Health sector performance for the first year #ManifestoExecution

IMG-20170518-WA0072

Introduction
The government policy on health is to ensure that all Ugandans have access to high quality and affordable health care so as to contribute to social and economic development. Accordingly, the Mission of the MOH is to provide the highest level of health services to all people in Uganda through delivery of promotive, preventive, curative, palliative and rehabilitative health services at all levels
Our vision is to facilitate the attainment of a good standard of health by all people of Uganda in order to promote a healthy and productive life
The sector intends to achieve the above by putting emphasis on health promotion and disease prevention and increasing access to health facilities.

Health Sector Key Manifesto Deliverables and Targets for the Period May 2016 – May 2017
The Health Sector Manifesto deliverables during the NRM period of 2016 -2017 include:
Realigning our strategies to focus on Health Promotion and Disease Prevention through Health Education; Sanitation Improvement; Control of Malaria, HIV, and TB; and Nutrition Education.
Improving access to Immunization Services, thereby increasing DPT coverage from 90% to 95%.
Improving maternal health services in order to reduce maternal mortality
Strengthening mechanisms for control and management Communicable diseases including HIV, TB, and other infectious diseases.
Control of Non Communicable diseases including diseases of life styles, cancers, and mental health.
Increase access of the population to health facilities through construction of hospitals, HC IIIs in sub-counties without HCIII, and HCIVs in constituencies with no HC IV. Rehabilitate and Equip existing infrastructure which is in a poor state. Improve staff accommodation especially in the most rural areas. Eliminate shoddy work in all construction and rehabilitation works.
Ensure availability of essential medicines, vaccines and health supplies in all health facilities. Reduce drug thefts and improve on supply chain management
Increase staffing in health facilities to over 80% in the first year of the manifesto.
Increased capacity to diagnose, control and appropriately respond to disease outbreaks
Improve financing of the health sector through introduction of a national health insurance scheme.
Strengthen governance and accountability, including improving the image of the sector.

Key Achievements

General Achievements
The following achievements have been registered in the key sector indicators between 2011 and 2016 (UDHS):
Reduction of Maternal Mortality Ratio from 438/100,000 live birth
Indicator
2011
2016
Infant Mortality Rate
54/1000
43/1000
Under five Mortality Rate
90/1000
64/1000
Maternal Mortality Ratio
438/100,000
336/100,000
Deliveries in Health Facilities
42%
73%
Average Number of children per woman of reproductive age
6.3
5.4
Contraceptive Prevalence Rate
30%
39%
Measles vaccination coverage
75%
80%
Stunting among under 5
33%
29%
Percentage of households with at least 1 treated mosquito net
60%
78%
Others Indicators from our routine information system
Proportion of staff positions filled
52%
71%
Health Facilities without stock outs
35%
75%
Patients on HIV treatment
600,000
930,000
Source UDHS 2011, 2016 and MOH reports
Health Promotion and Disease Prevention
The sector has refocused its plans/budgets on preventive interventions especially community mobilization and empowerment, immunization, sanitation/hygiene, Malaria prevention and control, HIV /Aids, NCDs and nutrition.
To undertake this a Directorate of Public Health has been created in the new structure and recruitment has commenced.
Health messages for behaviour change have been redesigned to communicate in a manner that gives adequate time for the population to understand and the ministry is working closely with other key sectors, Local Governments and Partners to provide relevant information that emphasizes health promotion and disease prevention.
The Ministry is putting in place Community Health Extension Workers (CHEWs) per parish to monitor and promote community health activities. The Policy and Strategy for CHEWs has been approved by top management and is due to be presented to cabinet for approval.

Availability of essential medicines, vaccines and health supplies

The Ministry has Instituted control mechanisms to avoid drug pelifirage in the supply chain and at health facilities. Relevant control tools for management of stocks of levels have been developed and we have increased supervision, inspection, and auditing of medicine together with Health Monitoring Unit and Local Governments in order to curtail theft of drugs.
In addition, the community is continually being sensitized about government embossed medicines to check on theft.
Disciplinary action including speedy prosecution of those found to steal medicines is being implemented in close collaboration with the Health Monitoring Unit.
As indicated above, in the last FY, 75% of health facilities had no stockouts. However, these gains are likely to be lost if the crucial problem of inadequate budget for essential medicines is not addressed.
Expired Medicines: Occasionally the sector experiences some stocks of expired medicines mainly from donations with short shelf life. This raises risks of repackaging and reselling expired medicines. The MOH has put in place guidelines on permissible shelf-life and appropriateness of donated medicines. The NDA is enforcing this guideline and also managing expiries in the private sector.

However, inadequate funding of the NMS in order to provide adequate essential medicines and health supplies to the districts remains a challenge.

Human Resources for Health / Staffing of our health facilities
The staffing levels in government health facilities improved to 71% over the last 1 year. The Ministry continues to work with local governments and HSC to fill a number of vacant posts. However, the sector continues to face the problem of chronic absenteeism of health workers. To address this the ministry is working with LGs, HSC and MOPS to enforce disciplinary action on absconding staff, Introduction of attendance registers (Manual or digital), regular spot checks and inspection, and enforcing duty rosters and work schedules for all staff. The Ministry has also asked Health Partners to desist from dual employment of public officers.
The ministry continues to allocate funds in order to prioritize, recruit and promote certain critical cadres of staff who have been difficult to recruit e.g. Doctors, Midwives, Anaesthetists, Ophthalmic Officers, and Public Health Nurses, etc.
Working with LGs, the MoH continues to provide non-monetary incentives to motivate health workers especially accommodation; rewards and recognition for good performance; and preferential scholarships for upcountry staff.
Following a recent presidential pledge to provide for the health worker’s SACCO, MoH plans to work with relevant organs to establish a health workers SACCO in FY 2017/18 so that they can also benefit from the government wealth creation program.
During the year, the government developed Internship Training Guidelines to regulate and streamline the training of Medical, Pharmacy and Nursing graduate interns.

Improvement in Health Infrastructure and equipment

During the year under review, there was significant progress or completion of various infrastructural developments as follows:
Completion of rehabilitation and equipping of 9 hospitals under World Bank funding (Mityana, Nakaseke, Kiryandongo, Entebbe Grade B, Nebbi, Anaka, Iganga, Moyo and Moroto). Construction of 26 HC IVs under the same loan commenced and are expected to be completed by June 2017.

Kawempe and Kiruddu hospitals in Kampala were completed and were occupied by Mulago Hospital which was temporally closed for rehabilitation.

Reconstruction and equipping of Lower Mulago Hospital progressed to 72% and is expected to be completed by the end of 2017.

Construction of the Maternal and Neonatal Health unit at Mulago Hospital (Women Hospital) has progressed to 75% and is scheduled to be completed by August 2017.

Renovation of the old Cancer Bunker at Mulago Hospital was commenced and completed and awaits installation of the Cobalt 60 Machine. The machine will arrive in the country by July 2017.
Construction of the 6 Bunkers at Uganda Cancer Institute (UCI) to house super specialized cancer treatment equipment progressed well. The bunkers are scheduled to be complete by the end of 2017.

The project to transform the UCI into an East African Centre of Excellence in cancer care and treatment commenced and is scheduled to be completed in 5 years.

Construction of the super national reference laboratory at Butabika was completed and commissioned in November 2016.

Partial Rehabilitation of wards and construction of staff houses in 13 referral hospitals continued under GOU capital development funds in Mbarara, Arua, Fort Portal, Kabale, Masaka, Hoima, Gulu, Jinja, Lira, Mbale, Mubende, Moroto and Soroti hospitals.

Construction of 68 staff houses in Karamoja region under Italian Government grant progressed according to schedule

With JICA support Hoima and Kabale Hospitals were expanded and equipped

Construction of the Regional specialized paediatric hospital was commissioned in February 2017 in Entebbe and will be completed in 3 years-time

The sector continues to improve investigative capacity in the centers of excellence (Uganda Heart Institute, UCI, Kidney Transplant Unit in Mulago etc.) in order to reduce referrals abroad.

In addition, plans to launch construction works for the state of the art super specialized hospital at Lubowa through a Private Public Partnership have been concluded and works will commence in 2017.

Regarding infrastructure improvement at lower local government levels, the MOH policy, over the next 5 years, is to provide a HC III in every sub-county, a HC IV in every constituency and general hospitals in few selected districts with poor access eg. Islands and mountainous areas. Currently 93 sub counties have no government health facility at all and 225 Sub Counties have no HC IIIs but have HC IIs that need to be upgraded to HC IIIs.
Priority will be given to the 93 sub counties without any government health facility and subsequently upgrading the HC IIs in the 225 sub counties to HC IIIs will be considered in a phased manner. In big and large sub counties, additional new HC III’s shall be constructed to attain a 5km walking distance to a health facility.

Construction of new General Hospitals shall be a special consideration for improving access to unique terrain, islands and big populations – over the

During the year under review the MOH was undertook an assessment of the status and distribution of the health facilities to identify sub-counties and constituencies that will be prioritized in the short and medium term.

Over 7000 Beds and mattresses were provided to hospitals and health centres in line with the commitments in the NRM manifesto

To address the problem of shoddy works the Ministry has put in place a strict and regular monitoring and supervision mechanism involving top management, the up graded health infrastructure department and the Health Monitoring Unit.

Service Delivery

A number of service delivery interventions were implemented during the year and include among others:
Routine Immunization services bringing to vaccination coverage for DPT3Hep B to 95%. In addition, a number of polio and meningitis campaigns were carried out in border districts. Vaccination of school girls against HPV was rolled out in November 2015 and is ongoing.

Distribution of 24 million insecticide treated mosquito nets which when complete will bring net coverage to 100%. Malaria prevalence has reduced to less than 19% and in Kampala to as low as 1%.

A department of Ambulance Services was established and staff are being recruited who will soon start to draft the Policy and Guidelines for Ambulance Services.

Over 900,000 patients are receiving Anti-Retroviral treatment and the policy of Test and Treat was launched in November 2016.

Transmission of HIV from infected mothers to their new born babies fell to less than 3,000 babies during the year

Over 100 gene expert machines were procured and distributed to health facilities across the country to strengthen diagnosis and treatment of TB

Governance and Leadership

Management has put in place new measures to strengthen prompt accountability and value for money.

The ministry fleet of vehicles has been reviewed, vehicle reallocation done in line with Ministry of Public Service Standing Orders. A vehicle tracker system to monitor movement of vehicles and fuel control is being installed. Servicing and repair of vehicles has been centralized.

The Ministry of Health Supervision structures have been strengthened. A draft revised supervision strategy and guidelines has been prepared and is under review.

The Organ Transplant Bill is before first parliamentary council.

A bill for Mulago Hospital Autonomy is in draft and stakeholder consultations are ongoing.

Health Financing

A Certificate of Financial Implications for the National Health Insurance Scheme draft Bill has been obtained and the Bill will soon be presented to Cabinet and Parliament as a priority. This will help to alleviate the current underfunding in the sector which stands at 6.4% of the national budget.

CHALLENGES

Inadequate staffing at all levels especially local governments (staffing norms at 71%) is below the manifesto target of 100%. This is made worse by shortage of some critical cadres especially Doctors, Midwives, Anaesthetists, Ophthalmic Officers, and Public Health Nurses etc.

Inadequate funds for service delivery at lower level health centres (wage and non-wage) especially HC III, HC IV, and General Hospitals. This has resulted for example in accumulation of utility bills, poor maintenance of infrastructure and medical equipment and understaffing.

Funding gap for ARVs, Anti malarials medicines and Laboratory Reagents – leading to occasional stock outs

Dilapidated health infrastructure – some hospitals and health centres have not been repaired for many years.

SECTOR PRIORITIES FOR MAY 2017 –MAY 2018

Prepare and present a Cabinet memo / concept note for recentralization of some key staff in Local Governments

Continue implementation and supervision of ongoing service delivery programs and infrastructural projects above

Develop guidelines for an efficient and effective referral system.

Table the Health Insurance Bill to Cabinet and Parliament

Mobilise resources for improving the welfare and remuneration of health workers

Mobilise resources for increasing funding for essential medicines and diagnostic supplies

Continue to strengthen governance, accountability and value for money and to further improve the image of the sector

CONCLUSION
The health sector is making steady progress to achieve most of the planned targets in the NRM manifesto. The recently conducted National House Hold Survey (2015) and Uganda Demographic Health Survey (2016) both show significant improvements in key health indicators. However, underfunding of the sector affects implementation of the planned interventions in almost all areas – medicines, staffing and improvement in the health infrastructure.

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