCIII, Matuma HCIII, Ariwa HCIII, Kulikulinga HCIII, Midigo HCIV, Barakala HCII, Lobe HCII and Mongoyo HCII.

Findings

9.6.1 Human Resource: Yumbe district had a challenge of attracting and retaining health workers due to its remoteness. However it is not recognised as a hard-to-reach area and as such, it did not have the related benefits. The output of many health facilities was found to be poor because the facilities lacked enough health workers such as midwives, nurses, doctors. The only hospital in the district had inadequate staffing levels, moreover, majority were support staff. The hospital had four doctors of the required 11 of whom one was a dental surgeon. Despite these challenges, the hospital was able to perform 146 surgeries in the month of December 2012 of which 110 were major and 36 were minor. The district had a total of 366 health personnel which translates into 69% of the recommended staffing levels. Staffing levels were supplemented by Baylor College and The AIDS Support Organization (TASO).

9.6.2 Infrastructure & Utilities: Most health facility structures were in fairly good condition and it was noted that the Northern Uganda Social Action Fund (NUSAF II) had greatly contributed to the infrastructural development especially in the lower level facilities.

NUSAF- funded projects in Lobe and Apo HCIIs

In Matuma HC III, a newly constructed five-stance pit latrine was awaiting handover and the works looked satisfactory. Priority had been given to staff accommodation in order to attract and retain staff. However, cases of shoddy works were still evident, especially in the case of placenta pits and some wards. At Lokpe HC III and Locombogo HCII, the placenta pits were at the same level with the ground making it easy for runoff water to enter. In Matuma HC III, a fairly new placenta pit had caved in and had been condemned and a new one was being built.



Poorly constructed incinerators in Lokpe HC II and Matuma HCIII

In terms of infrastructure maintenance a lot is still required. Yumbe hospital theatre and the hospital generally has old structures especially staff quarters which are in need of renovation, and some arrangements were found in place. For example the OPD and laboratory had been renovated and equipped by Baylor College in 2012, while discussions are ongoing with the Islamic Development Bank (IDB) and Organization of Petroleum Exporting Countries (OPEC) fund for the extensive renovation of Yumbe hospital.

9.6.2.1 Water: Only six health centres had borehole water within their proximity. Water harvesting is very poor in Yumbe and most of the gutters and tanks in half the facilities were non-functional due to poor maintenance. Two plastic tanks at Barakala HC III and Lokpe HCII were never installed by the contractor for over one year. The district water engineer was tasked to follow this.

Broken gutters at Yumbe HCIII and Midigo HCIV

9.6.3 Management of Medicines and other Supplies: Yumbe hospital had the most essential medicines and supplies. The team followed the chain of medicines management from the central drug store to the user departments. The HMIS tools like requisition and issue vouchers, dispensing logs and stock cards were in place apart from OPDs which lacked the standard dispensing logs. Although some internal controls to avoid wastage and theft of medicines at the ward level existed, a sampled audit of six medicine types revealed some discrepancies in these medicines. This is a result of late update of stock cards vis-a-vis the medicines issued.



In terms of storage, the central drug store was very small compared to the existing medical supplies from NMS and as a result some items had been kept on the veranda which compromises drug efficacy.

At the other health facilities health workers also acknowledged the presence of essential medicines. However HMIS tools for medicines management were poorly updated and periodic stock-taking was not done except in Mutuma HCIII. At every health facility, the Unit endeavored to train and assist health workers in proper medicines management including the usage of HMIS tools and the importance of timely updating.

9.6.4 Medico-legal Issues: The Unit came across an unlicensed drug shop in Yumbe called Allied Drug Shop, in which the attendant by the name of Gerile Swale was conducting ‘”surgical” procedures illegally. A lady died from suspected post-operative bleeding and sepsis one week after Swale “operated” on her for what seemed to be an inguinal hernia. The Unit worked closely with the local police to ensure that Mr. Swale was brought before the courts of law. He was convicted and fined 5million shillings.

9.6.5 Service Delivery: Service delivery in the district was noted to be less than recommended. The unit participated in a community dialogue session at Lokpe HCII between the health workers, community and the local leaders. The women reported that the sub-county chief had passed a by-law authorising health workers of the facility to charge 5,000/= for every mother who delivered in the community and brought the child for immunisation. We explained that health services at the facility should be free of charge and demanded that this fee is scrapped off immediately.

9.6.5.1 Immunisation: Immunisation for DPT 3 was at 57% and measles at 52%. This was attributed to inadequate staff, logistics (bicycles and motorcycles), and poor access to the facilities, poor community attitudes due to low literacy levels, vaccine stock-outs and inadequate supply of gas. UNICEF is working with the district to address this problem through its Family Health Days programme.



An immunisation outreach and a community dialogue session at Lokpe HCII

9.6.5.2 Reproductive Health: Uptake of family planning services was found to be very poor, mainly due to local perception and attitudes. High levels of teenage pregnancies were also noted with girls as young as 15 and 16 getting pregnant. The tables below give a snapshot of service utilization in ANC and other maternity services in Yumbe district.

Yumbe’s Achievements

The following scenarios that happened in Yumbe district are worth showcasing and celebrating:

• In February 2013, Yumbe hospital received the Face Innovators Award in the Health Innovation Category from Ministry of Health and Intra Health International for their using improvised lighting to conduct operations after their power system had broken down.

• The case that involved an illegal drug shop attendant was brought to a successful conclusion. The drug shop owner was convicted and fined 5 million shillings for conducting operations in a non- gazetted area and operating a drug shop without a licence.

• The 5,000/= fee that was being paid by mothers who did not deliver at the health facilities but brought the children for immunization, had since the monitoring visit, been scrapped.

Recommendations for Yumbe District

• Adolescent reproductive health services need to be scaled up in the district to reduce the high number of teenage pregnancies.

• Pharmacies and drug shops should be closely monitored by the District Drug Inspector to ensure that they conform to best practices.

• Construction projects in the district should be adequately supervised by the District Engineer and contractors who engage in shoddy works should be blacklisted. Standard designs of health facilities, placenta pits and incinerators should be sought from the District Engineer and Central Government prior to construction.

• The discussion and paper work for the extensive renovation of Yumbe hospital should be followed up and fast-tracked if possible.



9.7 KIRYANDONGO DISTRICT

This monitoring visit was conducted as part of the routine MHSDMU monitoring activities. Its main purpose was to verify the previous reports received through mTrac regarding poor service delivery, negligence, absenteeism and extortion at Kiryandongo hospital and other health facilities. 18 health facilities were visited Kiryandongo Hospital, Kigumba HCIII, Panyadol HCIII, Mutunda HCIII, Masindi Port HCIII, Diima HCIII, Nyakadoti HCII, Yabweng HCII, Kiroko HCII, Karuma HCII, Kaduku HCII, Diika HCII, Kitwara HCII, Teecwa HCII, Kicwabugingo HCII, Apodorwa HCII, Kiigya HCII and Mpumwe HCII.

The aspects of healthcare delivery reviewed included: human resource, infrastructure and equipment, finance and administration, medical supplies, medical services delivery, laboratory, infection and vector control.

Findings

9.7.1 Human resources: On a positive note the staff registers for attendance were found to be well updated, especially in the lower-level health facilities. However like many other districts Kiryandongo was found to lack sufficient numbers of human resources for health. All the health all facilities visited were found to have less than the MoH recommended number of staff. This cut across all levels of health facilities but Kiryandongo District Hospital was the most affected in this regard. The table below provides an overview on the status of Human Resources for Health in Kiryandongo.

Facility Staff found on duty Positions filled Recommended by MoH

Kiryandongo Hospital 79 93 190

Kigumba HCIII 07 13 19

Diima HCIII 11 15 19

Mutunda HCIII 06 12 19

Panyadoli HCIII 05 09 19

Masindi Port HCIII 04 08 19

Kaduku HCII 04 04 09

Kitwara HCII 03 04 09

Tecwaa HCII 03 04 09

Nyankadoti HCII 05 05 09

Diika HCII 04 05 09

Kicwabugingo HCII 01 04 09

Karuma HCII 04 04 09

Yabwengi HCII 04 04 09

Mpumwe HCII 03 04 09

Kiigya HCII 03 04 09

Table 23: Table: Human Resource structure in all facilities visited

9.7.2 Finance and Administration: Most of the lower health centres (especially HCIIs) had better accountability when compared to the hospital. The district hospital was found having irregularities in its financial accountability and up to 16,136,258 UGX was not properly accounted for.



9.7.3 Infrastructure and Equipment: The lower-level health facilities were observed to have better maintained infrastructure when compared to the district hospital, whose infrastructure was generally dilapidated. However some lower-level health facilities, for example Kigumba HCIII, were also not well- maintained. Cases of shoddy work in new constructions were also witnessed for example at Nyakadoti HCII and Kiroko HCII. The pictures below illustrates this:

Unkempt Kigumba HCIII

Non-functional X-ray machine, due to faulty batteries, at Kiryandongo hospital

Shoddy work At Nyakadoti HCII

9.7.4 Vector and Infection Control – Infection control in all health facilities visited was found to be fair with functional waste bins for medical and other waste, placenta pits (for HCIIIs) and on-site burning ditches. However vector control was lacking and with the exception of Nyakadoti HCII and Kaduku HCII, all the other facilities visited complained of bats infestation. The doors and windows of several buildings in Mutunda HCIII had been eaten away and wasted by termite infestation.



The placenta pit at Diika HCII

9.7.5 Management of Medicines and other Medical supplies: Lower level health facilities generally presented better accountability and management of medicines plus other supplies when compared to the district hospital. Massive gaps were found within the drug audits of the district hospital, especially within the requisitions and deliveries on the wards. For instance, no dispensing log books were being used in the peadiatric ward.

The small but decent and well-shelved drug store of Kitwara HCIII

Availability of medicines, particularly the essential ones, was found to be a major problem in Kiryandongo. By the time of our visit, NMS had just made a delivery to the district but these items had not yet been transported to the health facilities. This coincided with, and explained, the general stock-out of most essential medicines in the lower facilities. Expired drugs were found in all visited facilities, with the exception of only Nyakadoti HCII.

9.7.6 Service Delivery: The community and patients themselves reported to have more confidence with the services of lower facilities especially HCII’s and HCIII’s. It was easy to see why; in many lower-level health facilities most staff reported regularly for duty and they were smart in their uniforms. Examples of these facilities are Karuma HCII, Masindi Port and Kitwara HCII. However the over-usage of services at these facilities was placing a



considerable strain on the few health workers and limited absorption capacity of the health centres. The volume of work was observed to be considerably high in comparison with the allocated resources. In the district hospital, most patients admitted in the wards were being seen by only nurses and not doctors. Also, all patients seeking to use ambulance services were made to pay a certain fee, in spite of the fact that ambulance services are catered for in the hospital budget.

9.7.6.1 Laboratory services: Kiryandongo district lacked supplies for Determine Kits for over 6 months and this had greatly affected HIV testing services. Poor record keeping, especially with regards to issued kits, was noted at the district hospital. Irregularities were found in the documentation. For example, tallies of Determine and Stat Pac Kits were not reconciling with what had been documented in the stock cards.

9.7.7 Actions Taken by the Monitoring Team in Kiryandongo District

i. The Health Facilities found to be well organised and functioning normally were recognised.

ii. Where gross patient negligence was found, corrective measures were undertaken for example, at Kiryandongo hospital, several in-charges were cautioned and they committed to do their work properly.

iii. Regarding criminal issues police investigations were launched.

iv. A debrief meeting at the district hospital and one radio talk show were conducted in Masindi on King FM, as a way of giving feed-back to the community regarding the findings of the monitoring trip.

Recommendations for Kiryandongo District:

The CAO and other relevant actors should implement solid measures to streamline human resources at all health facilities, especially the hospital, so as to improve service delivery.

All un-accounted for funds should be refunded to the consolidated fund account.

The DHO’s office should set control measures for bats and termites in all health facilities

DHO office should comes up with concrete measures of handling expired drugs in all health facilities.



9.8 ARUA DISTRICT

The Unit carried out routine monitoring in Arua district between 28th January – 8th February 2013. The health facilities visited included; Arua Regional Referral Hospital, Omugo HCIV, Okollo HCIII, Ofaka HCIII, Cilio HCIII, Ogua HCII, Wadi HCIII, Bondo HCIII, Oli HCIV, Prisons HCII, Miltary HCII, Vurra HCIII, Opia HCIII, Logiiri HCIII, Lazebu HCII, Ajia HCIII, Adumi HCIV, Aroi HCIII, Adumi HCIV, Pajuru HCIII, Ayivuni HCIII, Ombidriondrea HCIII, Riki HCIII, Orivu HCIII, Silipi HCIII and Rhino camp.

Findings

9.8.1 Arua Regional Referral Hospital

9.8.1.1 Human Resource: Department in-charges as a good practice had their duty rosters and staffs lists displayed. The hospital was understaffed with only 15 (39%) out of the 38 required doctors. There was no resident surgeon and all acute cases were referred to Mulago NRH however, given the distance and prohibitive transport costs, many patients were at risk of death.

Absenteeism, late arrivals and early departures were rampant and was noted to be very high in all departments. The practice of late reporting and early departure was found mostly in the laboratory and OPD departments where staff did not even bother reporting back to work after lunch. There were also incidents of gross misconduct and unprofessionalism while on duty for example, the case of alcoholism where one health worker called Javuru Micheal reported for duty while drunk.

On a different note, many staff members complained of delayed and unpaid salaries and arrears. 14 staff members had missed their August and October salaries in 2012. There was also inadequate accommodation and over 70% of the health workers were renting outside hospital. Even the available houses at the hospital were in bad state of disrepair.

9.8.1.2 Management of Medicines and other Supplies: The hospital drug store was neat, well kempt and organised. A drug audit was conducted for the period starting from 1/July/2011 to 31/Jan/2013. Six medicines were chosen for the audit; i.e: Injectable Ceftriaxone, Quinine and Benzyl Penicillin. Oral medication Coartem (24, 18, 12 & 6), Cotrimaxazole and Caps amoxicillin. The audit found that medicines worth over 200,000,000/= could not be accounted for and investigations are on-going.

9.8.1.3 Infrastructure, Equipment and Inventory Management: The hospital structure is old, dilapidated and with old equipment in most of the departments. The maternity is too small and some expectant mothers were found sleeping on the floor. In fact only c-section delivered mothers were allowed to use bed facilities. There was also a stalled lagoon construction project. This was due to an on-going court case filed by a neighboring hotel and community wherein an injunction was issued against the continuance of the project after the plaintiff’s cited environmental concerns. The delay to build the lagoon had caused waste disposal problems and hampered the opening to the new state-of-the-art building meant to ease the problems of limited space in the wards, especially the medical ward.



The hospital block that was not in use due to an on-going court case

There was very poor inventory management. The hospital inventory had not been updated and many equipment plus items were not included on the list for example:

i. Toyota Land Cruiser Wagon UG 4196M

ii. Toyota Land Cruiser Wagon UG 1937M

iii. Nissan Hard Body Double Cabin UAA 455N

In addition to not including the above vehicles on the hospital inventory list, there was a case of vandalizing another hospital vehicle. This was a Toyota Land Cruiser Wagon UG 1116M for medical equipment. The vehicle was vandalized during the 2012 Christmas holiday where all the four newly-acquired tyres and reams were stolen. The vehicle had since been grounded. Furthermore, three of the hospital motorcycles listed in the hospital inventory could not been seen. These motorcycles are: Jailing UG 1998M, Jailing UG 2010M and Jailing UG 1806M.

The hospital had been procuring medical equipment, and by end of January 2013 LOTs 1 and 2 had been delivered. However most of the equipment delivered did not meet the required specifications and the original documents accompanying the procured items could not be seen apart from the photocopies. The items in question were:

i. Oxygen concentrator

ii. Ultra sound scan

iii. Operating table

iv. Infusion pump.

9.8.1.4 Service Delivery

Arua Regional Referral Hospital was faced with water shortages especially during the dry season. The hospital was also severely hit by shortage of blood. The blood bank vehicle had also broken down thus affecting outreaches and blood donation. Furthermore, the influx of Congolese and Sudanese patients from across the borders were causing a strain on hospital resources and contributing to an insurmountable workload for the few health workers at the hospital.



Findings from the other Health Units in Arua District

9.8.2 Service Delivery: Extortion was at its peak in some health facilities like Okollo HCIII where patients were paying 5000/= to access medical services. The situation was worse in Omugo HCIV where the in-charge Ms. Abaru Asia and Mr. Onzima Charles were found selling medicines for diabetes at 14,000/= and charging 3000/= for diabetes testing. It was public knowledge and the price list for these drugs was even pinned up for public viewing as shown below: Furthermore at Omugo HCIV the patients were being charged 50,000/= to use the ambulance yet the facility had a budget for fuel.

There was no roof at Wadi HCIII maternity ward since it had been blown off by winds in 2010. At Ofaka HCIII, the midwives had abandoned their duties to a Nursing Assistant whom the monitoring team found delivering mothers on her own. HMIS compliance was noted to be poor and it was difficult to track trends in service delivery because most departments at the health facilities lacked patient registers.

In some areas the level of health facilities plus the related services and supplies was not commensurate to the community health needs. For example Wadi HCIII had been downgraded to HCII level, and this had resulted to shortage of drugs for patients because the area population is big. Some health facilities had expired drugs which included folic acid, contraceptives, ARVs and condoms. All the health centres visited in Adumi health sub-district had poor medicine accountability, and had medicines stock outs. There was a strong correlation between poor accountability and medicines stock-outs.

9.8.3 Human Resource: Absenteeism was very high in Arua, especially for the case of in-charges. Of the 25 health facilities visited, only 3 (12%) in-charges were found present. Most health facilities did not have records for financial accountability; the in-charges claimed that their accountability documents were at the HSDs yet at some health sub-districts these documents were missing. Furthermore there were no staff attendance registers in most of the facilities visited, including Omugo HCIV.

Supervision and monitoring were noted to be lacking because the DHO had not visited most of the facilities for more than 3 years. Some of the facilities not visited over long periods of time include Okollo HCIII, Bondo HCIII and Wadi HCIII.

9.8.4 Infrastructure, Equipment and Utilities: Generally the management of infrastructure, equipment and utilities at most health facilities was not in good condition. Solar in most of the facilities was non-functional due to batteries; in fact some had never worked at all since installation and deliveries in maternity wards were being done using lamps at night. All the solar-powered phones in the district had never worked. The new constructions handed over to Ajia HCIII and Arivu HCIII had been poorly constructed, with the floors cracked under Magtech contractor. Some facilities had grossly mismanaged their equipment and infrastructure including beds, mattresses and buildings for example at Silipi HCIII and Bondo HCIII as shown in the pictures below:



Abandoned beds at Silipi HCIII An abandoned mattress at Bondo HCIII

The abandoned maternity ward at Bondo HCIII

Cases of poor stewardship also extended to cars, for example a brand new ambulance donated by UNHCR to Okollo HCIII for referral broke down due to poor servicing and lack of tyres.

The grounded ambulance at Okollo HCIII

Recommendations for Arua District

Attention should be given to recruitment and retention, especially of core clinical staff.

Absenteeism should be strongly discouraged and punitive action taken against acts of unprofessionalism among health workers, for example those illegally selling government drugs.

Regarding buildings renovations should be prioritised especially maternity roof at Wadi HCII. Joint supervision and regular spot-checks on the contractors while construction is on-going and before constructions are handed over would go a long way to reduce the occurrence of shoddy work.

The district should organize and implement sessions for training of its staff in proper management of medicines and other supplies in order to avoid wastage.

• Compliance to HMIS procedures should be emphasised and proper record keeping, including updating health facility inventory, should be strictly enforced. Missing, underutilized or wasted items should be gathered and put back to proper use.



9.9 SHEEMA DISTRICT

The field monitoring exercise in Sheema district was carried out between 25th- 29th of November 2012. The visit was prompted by a number of complaints generated through MTrac’s anonymous SMS service and the Unit’s tollfree line. The monitoring team visited Kitagata District Hospital, Shuuku HCIV, Sheema HCIV and also carried out a financial audit of the DHO’s office.

Findings

9.9.1 Kitagata Hospital

Kitagata hospital is the only government hospital serving Greater Bushenyi which consists of five other districts. However a number of services were found to be dysfunctional. For example, there were no x-ray services, dental services, no water supply and no electricity.

9.9.1.1 Human Resource: Absenteeism and late coming by staff was high at the hospital. The monitoring team arrived at 9:00am but found only the medical superintendent and three nurses at the facility. In the laboratory no staff was found present, all of them were reportedly attending a workshop and the laboratory was left to be run by volunteers and students (25 of them) without supervision. The health workers attributed this to many reasons. Among them a lack of staff accommodation. Staff members used to get a ‘top-up’ allowance which was later scrapped and the explanation given by management was that there was no money; however patients were still being charged. Staff members complained of work overload due to general understaffing, for example the dental department had only one doctor in the unit; patients admitted were only seen by nurses until when discharged and clinical officers only worked in OPD but did not do ward rounds. A considerable number of critical staff, mostly the core clinical staff had taken leave and this created more workload for the few remaining staff.

The fact that the district had allowed so many staff members to go on study leave simultaneously partly explains the heavy negative impact on service delivery. Related to this, the monitoring team also found abscondment from duty by the hospital staff to be a major cause of severe understaffing. Some staff who had absconded had not been deleted from the pay roll at the time of the Unit’s visit. The table below shows some of the Kitagata Hospital staff who had absconded from duty since 2012.

Name Sex Designation RemarkBiira Bamwenda Sarah F Nursing Officer AbscondedBwambale Wahumbwa Nelson M Nursing Officer AbscondedKyaligonza Imelda F Nursing Officer AbscondedKyomugisha Evalyne F Nursing Officer Absconded

Table 24: Staff who absconded from duty in Kitagata Sheema

9.9.1.2 Infrastructure, Equipment and Utilities: The monitoring team was not able to carry out an equipment audit because the hospital lacked an equipment inventory. All the dental equipment was old and broken down and no substantial services were being given in this section. The hospital x-ray had not been working for close to one year and no efforts had been made to repair this equipment. Mattresses in the maternity ward were all rotten and the same ward also lacked Blood Pressure machines yet the staff are expected to perform



and deliver mothers without such important equipment. Most beds in the male ward lacked mattresses; a lot of equipment was malfunctioning. Although the wards had well-partitioned stores suitable for medicines to give other side rooms for patients, these rooms were instead being used to store malfunctioned equipment. The hospital had no functional autoclave or boiler, and no sterilization was being done. Some computers at the hospital had been supplied by Uganda Communications Commission which had promised to network them but never showed up for over a year, so the computers were largely monumental.

The entire hospital did not have running water for almost a year and as such sanitation and hygiene at the hospital premises was appalling. The main water pipe that supplies the hospital had 52 illegal connections and as a result water shortage. Regrettably, the leadership of Kitagata sub-county had also authorised the diversion of the hospital water to the quarry company.

The quarry site where part of the hospital water had been diverted

In addition, the hospital had no infection control system in place. There were no watering cans, no soap for washing hands and this put everyone at risk.

9.9.2 Finances and administration: The monitoring team found the hospital books of accounts fairly well kept; a missing Shs. 5,000,000/= was refunded and the matter handled administratively.

9.9.3 Service Delivery: The monitoring team established that extortion was standard practice at Kitagata Hospital. Patients were being charged Shs. 5,000/= by the hospital for services rendered and patients who needed to see a doctor were charged 10,000/. Those who could not afford were sent to clinical officers regardless of their condition. Patients were made to buy exercise books to be used for admission notes. On discharge, they would buy another exercise book for discharge notes. The laboratory did not work at night and many patients were admitted and discharged with no tests done. As mentioned earlier, the laboratory section was probably the most under-utilised section of the hospital despite being supported by interns.

9.9.4 Medical Supplies: There was stock-out on critical supplies which determined what services could be offered. For example there was no cannula gauge 24 on the pediatric ward and patients were told to go and buy from outside the hospital. The store also had stock-outs, especially for mama kits, Depo-Provera and oral contraceptives which had not been supplied. However in the pharmacy section a commendable job was being done and credit is given to the staff in the store for accounting for all the medicines requisitioned from the store.



Random selection of drugs (like carbamazepine, diclofenac injection, Ampicillin injectable, omeprazine, quinine injection, Amoxyl, caplopil, ceftriaxone injection, metronidazole infusion) all balanced from the store to the pharmacy and wards. Furthermore, the store was well organised and maintained. This is an example of best practice in proper management of medicines.

The well-organised drug store at Kitagata Hospital

9.9.5 Shuku HCIV: The Unit found the facility understaffed with up to 62% of the positions vacant. Out of the 34 staff meant to be at the facility, only 13 health workers were at the HCIV and none of these was dressed in uniform.

The drug store was well organised, well-stocked and drugs were all accounted for.

The latrines were very dirty and unkempt.

• The newly constructed theatre was not functioning due to lack of personnel and power. Multiplex which constructed the theatre did not connect power to allow it function.

• The monitoring team could not access financial accountabilities due to the absence of the sub-accountant. Shuuku HCIV did not have a bank account; the CAO only informed them of how much they were to collect.

• There were no support supervision reports on site despite the huge financial claims by DHT for the same.

• The facility had staff members who had worked for over three years but were still on probation. E.g. Tusingwire Dinah, an Enrolled Nurse.

• The ambulance had very old tyres which needed immediate replacement.

9.9.6 Kabwohe HCIV: At Kabwohe HCIV the monitoring team found the facility in-charges also doubling as the DHO of Sheema district. This makes the facility miss out on the services of a doctor on a daily basis. The facility had a lot of expired drugs, i.e. ORS, Coartem, Dexo and Fansidar. It also lacked beds, mattresses and most patients were found sleeping on the floor. Like in Shuuku HCIV, financial accountability at Kabwohe HCIV could not be accessed due to the absence of the sub-accountant.



9.9.7 Findings from the Financial Audit on Sheema DHOs Office

The audit for covered the period of two financial years, that is 2010/11 and 2011/12 and below we provide a summary of the audit findings.

Releases: Sheema district received over 500M for this period of two financial years and a breakdown of the funding allocation is shown below:

Table 25: Breakdown of Sheema District funding allocations

SHEEMA DISTRICT FINANCIAL ALLOCATION

YEAR AMOUNT

2010/11 198,896,792

2011/12 312,096,589

TOTAL 510,993,381

Accountabilities: The funds were fairly accounted for apart from some payments which were found to have been over-paid, i.e. the rates for SDA which were over-exaggerated. The money in question was approximately 7 million shillings and it was agreed by the suspects in question to refund.

Table 26: Overpaid allowances in Sheema

OVER PAID ALLOWANCES (SHEEMA DISTRICT)

FINANCIAL YEAR AMOUNT

2010/11 385,000

2011/12 6,610,000

TOTAL 6,995,000

Recommendations for the DHO’s office:

The money paid over and above of the legal rates should be recovered fully from the respective office(r) s.

The district leaders should set stringent measures within the health facilities to stop absenteeism and late coming.

Staff who absconded from duty should be removed from the payroll

The hospital administration should set up an equipment inventory and ensure that it is regularly updated.



9.10 KIBAALE DISTRICT

The visit was prompted by numerous complaints on the MTrac platform about health service delivery in the district and the visit took place from the 4th-16th of June 2013. Kibaale district has 34 health facilities and this includes one general hospital called Kagadi Hospital, three health centre IVs and the rest are lower-level health facilities. The health facilities visited include: Mataale HCIII, Mugarama HCIII, Kakumiro HCIV, Kagadi Hospital, Rugashari HCII, Mugalike HCII, Kabubwa HCIII, Masaka HCII, Kyakabadiima HCII, Isunga HCIII, Kyabasaija HC III, Kyebando HCIII, Burorora HCIII, Igayaza HCII, Mukooro HCII, Nyamarwa HCIII, Kyabasara HCII, Kibaale HCIV, Kasambya HCIII, Mabaale HCIII, Kiryanga HCIII, Kakindo HCIV, Nkooko HCII, Kyamasega HCIII, Kisiita HCII and Kigando HCII.

Findings

9.10.1 Human Resource: The status of human resources in Kibaale district, at the time of this monitoring visit, had improved to 65% up from the previous 46%. This can be attributed to seconded staff from the IDI through the Saving Mothers Giving Lives (SMGL) project. The three HCIVs in the district had a minimum of two medical officers seconded by IDI while Kagadi Hospital had three seconded medical officers. The same programme also seconded midwives to HCIVs and IIIs which had translated into better ANC services as evidenced by the data in the ANC and maternity registers. The ANC coverage for 1st, 2nd and 4th visits was 90%, 70% and 40% respectively. That aside however, it was noted that 50% of health units did not have a daily staff register and those facilities which had registers were not updating them properly. Absenteeism and late coming among staff members was also noted, for example in Mugarama HCIII where only 2 staff members out of the 8 staff were on duty at 10.30am. Monitoring of health services was generally poor in the district and this was partly attributed to lack of transport. There was lack of support supervision by DHO and DHT especially in hard-to-reach areas like Masaka HCII while sub-county chiefs and L.CIII chairpersons were reportedly not seen on the ground.

9.10.2 Medical Supplies Management: Most facilities in Kibaale had clean, organised and shelved drug stores and this can largely be attributed to the SURE programme which supplied pre-fabricated shelves and conducted on-site stores management trainings. Contrary to reports by the community, medicines were present in 90% of facilities visited including anti-malarials. However, stock cards were not well-updated in most facilities. Documentation and accountability for medicines usage was generally poor except in Kakumiro HCIV and Isunga HCIII.

Expiry or near-expiry of medicines was common and coartem topped the list. In Mabaale HCIII, there were 164 boxes of coartem that had expired during the period May 2012 to March 2013. In line with the absenteeism argument made earlier, it was also noted that the facility in-charge worked only twice a week and did not have full knowledge of what was in his store. In Kyebando HCIII, 41 boxes of the 107 boxes of coartem (no.6) were due for expiry that same month, Kyamasega HCII also had a lot of expired drugs while at Isunga HCIII, and expired drugs had never been collected in six years. The DHO said he lacks transport to redistribute drugs to other facilities and also carry away expired medicines.



9.10.3 Theatre Functionality: Theatres were fully functional in the four facilities which conducted both major and minor surgeries. All the theatres visited were structurally sound and clean and had most of the necessary equipment although there were isolated cases of malfunctioning equipment like the second oxygen concentrator at Kakindo HCIV. Although not stable, all the four theatres had a source of power supply either in the form of the national grid (UMEME), solar or generator. The theatres in the HCIVs had been renovated by IDI through the Saving Mothers Giving Lives (SMGL) project.

9.10.4 Service Delivery: There was severe understaffing in some areas and this heavily affected the available services. One case in point is Kyamasega HCII where the facility had been abandoned; the only health worker reports on Tuesdays and sees all the patients for the week. The health worker cited lack of accommodation, insecurity and lack of co-workers as reasons for his one-day-of-work policy. This problem was raised in the district meeting and the DHO was asked to prioritise accommodation and second more staff. Two staff members have since been deployed at the facility.

Abuse of office and extortion by some health workers was also found in Kibaale. A paediatrician attached to Fort Portal Regional Referral Hospital (FFRH) was conducting surgeries in Kagadi Hospital for a fee with the full knowledge of the Kagadi Hospital administration. Theatre records revealed that some patients at the hospital were also matched with those in the cash register at his private located next to the hospital. Some patients were charged as much as 200,000/=. He spent more time in Kagadi than at his station of deployment.

There was also underutilisation of some essential services at some health facilities. For example in Kakindo HCIV, a brand new electric centrifuge and an incubator had been stored away and not used for the last five years; the laboratory technician cited lack of space. The facility In-Charge was asked to rearrange the laboratory or provide alternative space within the facility.

In terms of immunisation, all facilities visited had immunisation services except Igayaza, Masaka & Kyamasega HC IIs which did not have fridges. The digital displays of some fridges were not in synchrony with the internal thermometers e.g in Nkoko HCIII, the digital monitor read 3.60C while the thermometers read -50C. In Mukoora HCIII, the EPI fridge had vaccines but the temperature is reading 200C instead of the recommended 2 to 80C. In Nkoko HCIII, all the solar fridge compartments were frozen. In Mukoora HCIII, the gas cylinder was empty and the solar power was non-functional; the monitoring team helped take the vaccines to Kakumiro HCIV. The fridge monitor was reading 240C and the internal thermometers were broken in Kyabasara HCII. The fridge thermometers in Kisita HCIII were reading 00C. The temperature control charts were not updated regularly in 80% of health centres while the temperature recordings were higher than 80C in Mataale HCIII. Vaccine control books were poorly updated in all H.Cs and absent in Kyabasaija HC III and Mugarama HCIII. There were no Polio, BCG, and DPTHepB vaccines in Isunga HCIII for the last one month despite informing the DHO and cold chain supervisor. The immunization coverage for the FY12/13 was: 1st quarter-DPT3=44 percent and measles 47 percent.2nd quarter-DPT3=70 percent and measles=84 percent.



9.10.5 Utilities and Equipment Maintenance: Generally inventory ownership and management was found to be poor in the district. The examples are endless; two cars belonging to the District Health Office were involved in road traffic accidents and this had affected support supervision services in the district; a tricycle ambulance donated by IDI to Kyakabadiima HCII was also involved in a road traffic accident and was due for inspection by the Inspector of Vehicles before repairs could begin; the motorcycle belonging to Mukoora HCII had been abandoned at a private garage in Kakumiro HCII for close to two years and the DHO was told to find funds to get this motorcycle repaired.

Water shortage was found to be a serious problem in many (60%) health facilities and some had to fetch water from as far as 2km away. Water harvesting was only functional in Nyamarwa HCIII, Kakumiro HCIV, Kisita HCIII, Kitaihuka HC II, Nalweyo HC III, Kakindo HCIV, Igayaza HCII and Mugarama HCIII. There was no flowing water in Kagadi Hospital because the submersible pump had broken down and this greatly affected sanitation at the hospital and the neighbouring community. Meanwhile the priorities and actions of some local leaders were noted to be more detrimental than helpful to the situation; for example the sub-county chief had resolved to sell an uninstalled water tank at Kakindo HCII despite having no water at the facility.

The un-installed water tank at Kakindo HC II which was about to be sold by the S/C chief.

Achievements in Kibaale District

• After the Unit’s intervention, there an improvement in the attendance of six health workers who had had been irregular at their facilities has been reported

• In the dissemination meeting, it was resolved that the district quickens the process of finding alternative accommodation for the RDC and a timeline of four months was set.

• Water has been restored to Kagadi hospital after the district fixed the pump

• An extra health worker has now been deployed at Kyamasega HCII and daily OPD services have resumed.

• The sale of the water tank at Kyakabadiima HC II was halted and plans are underway to have it installed.

• The district has prioritised the recruitment of a permanent cold chain supervisor after the MHSDMU team highlighted the problems in the immunisation services.

Recommendations for Kibaale District

• Immunizations services in the district should be well monitored and attention should be given to the areas highlighted.

• The process for acquiring alternative accommodation for the RDC should be first tracked.

• The two vehicles for the district health office should be repaired.

• Drugs nearing expiry should be redistributed by the DHO to other health facilities.



9.11 MOYO DISTRICT

Moyo Hospital

The monitoring visit to Moyo district was at Moyo Hospital and the findings are shown below:

9.11.1 Human resources: The hospital does not have any specialist medical officer in the departments, they only have 1 senior medical officer and 4 medical officers. The whole hospital did not have a pharmacist to advise and streamline the drug supply and management system. However the hospital was fairly staffed with 73% staffing levels.

9.11.2 Infrastructure and equipment: The hospital has dilapidated structures, for example the OPD section which is shown here below:

A dilapidated Moyo Hospital OPD

Out of the 86 staff houses in the hospital, only 48 are habitable by the hospital staff and the rest are in a very bad state with no ongoing renovations found at the hospital premises.

The hospital inventory book shows that there are 160 beds available in the wards but only 105 beds were found functional whereas 55 beds are broken without repair.

The hospital has 7 vehicles however only 3 are functional whereas 4 ambulances are grounded beyond repair.

Some of the grounded hospital vehicles and ambulances. One of the 4 functional ambulances



The hospital and the entire Moyo district had no running water. The hospital relies mainly on the two existing bore holes, one of which had broken down. The hospital has an electrical pump that they mainly use to pump water to the critical parts of the hospital like the theater, but it is so unreliable that it often breaks down.

9.11.3 Laboratory The hospital has a well-equipped laboratory however do not have a senior technologist. The staff also complained of having outdated equipment in the laboratory yet they studied newer technology.

The well-equipped Moyo hospital laboratory with backup power supply

9.11.4 Theatre: The theatrr had no regular power supply yet it is the only functional theatre in the whole district with no running water in the theater yet in the month of March 2013 the hospital had conducted 24 major surgeries and 109 minor surgeries.

Water tanks for temporary water storage in the hospital theatre.

Moyo Hospital Theatre



9.11.5 Medicines Supply and Management

The hospital was found well stocked with medicines however there is no pharmacist to streamline the supply chain management and ensure proper dispensing procedures are in place, thus there is no proper use of HMIS tools. This does not only affect the drug accountability requirement but also impacts on the drug requisition processes of the entire hospital.

Moyo hospital drug store



10 CONCLUDING REMARKS

Shared and Diverse Experiences: A Holistic Approach Embracing Health System Blocks

This report has, hopefully, taken the reader through the 13 districts of Uganda which were monitored by MHSDMU in 2013 – their success stories and challenges in delivering healthcare. What becomes very clear is that there are a number of overlaps and similar challenges faced by most of the health facilities visited. Most of them are coping with some of the major problems including limited funding and cost- containment; few HRH attending to huge populations with diverse health needs; poor stewardship of resources, etc. However it is also clear that although districts and indeed health facilities might have some shared experiences, there is also diversity in experiences. This means that we cannot afford to look at all health facilities as one homogenous block every time; rather both the diversities and similarities are taken into account when planning, implementing and evaluating health interventions. Successful planning and implementation of health sector goals requires the combination of the technicians and politicians, as well as the plethora of actors from all the other partner sectors.

What is needed is a holistic view to health, and the notion of embracing all the six health system blocks (medical products, health workforce, financing, health information, service delivery as well as leadership and governance). This report has shown that all facilities which had challenges were not performing poorly on all the blocks; rather a few neglected ones (for example HMIS or HRH) were impacting negatively on all the other blocks. All health sector actors therefore need to arise and support health facilities (ultimately the Ugandan Health System) to consolidate their good practices while at the same time improving their weak links. We should all be asking ourselves, while we push for particular strands of the health sector, whether we are taking a holistic systems-approach to health sector issues. If not, we will end up having only little “islands of success” which are not sustainable in the broader geopolitical context. Yet sustainability is a critical component for health systems to integrate holistic strategic processes to support sustainability efforts of initiatives, services and the mission of Uganda’s health sector as a whole. It will be crucial to generate new strategies for controlling complex mechanisms that affect expenditure and performance of healthcare sustainability while striving for the achievement of core objectives of health policies such as universal access, high-quality standards, efficiency and effectiveness, adequate funding and overall patient satisfaction.



APPENDIX 1: Court Convictions since MHSDMU’s Inception

CRB Origin Accused Offence Sentence

001/2010 MulagoNabagala Bety and

anotherExtortiion

4000000 or one year

imprisonment

003/09 ManafaWalimbwa Massa

CharliePossession of Government stores

12 months or 200000

049/010Mulago Birungi Josephine

Illegal possession of govenrment drugs

UGX 150000 or 3months

imprisonment in default

049/10 Major Stephen Theft convicted to 3 years in jail

05/011 Wandegeya Katwerebere Moses Embezlementsentenced to a fine of 2

million or 3 yrs in default

1009/009 Kaabong Dr Isanga Joseph Embezzlement5yrs imprisonment for each

count

106/010 Grace AremokokUnlawfull possession of government drugs

UGX 1,000,000

1071/011 Sembabule Ngecha Esau Lwegaba Jimy UGX 1000,000

1134/010 SorotiDr Anyama &

Makombe WEmbezzlement

1178/011 Mukono Kenganzi Operating without a license 3 months or UGX 200000

1188/011 Fort portal Nyakawesa ElizabethAbuse of office & possession of classified drugs

UGX 200000 or 3months

Imprisonment

1216/012 Tororo Tenywa MTheft and unlawful possession of government drugs

Convicted

1220/12 Nakasongola Kitali BetyOperating a drug shop without a license

Sentenced to 2 yrs imprisonment

1258/012 Kiryandongo Byaruhanga Deo Theft 4 yrs in jail

1401/09 KiruhuraTumwine Fred and 5

othersUnlawful possession of government stores

Fined each 800000

1409/010 Busia KyomwogeziBeing in possession of

smugled drugsOne milliom UGX

1409/10 Busia Kyomugezi MonicaIllegal possession of classified drugs and smuggling of drugs

Fined 2000000

1410/010 Busia Nduga AmstrongUnlawfull possession of government drugs One million UGX

1419/010 Busia Masaki JUnlawful possession of

government drugsThree Million UGX

1420/010 BusiaIdro Basil & Chepkok

DianUnlawfull possession of government drugs

UGX 4,000,000 or 3 yrs

imprisonment in default

15/010 Kasese Muhindo A Abuse of office 300,000 UGX




16/011 Kasese Masereka Micheal Unlawfull possession of government drugs

UGX 300000 for bothecounts

1622/010 Mubende Nabakooza speciozaCarrying out a businessof a pharmacist & being in possession of government drugs

UGX 100,000 or 3monthsimprisonment in default

1832/010 IgangaBakali Tenywa

andothersPossession of stolen property outside Uganda

1834/010 Iganga Mudoola Karim & Muyanya Awasi

Unlawfull possession of government Drugs

UGX 300000 each or 1 yrimprisonment in default

1835/10 Iganga Birungi JosephineIllegal possession of clasified drugs & unlawful possession of Government stores

Fined 150,000

195/010 Kasese Tushabe Milton Abuse of office & theft of HIV test kits Fined 200,000

198/010 AmuruDr.Olwedo and sixothers

Causing financial loss

Ngecha sentenced to 2 million or 2 years in defaults. Dr. Olwedo sentenced to a fine 500000 or 2 years in default.

201/11 Kayunga Lwanga Susan

Corruption, abuse of office,U. P. of government stores and being in possession of suspected property

A fine of 2 million or serve 2 years in default

2010/011 Kayunga Kibuule EmmaEmbezzlement, possession of classified drugs. Operating a drug shop without a license

UGX 3000,000 or 2yrsimprisonment

210/0101 Kalisizo Ssengero Ali Personation/forgery Community service

210/10 Rakai Ssengero Ali Personation convicted to community service

2132/010 Iganga Maganda James Embezzlement. Fraudulent false accounting and abuse of office

Acquitted on count one and convicted on 2 others and Sentenced to five and a half year in jail

2281/011 Lira Iwer RayOperating an illegal nursingSchool

6 Months or payment 1M

233/010 Nsangi Nantale Mpungu Illegal possession of classified drugs and operating illegal clinic Convicted

2505/010 Lira Akello Mary Grace Unlawful possession of government drugs

UGX 500,000 or 1 yrimprisonment in default

2505/10 Lira Akello mary graceOperating a pharmacywithout a license and unlawful possession of government stores

Fined 500,000

29/011 Kasese Baluka Didas Extortion100000 or six months in jailin default

291/0111 Soroti A I Angoli C AII AmenuM AIII Oinya I Embezzlement Imprisonment for 24 months




3132/010 Iganga Maganda James Causing Financial Loss

322/010 Lyantonde Masika Salima Unlawful possession of government drugs 19 months imprisonment

348/009 Major Stephen theft of a microscope 3yrs imprisonment

424/010 WandegeyaKawanguzi Emma, Mwerezi Deo, Ssenyonga peter

Illegal possession of government Drugs

Payment of UGX 100000 each or 2 yrs of imprisonment in default

441/010 Lyantonde Musiime H, Unlawful possession of government drugs

455/11 Ntungamo Edina Ninsiima Unlawful possession of government

Sentenced to one year of imprisonment

519/011 Nakaseke Kaise graceUnlawfull possessionof government drugs , Embezzlement, Abuse of office

UGX 500,000 or 1yr. UGX1000000 or 2yrs

526/09 Manafwa Wanzar Base Unlawful possession of government stores

Fined 20,000 or 1 year indefault

546/010 Lyantonde Nansubuga F , Kasaga Paul, mbabazi

Unlawfull possession of government Drugs

546/011 Rakai MaserekaIllegal clinic , unlawfull possession of government drugs and classified drugs

UGX 600,000 or 2yrsImprisonment

598/010 Mayuge Agutu florence

Embezlement, Unlawfull possession of government of stores, carrying out a business of a pharmacist

2,000,000 or 4yrs ofimprisonment in default

599/011 Mayuge Agutu FlorenceUnlawful possession of Government stores, Abuse of office, O.B.PH License

5 million or serve2 years in default.

600/12 Arua Al Chandiru Theft, unlawful possession ofGovernment stores

Sentenced to two yrs imprisonment.

633/011 Mayuge Okojoy Pancreas and onyango Joseph

unlawfull possession of government stores, Carrying out a bussiness of pharmacist, illegal training

UGX 2,100,000 or 2 yrsimprisonment in default

659/12 Soroti Okok David Destroying evidenceSentenced to a fine of300000 or serve 2 yrs indefault

667/011 Nwoya Komakech Stephen & Kitega Felix

Theft, unlawfull posssession ofGovernment stores 2yrs imprisonment

768/12 Sironko Nambafu betty Un lawful possession of government stores

Sentenced to a fine of 400000 or 12 months in default

81/010 Mulago Kaweesa Personation

829/11 Ntungamo Twinomugisha olive Unlawful possession of government stores

Sentenced to one yr imprisonment




855/010 Busia Anyango Beatrice

Unlawful possession of government drugs and being in possession of drugs smuggled from Kenya

Caution and not being in possession for a period of two yrs

856/010 Busia Nafula Beatrice andanother Possession of smuggled drugs

UGX 2,000,000 andcommunity service for six months

877/011 Ndyesinga prossy Unlawful possession of government stores UGX 200,000

887/011 Kamuli Ndyesiga Prossy Operating a drug shop without a license 200000UGX

891/11 Kamuli Bazanye Simon Impersonating and ForgeryConvicted on all charge and sentenced to a community service

910/012 Luwero Katabu PTheft and unlawful possessionof government drugs

UGX 200000 or 3 months imprisonment in default

924/11 Kiboga Wesonga Agnes Operating a pharmacy withouta license

Convicted to a fine of 200000 or serve six months indefault

934/011 Hoima Mugisha H

Abuse of office, Embezzlement , possession of government Drugs UGX 2000, 000 or one yr-

imprisonment

945/010 Rushere Mukose David Embezzlement UGX 58,000,000 and 4 yrs imprisonment

984/010 Masaka Nassiwa Christine Unlawful possession of government drugs Community service

E/295/10 Apac Ocepa Geoffrey Abuse of office and Embezzlement

Convicted on all counts .Ordered to refund 15720000. Pay a fine of 5 million or 4 years in jail on default

E/400/009 Kampala Dr.Baleke Kamba Samuel Embezzlement Four years Imprisonment and

refund of Shs. 39 millions

E/407/11 CID HQKayangwe Dennis Kisha

Personation, Uttering False documents 6 counts

Convicted sentenced to a fine 3500000 or serve 24 months in jail

GEF 1440/011 CID HQ Kayangwe Denis Personation and uttering False

Documents One and half yr imprisonment

1071/2011 SembabuleNakibule Scovia & Happy

Being in possession ofGovernment stores

Convicted to community service of 100 hrs and caution.

1070/2011 SembabuleSanyu Jacinta & Kisakye

Being in possession ofGovernment stores

Convicted to community service and caution

1258/2012 Kiryandongo Byaruhanga Deo Theft of solar panels Convicted to four years imprisonment.

6872/2012 CPS Kla Lutaya LeonardCarrying out business of a pharmacist without a licence and supplying restricted drugs

Convicted to one year or a fine of 800000/= for each CT

1668/2010 SOROTI Egonu C Fraudulent false Accounting and Embezzlement

Convicted to custodial sentence of 3years




4710/2012 KATWE Thembo AmosUnlawful possession of Gov’tStores

Convicted to community service

CRB 151/011 ABIM Okwera Aldo EmbezzlementConvicted and sentenced to a fine of two million shillings or serve two years imprisonment

CRB 945/10 RUSHERE Mukose David Embezzlement Convicted and sentenced to four years custodial sentence



Appendix 2: List of Radio Talk Shows done by MHSDMU in 2012/13

DISTRICT RADIO TOPIC LANGUAGE MONTH/12

KABALE VOICE OF KIGEZI

Intro of mTrac & MHSDMU’ Role; How to use mTrac’s SMS’s Toll free 8200 to report; any health service anomalies or appreciation Rukiga AUG

KISOROVOICE OF MUHABURA

Intro of mTrac & MHSDMU’ Role; How to use mTrac’s SMS’s Toll free 8200 to report; any health service anomalies or appreciation . KIFUMBIRA AUG

MBARARA RADIO WEST Intro of mTrac & MHSDMU’ Role; How to use mTrac’s SMS’s Toll free 8200 to report; any health service anomalies or appreciation Runyankole AUG

KABAROLE VOICE OF TOORO

Intro of mTrac & MHSDMU’ Role; How to use mTrac’s SMS’s Toll free 8200 to report; any health service anomalies or appreciation . RUTOORO AUG

KAMWENGE VOICE OF KAMWENGE

Intro of mTrac & MHSDMU’ Role; How to use mTrac’s SMS’s Toll free 8200 to report; any health service anomalies or appreciation . Runyankole AUG

KASESE KASESE GUIDE Intro of mTrac & MHSDMU’ Role; How to use mTrac’s SMS’s Toll free 8200 to report; any health service anomalies or appreciation .

Runyankole & English AUG

MASINDI BUNYORO BS Intro of mTrac & MHSDMU’ Role; How to use mTrac’s SMS’s Toll free 8200 to report; any health service anomalies or appreciation .

Runyoro & Rutooro AUG

JINJA BUSOGA FM Intro of mTrac & MHSDMU’ Role; How to use mTrac’s SMS’s Toll free 8200 to report; any health service anomalies or appreciation . Lusoga AUG


Responding to mTrac & MHSDMU toll free line; complaints from the district & following up; any health service anomalies or appreciation

Rukiga SEPT

KISORO VOICE OF MUHABURA

Responding to mTrac & MHSDMU toll free line; complaints from the district & following up; any health service anomalies or appreciation Kifumbira SEPT

KAMWENGEVOICE OF KAMWENGE


Runyankole SEPT

KASESE KASESE GUIDE Responding to mTrac & MHSDMU toll free line; complaints from the district & following up; any health service anomalies or appreciation

English & Runyankole SEPT

KABAROLE

VOICE OF TOORO


Rutooro SEPT

MASINDIBUNYORO BS Responding to mTrac & MHSDMU toll free line; complaints from the district &

following up; any health service anomalies or appreciationRunyoro SEPT

JINJABUSOGA FM Responding to mTrac & MHSDMU toll free line; complaints from the district &

following up; any health service anomalies or appreciationLusoga SEPT

KABALEVOICE OF KIGEZI

Educating the public and health workers on their; right to health, right to question what is wrong, especially late coming, drug theft, abuse of office and other HR issues Rukiga OCT

MBARARA RADIO WEST Responding to mTrac & MHSDMU toll free line; complaints from the district & following up; any health service anomalies or appreciation Runyankole SEPT

KISORO VOICE OF MUHABURA

Educating the public and health workers on their; right to health, right to question what is wrong, especially late coming, drug theft, abuse of office and other HR issues

RunyankoleOCT

MBARARA RADIO WESTEducating the public and health workers on their; right to health, right to question what is wrong, especially late coming, drug theft, abuse of office and other HR issues

Runyankole OCT

KAMWENGE VOICE OF KAMWENGE


Runyankole OCT



DISTRICT RADIO TOPIC LANGUAGE MONTH/12

KABAROLE VOICE OF TOORO


RUTOORO OCT

KASESE KASESE GUIDE

Responding to major district complaints, visit some of the most areas of complaints, and getting feedback

English & Runyankole NOV


Responding to major district complaints, visit some of the most areas of complaints, and getting feedback

English & Runyankole NOV

JINJA BUSOGA FM Responding to major district complaints, visit some of the most areas of complaints, and getting feedback

English & Luganda NOV

MASINDI BUNYORO BS Responding to major district complaints, visit some of the most areas of complaints, and getting feedback

English & Runyoro NOV

KABAROLECOICE OF TOORO

Responding to major district complaints, visit some of the most areas of complaints, and getting feedback Rutooro NOV

MBARARA RADIO WEST Responding to major district complaints, visit some of the most areas of complaints, and getting feedback Runyankole NOV


Re-emphasing the role of mTrac’s anonymous hotline 8200 and MHSDMU’S toll free line 0800100447. The role of MHSDMU’S and how it has used mTrac to improve reporting on major issues in the health sector. Why people need to continue making use of mtrac as a means to improve on their health services within their communities.

Rukiga DEC

KISOROVOICE OF MUHABURA

Re-emphasing the role of mTrac’s anonymous hotline 8200 and MHSDMU’S toll free line 0800100447. The role of MHSDMU’S and howit has used mTrac to improve reporting on major issues in the health sector. Why people need to continue making use of mtrac as a means to improve on their health services within their communities.

KifumbiraDEC

KABAROLE VOT

Re-emphasing the role of mTrac’s anonymous hotline 8200 and MHSDMU’S toll free line 0800100447. The role of MHSDMU’S and howit has used mTrac to improve reporting on major issues in the health sector. Why people need to continue making use of mtrac as a means to improve on their health services within their communities. Rutooro DEC

MBARARA RADIO WEST

Re-emphasing the role of mTrac’s anonymous hotline 8200 and MHSDMU’S toll free line 0800100447. The role of MHSDMU’S and howit has used mTrac to improve reporting on major issues in the health sector. Why people need to continue making use of mtrac as a means to improve on their health services within their communities. Runyankole DEC

MASINDI BUNYORO BS

Re-emphasing the role of mTrac’s anonymous hotline 8200 and MHSDMU’S toll free line 0800100447. The role of MHSDMU’S and howit has used mTrac to improve reporting on major issues in the health sector. Why people needto continue making use of mtrac as a means to improve on their health services within their communities. Runyoro DEC

JINJA BUSOGA FM

Re-emphasing the role of mTrac’s anonymous hotline 8200 and MHSDMU’S toll free line 0800100447. The role of MHSDMU’S and howit has used mTrac to improve reporting on major issues in the health sector. Why people needto continue making use of mtrac as a means to improve on their health services within their communities. Lusoga DEC


Re-emphasing the role of mTrac’s anonymous hotline 8200 and MHSDMU’S toll free line 0800100447. The role of MHSDMU’S and howit has used mTrac to improve reporting on major issues in the health sector. Why people needto continue making use of mtrac as a means to improve on their health services within their communities.

Runyankole DEC

KASESE KASESE GUIDE

Re-emphasing the role of mTrac’s anonymous hotline 8200 and MHSDMU’S toll free line 0800100447. The role of MHSDMU’S and howit has used mTrac to improve reporting on major issues in the health sector. Why people needto continue making use of mtrac as a means to improve on their health services within their communities.

English & Runyankole

DEC







REPUBLIC OF UGANDA

Medicines & Health Service Delivery Monitoring Unit Plot 21, Naguru Drive Naguru P.O. Box 25497 Kampala, Uganda Office: 0414-288 442/5 Toll Free: 0800 100 447

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