Highlights of the Annual Health Sector Performance Report FY 2011/12 Dr. Jane Ruth Aceng Director General Health Services 18th JRM - 24th September 2012 Speke Resort, Munyoyo

Outline Background Overview of the sector performance for FY 2011/12 Progress in implementation of priority activities under the; Uganda National Minimum Health Care Package Integrated Health Sector Support Systems.

Background to the report AHSPR 2011/12 mainly focuses on: the progress of the annual work-plans overall health sector performance against the National Development Plan Joint Assessment Framework 4 HSSIP targets set for the FY 2011/12

Back ground cont… Takes into consideration the annual performance in terms of; Effectiveness responsiveness and equity integrated support systems strengthening the status of programme implementation and overall development mechanisms.

Data used Focuses on the 26 HSSIP core indicators which are linked with the monitoring of the National Development Plan through the Office of the Prime Minister and international initiatives such as the Millennium Development Goals. Based on the health facility and district reports gathered as part of the Health Management Information System, administrative sources and programme data Population based surveys, e.g. Demographic Health Survey and the Aids Indicator Survey Service Availability and Readiness Assessment Study 2012 Other relevant sources of data

Progress 2011/12 FY

Financial Resources (inputs) Total public health expenditure per capita increased from UGX 20,765 billion (US$ 9.4) in 2010/11 to UGX 25,142 billion (US$10.29) in 2011/12 External (donor) contributions constituted 34.8% of total public health expenditure in 2011/12, compared with 14% in 2010/11. The GOU expenditure on health % of total Gov’t expenditure declined from 8.9% in 2011/12 to 8.3%, far short of the Abuja target of 15%.

Policies and Guidelines (inputs) A number of policies and guidelines were developed and some disseminated during the year Quality Improvement Framework and Strategic Plan Ministry of Health Client Charter The Public Private Partnership for Health Policy Medicines Management Manual Human Resource Operations Manual National Laboratory Quality Manual Data Demand and Use Manual

Workforce (1) Overall, 58% (31,951 out of 55,443) of public sector positions were filled, short of the 65% target for 2011/12 FY. (These include all staff (professional and support) in public health facilities). Staffing levels are as low as 19% in Namayingo district while some (37.7%) of the districts have staffing levels between 40 and 59%.

Workforce (2) Village Health Teams Additional 15 districts have fully established VHTs (Total 84 districts) Overall 78% of villages have trained VHTs 110,000 VHT members received bicycles

System Outputs (availability, access) Medicines availability improved significantly. 70% of facilities reported no stock out of six tracer medicines up from 43% in 2010/11. The % of HC IVs providing comprehensive emergency obstetric care (Caesarian section) remained low at 25% compared to 24% in 2010/11. Access to HIV counseling and testing services stagnated at 38% (1,905 out of 5,033 facilities) The % of facilities offering PMTCT services increased from 32% in FY 2011/10 to 36% in FY 2011/12. Per capita Outpatient department utilization increased from 1.0 dollar in 2010/11 to 1.2 dollars in 2011/12.

System Outputs (quality, safety) TB treatment success rates increased slightly from 70% to 71.1%, but fell short of the 85% target of FY 2011/12. Client satisfaction not assessed

Service coverage and determinants (1) Delivery in health facilities – was 40% up from 39% in 2010/11 though below the HSSIP target of 50%. (UDHS 2011 – 58% supervised deliveries with 44% in public facilities and 12% in private facilities) The % of pregnant women attending four ANC visits increased from 32% to 35%. (UDHS 2011 47.6% among women 15 – 49 years with a live birth in the 5 years preceding the survey) The % of pregnant women who have completed IPT2 for malaria risk reduction was 44% up from 43% in 2010/11. (UDHS 2011 27% among women 15 – 49 years who had a live birth in the 2 years preceding the survey. )

Service coverage and determinants (2) Immunization coverage with DPT3 was 85% down from 90% in 2010/11 however, above HSSIP target (82%) for the year (UDHS 2011 - 67.9% for children with vaccination cards at time of survey) Measles coverage among children under one year increased to 89% from 85% 2010/11. (UDHS 2011 - 58.4% for children with vaccination cards at time of survey)

Service coverage and determinants (3) % of children exposed to HIV from their mothers accessing HIV testing within 12 months was 28.3% down from 30% in 2010/11 % eligible persons receiving ARV therapy was 59.3% up from 53% in 2009/10 % of households with pit latrines was 72% from 71% in 2010/11.

Service coverage and determinants (4) % U5 children with height /age below the lower line (stunting) was down to 33% but on track with HSSIP target (UDHS 2006 was 38%) % U5 children with weight /age below the lower line (wasting) was down to 14% but on track with HSSIP target (UDHS 2006 was 16%) Contraceptive use measured by; Contraceptive Prevalence Rate was 30% up from 24% in 2006 (UDHS 2011) Couple Years of Protection increased to 1,841,958 from 803,139 in 2010/11 (HMIS)

Trends in the Health Indices Indicator 1990 1995 2001 2006 2011 % Reduction from Baseline HSSIP 2015 Target MMR (per 100,000 live births) NA 506 505 435 438 16% 131 Neonatal MR (per 1,000 live births) 27 33 29 7% 23 IMR (per 1,000 live births) 101 81 88 76 54 49% 41 Under 5 MR (per 1,000 live births) 180 147 152 137 90 50% 56

Local government performance District league table

District League Tables 2011/12 12 indicators were selected 8 - coverage and quality of care (75%) Pentavalent Vaccine 3rd dose coverage (15) Deliveries in gov’t and PNFP facilities (15) Outpatient visits per capita (10) HIV testing in infants at-risk (10) Latrine coverage (10) Sulphadoxine / Pyrimethamine 2nd dose for IPT (5) 4th antenatal care visits (5) TB Treatment Success Rate (5)

District league table cont… 4 - management indicators (25%) Approved posts that are filled (10) HMIS completeness and timeliness of reporting (5) DHMT meetings held as planned (5) Timely submission of medicine orders (5)

Top10 and bottom ranking districts TOTAL SCORE RANK KABAROLE 83.3 1 GULU 83.1 2 LYANTONDE 79.0 3 KIBOGA 72.0 4 MPIGI 71.8 5 MBALE 71.7 6 LIRA 71.1 7 MASAKA 70.8 8 BUSHENYI 70.7 9 KABALE 69.6 10 DISTRICT TOTAL SCORE RANK NTOROKO 41.5 103 HOIMA 41.4 104 KWEEN 40.8 105 GOMBA 40.2 106 AMOLATAR 39.1 107 ALEBTONG 35.3 108 KAABONG 33.9 109 AMUDAT 28.3 110 LAMWO 23.4 111 NAPAK 14.3 112

Trends in selected DLT Indicators  FY DPT3 Coverage Deliveries in Pub. & PNFP facilities OPD Per Capita HIV testing in HIV exposed babies IPT2 ANC4 Approved posts filled % Completeness facility reporting Medicine orders submitted timely National Average 10/11 90 39 1 30 43 32 52 85 47 58.4 11/12 79.9 37.6 1.2 28.3 45.7 34 54.4 86.5 28.1 56.8 Increase Decline

Key observations Hard-to-reach districts New districts improved performance with 6 new districts in 2011/12 compared to only one scoring above the national average in 2010/11. Butambala scored the highest among the new districts (14th overall) 9 of bottom 10 ranking districts are new Hard-to-reach districts There was improvement in performance of the 25 hard- to-reach districts with one third (9/25) scoring above the national average

Summary (1) There was decrease in GOU allocation for health Donor financial contributions increased during the year Human resources for health increased slightly but much below target of 65% VHT establishment increased Availability of medicines and OPD utilization increased Access to HCT, PMTCT and EmOC services still low

Summary (2) Client satisfaction not assessed to determine quality of services There was improvement in almost all service coverage indicators with the exception of DPT3 and HIV testing for exposed babies which showed a downward trend from the previous year. However, most improvements were below the HSSIP indicator targets. There is very slow progress in reduction of maternal and neonatal mortality whereas there is significant reduction in infant mortality and under five mortality.

Summary (3) The gains in the health sector performance during the year under review can be attributed to a number of deliberate efforts and interventions e.g. increased funding for EMHS improved logistics management and supervision; training in leadership and management at all levels; Scaling up of VHTs.

Challenges Decrease in the already inadequate funding Efforts in attaining and maintaining an adequately sized, equitably distributed and appropriately skilled health workforce were hampered by the limited wage bill.

Recommendations Reducing off budget funding by ensuring that all projects and donor inflows are aligned to HSSIP and reflected in the budget. Reducing out–of-pocket funding for health care by introducing prepayment systems like health insurance. Increased wage bill to fill vacancies and improve remuneration of health workers.

Recommendations Increase coordination and partnership with private providers in implementation of the sector priorities. Strengthen supervision, monitoring and evaluation of implementation of the HSSIP 2010/11 – 2014/15 at all levels. Funding of priority interventions at all levels of care.

Acknowledgement Development Partners, Civil Society Organizations, Private Sector, all stakeholders and Clients of the health system for the support and contribution to health sector performance. All health workers who have contributed to the sector progress. Special thanks to: The World Health Organisation, Kampala Office, who financed the printing of the Annual Health Sector Performance Report.