A Promise Unmet: Access to Essential Medicines in Three ... · X Access to Essential Medicines in...

AGHA

A Promise Unmet:Access to Essential Medicines in

Three New Districts of Uganda

September 2007

ACTION GROUP FOR HEALTH, HUMAN RIGHTS AND HIV/AIDS (AGHA) UGANDA

� Access to Essential Medicines in Three New Districts of Uganda

A Promise Unmet:Access to Essential Medicines in Three New Districts of Uganda

ACTION GROUP FOR HEALTH, HUMAN RIGHTS AND HIV/AIDS (AGHA) UGANDA

September 2007

Plot 69, Kanjokya Street

KamwokyaP.O Box 24667 KampalaTel. +256 414 348 491Email: [email protected]

�� Access to Essential Medicines in Three New Districts of Uganda


Research Team

Core Research Team from AGHA1. Dr. Nelson Musoba2. Ms. Winfred Ngabiirwe3. Ms. Bao Pham

Researchers from Makerere University School of Public Health1. Dr. Elizeus Rutebemberwa2. Mr. Aloysius Mutebi

District Research TeamsIbanda1. Dr. Julius Bamwine – District Health Officer2. Mr. Jimmy Odonga – District Study Coordinator3. Mr. Steven Tushabe 4. Mr. Hannington Tindyebwa 5. Mr. Jackson Mugume

Isingiro1. Dr. William Nyehangane – District Health Officer2. Mr. Matthew Tumushabe – District Study Coordinator3. Mr. Nicholas Kwesiga 4. Mr. James Batyani 5. Mr. Geoffrey Mwesigwa

Lyantonde 1. Dr. Katumba Sentongo – District Health Officer2. Mr. Elias Karashote – District Study Coordinator3. Mr. Paul Nyonyintono4. Mr. Bernard Andinda 5. Mr. Ephraim Batungi 6. Ms. Agnes Namulwana

�V Access to Essential Medicines in Three New Districts of Uganda

V Access to Essential Medicines in Three New Districts of Uganda

Table of Contents

Research Team ...................................................................................... IIITable of Contents ................................................................................... VAbbreviations and Acronyms ................................................................... VIIAcknowledgements ................................................................................ VIIIExecutive Summary ................................................................................ IXThe Action Group for Health, Human Rights & HIV/AIDS .......................... XIII

Chapter 1: Introduction and Background .................................................. 11.1 The Right to Health in Uganda .......................................................... 11.2 Health Funding in Uganda ................................................................. 31.3 The Critical Importance of Antimalarials and Antibiotics ....................... 41.4 Decentralization Policy in Uganda ...................................................... 41.5 The Medicine Supply Chain .............................................................. 51.6 Human Resources for Health ............................................................. 5

Chapter 2: Materials and Methods .......................................................... 72.1 Objectives ....................................................................................... 72.2 Study Area ...................................................................................... 72.3 Study Design ................................................................................... 82.4 Sample Size .................................................................................... 82.5 Data Collection and Management ...................................................... 92.6 Ethical Considerations ...................................................................... 102.7 Completeness of Data on Medicine Stock- Outs .................................. 10

Chapter 3: Medicines Stock out Survey Results and Trends ........................ 133.1 Availability of Antimalarials ................................................................ 133.2 Availability of Antibiotics ................................................................... 15

Chapter 4: Challenges in Medicine Procurement ....................................... 174.1 Health Centre Staffing ...................................................................... 174.2 Medicines Funding ........................................................................... 204.3 Medicine Quantification and Forecasting ............................................. 204.4 Medicines Transport ......................................................................... 214.5 National Medicine Suppliers .............................................................. 224.6 Medicine Storage ............................................................................. 244.7 Coordination between Districts and Health Centres .............................. 25

Chapter 5: Conclusions and recommendations .......................................... 275.1 Conclusions .................................................................................... 275.2 Policy Recommendations .................................................................. 27

V� Access to Essential Medicines in Three New Districts of Uganda

References ............................................................................................ 32

Appendix 1: District Health Officer (Baseline): Key Informant Guide ............ 34Appendix 2: Records Review Tool: DHO (Baseline) .................................... 35Appendix 3: Data Collection Tool: Health Facility Survey (Baseline) ............. 36Appendix 4: Health Unit In-Charge (Baseline): Key Informant Guide ............ 38Appendix 5: Data Collection Tool: Health Facility Survey (Follow-Up) ......... 39Appendix 6: Map of Uganda ................................................................... 40Appendix 7: Health Centres in the Selected Districts ................................. 41

V�� Access to Essential Medicines in Three New Districts of Uganda

Abbreviations and acronyms

AAAQ – Available, Accessible, Acceptable and Quality CareAGHA – Action Group for Health, Human Rights and HIV/AIDSAIDS – Acquired Immunodeficiency SyndromeARI – Acute Respiratory InfectionARV/T – Anti Retroviral TherapyDHO – District Health OfficerDHT – District Health TeamEMHS – Essential Medicines and Health SuppliesFY – Fiscal YearHC – Health CentreHIV – Human Immunodeficiency VirusHSD – Health Sub – DistrictHSSP – Health Sector Strategic Plan ICESCR – International Covenant on Economic, Social and Cultural RightsIPH – Institute of Public HealthJMS – Joint Medical StoresKI – Key InformantMDGs – Millennium Development GoalsNGO – Non Governmental OrganizationNMS – National Medical StoresOI – Opportunistic InfectionOPD – Out Patient DepartmentPFP – Private for ProfitPHC – Primary Health CarePLWAs – People Living With HIV/AIDSRTI – Respiratory Tract InfectionTB – TuberculosisUBOS – Uganda Bureau of StatisticsUDHS – Uganda Demographic Health SurveyUG – UgandaUGX – Uganda ShillingsUNICEF – United Nations Children’s FundUSD – Unites States DollarWHO – World Health Organization

V�� Access to Essential Medicines in Three New Districts of Uganda

Our sincere thanks go to those who funded this study. We thank Conservation, Food and Health Foundation for their critical support, without which this proj-ect would not have been possible. In addition, we thank Physicians for Human Rights for their grant made available by the Bill and Melinda Gates Founda-tion. With their commitment, we have gathered critical information on essen-tial drug supply in new rural districts in Uganda while engaging health workers in human rights research and action.

To the District Health Officers and AGHA members in these districts, we offer our utmost gratitude. You willingness to undertake this important exercise and put AGHA onto the agenda in the infancy of your districts displays your com-mitment to human rights and to the betterment of the lives of people that you serve.

The core of this study involved health workers who took time off from their busy schedules to assist us as we collected the data. They were honest in their work, shared with us their experiences and assisted us by clarifying critical study questions. They cooperated fully to the betterment of the health system and the country, and for that, AGHA extends our gratitude.

Heartfelt thanks go to the research assistants. Your commitment to work under hard conditions, riding your motorcycles along dusty hills and pot holed mur-ram roads, is a manifestation of your love for information and your commit-ment to AGHA and to health rights in your districts.

To those not mentioned above, we acknowledge your immense contribution to the completion of the exercise. Your contribution was great and we hope it will be reflected in the findings as they are shared with other people.

Acknowledgements

�X Access to Essential Medicines in Three New Districts of Uganda

Introduction: The Ugandan Constitution mandates the state to “take all practical measures to ensure provision of basic medical services to the entire population.” This is also in line with Uganda’s international legal obligation to ensure the right to the highest attainable standard of physical and mental health as stipulated in the International Covenant of Economic, Social and Cultural Rights (ICESCR), to which Uganda is a signatory. Despite this constitutional commitment and inter-national legal obligations and promises to uphold the right to health, the Ugandan government has largely neglected its obligations in this arena. The country still has not made the financial commitment needed to provide available, accessible, acceptable and quality health care to all her people. Specifically, lack of access to essential medicines in rural Uganda continues to contribute to the country’s high mortality from malaria, pneumonia and other treatable diseases.

Objectives: When monitoring health systems to evaluate whether they meet na-tional and international health human rights obligations, medicines availability is a critical component, and this study sought to measure the Ugandan government’s success in this arena. AGHA chose to focus this study specifically on medicines to treat malaria and pneumonia as well as other opportunistic infections, because these diseases represent the two largest disease burdens in Uganda. AGHA select-ed to study three new rural districts in order to assess if these new districts have improved the availability and accessibility of health care services, a key rationale of decentralization and a requirement for Uganda to meet the progressive realiza-tion of the right to health. Specifically, the study sought to assess the trends of medicine availability in health facilities in the new districts for a period of three months and explore the challenges faced by health workers in getting medicines at the health facility level.

Methodology: A longitudinal survey was used in the selected health facilities. The baseline phase, which gave a cross sectional view of the human resources available at district level and workload at facility level for the previous three months, helped the team establish general trends in the districts. The survey phase, conducted from January to March 2007, had research assistants visit each selected clinic every two weeks to collect data on the medicines availability as well as the workload. In each of the three districts, additional qualitative data on medicine availability and challenges faced in medicine procurement was gathered using a structured questionnaire and key informant interviews.

Executive Summary

X Access to Essential Medicines in Three New Districts of Uganda

Survey Results:

Availability of Antimalarials: CoArtem is the Ministry of Health mandated first line treatment for malaria and has been fully paid for by development partners, so should be available at all health facilities at all times. However, this study found it was often unavailable in health facilities in all three districts. In Ibanda, 10-30% of health facilities experiences CoArtem stock outs over the course of 5 visits. In Isin-giro, all health facilities had CoArtem at 3 of the 6 data collection visits; the other 3 visits found 10-40% of health facilities had no CoArtem in stock. In Lyantonde, CoArtem stock out rates ranges from 10% to 50% at one visit, meaning half of all health facilities visited that day did not have the first line treatment for malaria—the leading killer in Uganda. In all the three districts, Chloroquine and Fansidar re-main the most available antimalarials in the health facilities—despite the fact these are proven to have high resistance rates in Uganda and are often ineffective.

Availability of Antibiotics: The study found high levels of stock outs in antibiot-ics at health facilities in all three districts. For example, for the first month of the study, 60-80% of health facilities in Ibanda had no access to the 4 major antibiotics traced by this study. In Isingiro district, access to any of the four antibiotics traced differed significantly, from less than 20% to 85% in stock, but never reached 100% coverage for any medicines during the survey time.

Conclusions: This study found out that antimalarial and antibiotic medicine sup-plies fluctuated significantly in all three districts, and rarely reached 100% cover-age. Especially problematic is the lack of CoArtem at many health facilities, which is the Ministry of Health mandated first line treatment for malaria and has been ful-ly funded by donors and government. Clearly there are major gaps in the medicine procurement and distribution mechanism for critical medicines across the board, a challenge that must be solved if health consumers in these new districts are to real-ize their right to health and have the weapons needed to fight the countries biggest killers—Malaria and RTIs.

This study went on to identify several key challenges which districts face in medi-cine procurement, which include:1. Severe lack of human resources in health facilities2. Serious gaps in national and district medicines funding3. Lack of training and staff to do proper medicine quantification and forecast ing4. Lack of medicine transport and storage facilities5. Challenges with national medical suppliers’ procurement and purchasing processes6. Gaps in coordination and communication between national suppliers and districts, and district and local health centres

X� Access to Essential Medicines in Three New Districts of Uganda

Policy Recommendations: AGHA has compiled a preliminary set of recommenda-tions that address the top 5 challenges in medicine access as identified by this sur-vey, which include budget gaps, medicine purchasing and distribution, monitoring and evaluation, human resources for health and communication systems. Through discussions with stakeholders, policy makers, and health workers about the study findings and its implications for the health sector in Uganda. All recommendations speak directly to solving the medicine stock out challenges faced by districts while also ensuring the health rights paradigm of accessible, available, acceptable and quality services is met by Uganda as soon as possible.

1. Medicine Purchasing and DistributionSignificant reforms are needed in the medicine purchasing and distribution system in order to address medicine stock outs. The Ugandan government must: •Create more flexible medicine purchasing systems •Increase funds available for transport, storage and distribution

2. Budget GapsThe government of Uganda must immediately allocate more resources to the health sector in order to provide the infrastructure and human resources needed to provide quality care to those in the most remote places and to guarantee essential medicines are available for all. The Ugandan government must: •Scale up health spending to meet the Abuja 15% target •Fully fund the Health Sector Strategic Plan (HSSP) •Increase the budget ceiling for health and loosen any macro economic re strictions which prevent more spending on health

3. Monitoring and EvaluationAlong with increasing health sector funding, Ministry of Health and Parliament must also ensure that those funds that are available for the procurement and distri-bution of essential medicines are being used as effectively as possible. The Ugan-dan government must: •Strengthen the role of the Health Unit Management Committees so they can hold government accountable for medicine delivery •Increase supervision and monitoring of medicine procurement and distribu tion by the Ministry of Health •Provide Regular Updates to Parliament and district local governments on Medicine Supply Levels •Develop a system for inspecting medications to keep expired medications from being delivered to districts and health centres

X�� Access to Essential Medicines in Three New Districts of Uganda

Human ResourcesThe low numbers of health workers and the lack of qualified staff at many health facilities is a huge barrier to addressing essential medicine stock outs. Parliament, the Ministry of Health, and the districts must all take responsibility for both increas-ing the capacity of the current health workforce and filling the staffing gaps. The Ugandan government must: • Create practical strategies for meeting health facility staffing targets as out lined in the HSSP • Provide regular training to health centre staff on stock cards and medicine forecasting • Provide incentives for health workers to join new districts

Communication SystemsSome of the challenges uncovered in this report point to a need for better commu-nication systems between districts, health facilities, and central bodies such as the NMS and the Ministry of Health. The Ugandan government must: • Develop regular communication mechanisms between district offices and health facilities about medicine supplies and needs • Improve communication between the Districts and the NMS about avail ability of medicines

X�� Access to Essential Medicines in Three New Districts of Uganda

The Action Group for Health, Human Rights and HIV/AIDS (AGHA) is a Ugandan Non-Governmental Organisation (NGO) founded in July 2003 to address issues of human rights as they relate to health with specific focus on HIV/AIDS. Since forma-tion, AGHA Uganda has reached out to hundreds of health professionals, lawyers, social scientists, PLWAs and human rights activists in the operational districts of Tororo, Rakai, Mbarara and Kampala, where the secretariat is based.

AGHA aims at creating a greater understanding of health rights among people and institutions while advocating to policy makers to develop better HIV/AIDS and over all health sector planning. AGHA has three campaigns addressing stigma and dis-crimination, health rights leadership building and health financing through which AGHA works to improve Uganda’s efforts towards a progressive realization of the right to health.

To combat stigma in health care settings, the AGHA is implementing an Anti Stigma Campaign through Stigma Task Forces. Through this, AGHA has trained 50 train-ers and held over 10 member-led stigma trainings for health workers in 4 districts, reaching over 200 health workers and community members with anti-stigma and discrimination messages.

The Health Rights Leadership Campaign includes AGHA’s successful student lead-ership program, as well as outreach, education and networking with health workers, CSOs, the general public and the media on health and human rights in order to im-prove the paradigm of medicine in Uganda that embraces human rights.

AGHA’s Health Financing Campaign aims to increase health funding in Uganda to at least 15% of the national budget through innovative advocacy and research, in-cluding policy forums, media outreach, meetings with key national leadership, and civil society engagement,

This medicines stock out survey will support AGHA’s Health Financing Campaign by providing needed data and evidence of the gaps in essential drug and health cov-erage in rural Uganda. It also helps support AGHA’s goal of building health rights leadership by engaging AGHA members who work in these new districts in inno-vative health research and advocacy. Finally, the focus on new districts allows an insight into the challenges faced by rural health providers and consumers, and can serve to help in policy planning at the district and national level to better meet key right to health indicators for the country.

The Action Group for Health Human Rights & HIV/AIDS

X�V Access to Essential Medicines in Three New Districts of Uganda

1 Access to Essential Medicines in Three New Districts of Uganda

AGHA has conducted a medicines stock out survey in three new districts in South-west Uganda, the results of which are presented in this report. When monitoring health systems to evaluate whether they meet national and international health human rights obligations, medicines availability is a critical component, and this study sought to measure the Ugandan government’s success in this arena. AGHA chose to focus this study specifically on medicines to treat malaria and pneumonia as well as other oppor-tunistic infections, because these diseases represent the two largest disease burdens in Uganda. About 320 children in Uganda die every day of malaria, a disease that must be controlled if Uganda is to improve health standards for citizens and meet the Millen-nium Development Goals for child and maternal health. Pneumonia and other opportu-nistic infections are deadly in their own right and also highly impact people living with HIV/AIDS. AGHA selected three new districts in order to assess if these new districts have improved the availability and accessibility of health care services, a key rationale of decentralization and a requirement for Uganda to meet the progressive realization of the right to health.

This chapter traces Uganda’s human rights mandate and policy promises for the health sector versus the resource reality. The chapter outlines available health sector financing in the face of the malaria and pneumonia disease burden, and delves into some of the challenges in decentralization, medicines supply chains and human resources for health which can lead to medicines stock outs, with special emphasis on the challenges fac-ing new districts in Uganda as they seek to increase the availability and accessibility of health care services in rural areas.

1.1 The Right to Health in Uganda

The right to the attainment of the highest standard of health (popularly known as the right to health), is a fundamental human right enshrined in article 12 of the Interna-tional Covenant on Economic, Social and Cultural Rights (ICESCR), to which Uganda is party. As enumerated in General Comment 14 , governments must provide health services which meet four key criteria in order to fulfill their right to health obligations. To achieve this, health services must be Available, Accessible, Acceptable and of good

Chapter 1Introduction and Background

Chapter 1Introduction and Background


Quality—often called the AAAQ test. To meet the AAAQ test, health systems must have strong infrastructure, health workers, equipment, and drugs among other key re-sources. Governments must ensure key inputs like sound health financing, appropriate human resource allocation and adequate accessible drugs.

What does this mean for Uganda and her health care system? Uganda has signed major international, regional and national instruments guaranteeing the right to health and outlining the government’s obligations to provide available, accessible, acceptable and quality health services. Internationally, as a signatory to the ICESCR Uganda has a legal mandate of putting in place the programs and resources needed to guarantee the right to health for all Ugandans.

At a regional level, Uganda is state party to the African Charter on Human and Peoples’ Rights, which also carries right to health obligations. Article 16 of the Charter states that: 1 Everyindividualshallhavetherighttoenjoythebestattainablestateof physicalandmentalhealth2 Statespartiestothepresentchartershalltakethenecessarymeasurestopro tectthehealthoftheirpeopleandtoensurethattheyreceivemedical attentionwhentheyaresick

Uganda is also party to the Abuja Declaration of 2001 whose target for health expen-diture is 15% of the total government expenditure. Although this declaration is not le-gally binding, it is a guideline for the Ugandan government to provide the health sector with the resources needed to meet the AAAQ test.

Nationally, the right to health is enshrined in the Ugandan Constitution in several sec-tions. Notably, section XIV(b) states that “all Ugandans enjoy rights and opportunities to access education, HEALTH SERVICES (emphasis added), clean and safe water, work, decent shelter, adequate clothing, food security and pension and retirement benefits” and section XX goes further to promise that “the State shall take all practical measures to ensure the provision of basic medical services to the population”.

Despite its legal mandate and promises to uphold the right to health, the Ugandan government has largely neglected its obligations in this arena. International human rights law recognizes that poor governments may struggle to reach these benchmarks immediately, but demands that even the poorest government put programs and funding streams in place to progressively realize the right to health. Despite an infant mortality rate of 79 per 1,000 and an under five mortality rate of 136 per 1,000 live births, the country still has not made the financial commitment needed to provide available, ac-cessible, acceptable and quality health care to all her people, as highlighted in the next section.


1.2 Health Funding in Uganda

Health spending in Uganda is estimated to cover approximately one third of what the country needs to meet its Minimum Health Care Package. Uganda spends only USD 14 per capita on health, of which USD 9 is out of pocket and USD 5 is from the public sector (government and donor funding). Yet to meet the minimum care package, the public sector must spend at least USD 28 per capita-- up to USD 40 when ARVs are included. Health spending has been between 7-9% of the Uganda National Budget over the last five years (HEPS, 2006). For the FY 2007/08 budget, 9% of the total budget was allocated to the health sector, falling far short of the 15% target declared by the African Heads of State in Abuja. Consequently, the New Vision has reported a short fall of UGX 15b for maternal and child health, about UGX 29b for human resources for health, UGX 78b for health supplies, UGX 1,185b for health infrastructure and UGX 9.5b for the village health team strategy (Namutebi, 2007).

Funding for essential drugs is especially critical to guaranteeing the right to health—and yet Uganda’s drug budget is severely under funded. The second Health Sector Stra-tegic Plan (HSSP II) states that funding for Essential Medicines and Health Supplies (EMHS) increased from a baseline of USD 0.80/capita to USD 2/capita by FY 05/06. This amount, however, is still far below the estimated minimum of USD 3.50 per capita required for the delivery of EMHS for the Uganda National Minimum Health Care Package. In a survey done by the Ministry of Health in 2005/06, only 27% of the sur-veyed health units had continuous availability of the essential HSSP indicator medi-cines with the other 73% having a monthly storeroom stock out of at least one of the essential medicines (Ministry of Health, 2006).

This year, the Ministry of Finance made a special budget allocation of 5.59 billion UGX for essential medicines for Health Centre IIIs as well as extra funding for drugs for regional referral hospitals. While this is a step forward for drug procurement, the Ministries of Finance and Health must be clear about how this funding responds to re-source gaps, and if it can really fill stated need. Indeed, when reading the Health Budget Statement in July, Uganda’s Minister of Health highlighted a UGX 156 billion shortfall in drug procurement funds—a huge gap which must be addressed immediately.

Despite these shortfalls, Uganda’s health indicators have improved over the past five years. The Uganda Demographic Health Survey (UDHS) 2006 has recorded some im-provements in maternal and child health status indicators. Uganda’s maternal mortal-ity rate has declined from 505 maternal deaths per 100,000 live births in 2000 to 435 maternal deaths per 100,000 per live births in 2006. The under five mortality rate has declined from 152 deaths per 1,000 live births in 2000 to 136 deaths per 1,000 live births respectively. However these ratios still fall far short of meeting both MDG Goal Four, which calls on governments to reduce the under five mortality rate by two thirds, and MDG Goal Five which calls on government to reduce the maternal mortality ratio by three quarters between 2000 and 2015. The current resource allocation trends for the health sector may not be enough to main-


tain—and indeed rapidly accelerate—these downward trends in order to meet the HSSP II and MDG goals. For instance, Uganda has only 2,209 physicians for a population of 28 million people and 7 hospital beds per 10,000 people (WHO 2007)—clearly no-where near the resources needed to provide accessible, available, acceptable and qual-ity health care to all. Without more funding to build the health sector, Uganda will not meet its health and human rights goals. 1.3 The Critical Importance of Antimalarials and AntibioticsIn Uganda, diseases that can be easily treated by simple medicine regimens continue to claim millions of lives because of the above mentioned gaps in health financing. This study focuses on two such diseases, malaria and pneumonia, which constitute two of the biggest disease burdens in Uganda. Malaria is the leading cause of illness and death in Uganda, making up half of the country’s disease burden, while acute respiratory illnesses come in second at 14.1% of the disease burden and contribute to HIV/AIDS mortality and morbidity

The country has addressed malaria through the home and community management of fever strategy (Nsungwa-Sabiiti et al, 2004) as well as through aggressive outreach to donors, which has resulted in full funding for the Ministry of Health mandated first line malaria drug, CoArtem. Although this strategy was implemented four years ago, it continues to be hampered by lack of supplies, de-motivated medicines distributors and lack of confidence in the medicines distributors from the community (Fapohunda et al. 2004) as well as gaps in human resources at the community and district level. As for pneumonia and other RTIs, Uganda does not currently have a home based management strategy; therefore children who suffer from this condition are expected to be treated at the local health facilities (Peterson et al. 2004), which makes access to these drugs essential at all health centre levels. In 2004, WHO and UNICEF released a joint state-ment emphasizing that many deaths from pneumonia could have been prevented each year if patients, especially children, had access to antibiotics (WHO/UNICEF 2004). By tracing their availability, this study illustrates how close Uganda is to fulfilling its AAAQ right to health responsibilities for the most deadly—and easy to treat—condi-tions.

1.4 Decentralization Policy in UgandaUganda’s decentralization policy was designed to devolve decision making to lower levels of the health systems in order to solve AAAQ challenges and bring health care closer to the people. However, the plan has met with resource challenges. Since 2006, Uganda has carved out 22 new districts, bringing the total number of districts to 80. This redistricting has exacerbated health sector resource challenges and may in fact lead to a decline in AAAQ. While the government health sub district concept is good, implementation has been difficult. Despite the creation of new districts health funding has remained the same-based on population, not on need. The same envelope of avail-able health funding is now divided between more districts which may serve the same


population in total but have new infrastructure demands including the need to build more health centres, offices, offer transport, and more to properly serve people in the new dis-tricts.

This study took place in the districts of Lyantonde, Isingiro and Ibanda. Lyantonde was cut of from Rakai district, and Isingiro and Ibanda were cut off from Mbarara district. The new districts face significant challenges and we hope this study, by addressing the medicines issue, will help to highlight the key interventions that the government should address in health service delivery to reach right to health norms.

1.5 The Medicines Supply ChainProvision of medicines and supplies is core to the delivery of quality health care and a critical indicator of the fulfillment of right to health obligations. Currently the local gov-ernment fiscal decentralization annual negotiations with the health sector have stipulated that 50% of the primary health care conditional grant should be spent on medicines and health supplies. The amount of money allocated to and expended by local governments on medicines is used to assess performance of local governments in delivery of the minimum heath care package Availability of medicines at the service delivery level is hampered both at the lower levels in their capacity to quantify, forecast and place timely orders to the National Medical Stores, and the capacity of the national medical stores to handle all orders and undertake timely delivery. The different levels of the logistics chain therefore need to address their unique capacity challenges to ensure that stock out levels of essen-tial commodities is kept to a minimum. The supply chain will be explored in this study, and areas for improvement highlighted, but as the above drug spending statistics show, without more government spending on medicines, Uganda will never be able to fulfill its right to health obligations to provide available and accessible care to all.

1.6 Human Resources for HealthUganda, like many other countries in sub-Saharan Africa, also suffers from a severe shortage of health workers. Numerous studies have shown that the number and quality of health workers is positively associated with important health indicators like immuniza-tion coverage and infant, child, and maternal mortality rates (WHO, 2006).

Health workers are poorly distributed globally and locally. Globally, the Africa region suffers more than 24% of the global burden of disease, but has access to less than 3% of the world’s health workers. Similarly, within a country health workers tend to congregate in urban areas, leaving rural areas with fewer health workers per capita. (WHO, 2006) Uganda faces this problem, with a high percentage of health workers living and working in Kampala and far fewer serving in rural areas like Karamoja and Northern Uganda.

Recent attempts to quantify the global shortage of health workers have demonstrated that the minimum recommended number of health care providers (doctors, nurses, and


midwives) needed for a country to achieve a satisfactory level of basic health indica-tors is 2.5 per 1,000 people (Joint Learning Initiative, 2006). The WHO has generally adopted this standard as well, recommending a similar ratio of health care providers to patients in order to meet MDGs. However, Uganda has just 0.8 health care providers per 1000 people (WHO, 2007).

More specifically, the general WHO recommended doctor to patient ratio is 1 doctor per 5000 people. The extremely low percentage of doctors in the overall count of health workers (about 2200 in all of Uganda) negatively impacts the quality and accessibility of health services in Uganda and especially, in the three districts studied, which have unacceptably low doctor to patient ratios. In general, Uganda suffers from a shortage of doctors with only .08 physicians per 1,000 people (WHO, 2007), which translates into 0.4 doctors per 5000, less than half of the 1 doctor per 5,000 people recommendation. This shortage of skilled health professionals in hospitals and health facilities negatively impacts both the quality and accessibility of the Ugandan health care system.


2.1 ObjectivesGeneral objective:The purpose of this study was to track the availability of essential medicines in rural districts’ health facilities to assist policy makers with evidence for planning and advocacy.

Specific objectives:1) To assess the trends of medicines availability in health facilities in the new districts2) To explore the challenges faced by health workers in getting medicines at the health facility level3) To identify the gap between medicines availability and medicines demand

2.2 Study AreaThe study was undertaken in the three new districts of Lyantonde, Isingiro and Ibanda, all in Southwestern Uganda. These districts were created in July 2006, and started providing services, including health care, immediately thereafter. A summary of their demographic and health related characteristics as of financial year 2006/07 are shown below:

Table 1: Characteristics of the studied districtsCharacteristic Lyantonde Isingiro Ibanda

1) Population

Total population 70,300 316,028 222,698

Under five 14,200 63,838 44,985

2) Health facilities

Hospitals 1 0 1

HC IVs 0 3 2

HC IIIs 4 13 6

HC IIs 5 30 25

3) Health workers

Doctors 3 3 5

Clinical officers 8 14 6

Registered nurses 9 9 12

Enrolled nurses 37 39 37

4) Burden of disease

Malaria Malaria Malaria

ARI / RTI RTI RTI

Pneumonia /Trauma Intestinal worms Intestinal worms

Chapter 2Materials and Methods


In Uganda, the heath sector has inadequate and poor quality health infrastructure. Only 72% of the population lives with in 5 kilometre radius from a health facility and existing health facilities are dilapidated and poorly equipped (MoH, 2007/8). Ac-cording to the WHO’s 2007 country profile of Uganda, the health infrastructure is inadequate, especially in rural areas, leaving 51% of the population without access to health care (WHO 2007).

The provider-patient ratios in the three surveyed districts fall far below the recom-mended ratio of 2.5 doctors, clinical officers, nurses and midwives per 1,000 people. In Lyantonde the ratio is 0.8 health care workers per 1,000. In Ibanda and Isingiro, the ratio is just 0.2 health care workers per 1,000 people.

The three districts in this study have much lower doctor-patient ratios than the al-ready low ratio of 0.4 doctors per 5,000 people country-wide. Lyantonde has only 0.2 physicians per 5,000 people, which is just one-fifth of the WHO recommendation of 1 doctor per 5,000 people. The situation in Isingiro and Ibanda is even more dire. Isingiro has only 0.05 physicians per 5,000 people, and Ibanda only 0.1 physicians per 5,000. These districts neither meet the WHO standard nor Ugandan government staffing norms, which can adversely affect the realization of the right to health as the principles of accessibility and availability are compromised.

2.3 Study DesignA longitudinal survey was used in the selected health facilities. The baseline phase, which gave a cross sectional view of the human resources available at district level and workload at facility level for the previous three months, helped the team establish general trends in the districts. The survey phase, conducted from January to March 2007, had research assistant visit each selected clinic every two weeks to collect data on the medicines situation as well as the workload. AGHA took malaria and pneu-monia cases as tracers because these diseases represent the top disease burdens in the districts surveyed and indeed nation-wide, and can be successfully treated with the right drugs if they are available.

2.4 Sample SizeIn order to balance the statistics from each district, the same number of health facili-ties were selected from each of the three districts. The levels of selected health facili-ties were similar across the districts. The table below shows the health units accord-ing to the levels and per district.

Table2:NumberofselectedhealthfacilitiesperdistrictLevel of facility Lyantonde Isingiro Ibanda

HC IV / Hospital 1 1 1

HC III 4 3 4

HC II 5 6 5


A total of 10 health centres were selected per district. These selected health centres included HC IVs, HC IIIs, and HC IIs. Lyantonde Hospital—which had until re-cently been a health centre IV but was elevated to the hospital level when Lyantonde became a separate district—was monitored as a proxy health centre IV to provide bal-ance with the other districts.

The selected health facilities were spread throughout each district so most of the sub-counties were represented. The health facilities chosen reflect general utilization pat-terns in Uganda; in order to ensure the study captured health facilities that served the affected communities, each clinic was on a main road, had high OPD attendance, had qualified health workers present, and had been open at least a year.

2.5 Data Collection and ManagementData was collected from both the District Health Offices and the health facilities. A summary of the data collection methods is shown in the table below.

Table3:DataCollectionMethods

Theme Analytical attributes

Data sources Method of data collection

1. Types of services delivered - Prevention - Treatment - Care and support

- No of clients per month - No of episodes for visits per month

- DHO - Health unit in-charges

- Records review (Baseline and on-going) - Key informant (Baseline)

2. Types of providers - Government - Faith based - NGO - PFP

At what levels: Hospital, HC IV, HC III, HCII, non-facility based

-DHO

-Records review (Baseline)

3. Human resources Doctors, clinical officers, midwives, nurses, lab technicians, lab assistants, nurse aides/assistants

- Number available as of 01-07-06 - Sex - Year of qualification

-DHO - Health facility in-charges

-Records review -Survey (Baseline)

4. Commodities -antimalarials: Chloroquine, Fansidar, Quinine, Coartem -antibiotics: Amoxycillin, Cotrimoxazole, Ampicillin, Erythromycin, Ciprofloxacin -analgesics: Paracetamol, Aspirin, Ibuprofen -Others: - Nalidixic acid, Mebendazole

-Stock-outs on previous 3/12 -Availability at that time -% of HCs with the drug -Trends in availability over time

-DHO -Health facility in-charges

-Records review -Survey -KI guide (Baseline and follow up)

�0 Access to Essential Medicines in Three New Districts of Uganda

Data was collected every two weeks for five rounds in Ibanda, six rounds in Isingiro and seven rounds in Lyantonde.

Quantitative data was collected using tools developed by the AGHA and IPH research teams and tested in the field to incorporate participants’ suggestions. Once data was collected, questionnaires were taken to the district to the DHO’s office. They were checked for completeness and then sent to the AGHA offices where the data entry and analysis took place. Some of the filled data forms were picked from the districts dur-ing a supervision and verification exercise whose aim was to verify that the data was collected properly. The qualitative data was generated through key informant inter-views.

Data collection and analysis was supervised by researchers from the Institute of Pub-lic Health who have a track record of doing national and international research. They conducted all the key informant interviews and the record review at the district health offices.

Research assistants, who were all health inspectors, collected data from the health facilities. These research assistants were identified with the help of the District Health Office and did not collect data from facilities where they worked in order to mini-mize bias. Research assistants were all trained and the survey tool piloted to ensure it would respond to the needs of the survey.

2.6 Ethical considerationsData was collected after getting permission from the DDHS office. Consent was sought from all the respondents. Confidentiality was observed with the data at all levels.

2.7 Completeness of Data on Medicine Stock- OutsTen facilities were selected from each of the districts: Ibanda, Isingiro and Lyantonde. Data completion in Ibanda and Lyantonde was over 95%. In Isingiro, completeness reached 85% only because there were no health workers at one of the health facilities that was monitored. The single nursing assistant assigned to the clinic was on leave, so there was no one to assist with the data collection—which in and of itself high-lights the critical challenge of human resources in these new districts.

The visits to all the health facilities started Tuesday 2nd January 2007 and all subse-quent visits were done exactly two weeks after that. Visits were made to all the health facilities on the same day. In those cases where it became impossible to visit the same day, the visits were done the next day and the data collected would not differ from data collected the previous day.


During each of the visits, research assistants checked to see whether the medicines were available or not through physical verification as to whether the medicines were actually available in the medicines store. Medicines would be recorded as either in stock with a ‘yes’ and if not available, it was indicated as a ‘no’.


Access to essential medicines is a critical component to achieving the right to health paradigm of available, accessible, acceptable and quality health care. This study tracked antimalarial and antibiotic medicines stocks at health facilities in three new districts in Southwestern Uganda. Medicine stock outs fluctuated month to month at all health facilities and rarely reached 100% availability, raising questions about the true accessibility of these lifesaving medicines.

3.1 Availability of Antimalarials

CoArtem is the Ministry of Health mandated first line treatment for malaria and has been fully paid for by development partners, so should be available at all health facilities at all times. However, this study found it was often unavailable in health facilities in all three districts. In Ibanda, 10-30% of health facilities experienced CoArtem stock outs over the course of 5 visits. In Isingiro, all health facilities had CoArtem at 3 of the 6 data collection visits; the other 3 visits found 10-40% of health facilities had no CoArtem in stock. In Lyantonde, CoArtem stock out rates ranges from 10% to 50% at one visit, meaning half of all health facilities visited that day did not have the first line treatment for malaria—the leading killer in Uganda. The availability rates were even lower for quinine in all districts, with stock out levels ranging from 10-75% of health facilities surveyed. In all the three districts, Chloroquine and Fansidar remain the most available antimalarials in the health facilities—despite the fact these are proven to have high resis-tance rates in Uganda and are often ineffective.

This study therefore shows disturbing fluctuations and frequent stock outs of CoArtem, which is the first line treatment for malaria, and which should be in all health facilities. Its absence exposes clients to less effective treat-ments that could result in continued illness or death.

These findings underscore the importance of addressing health systems in totality, not just focusing on one component, like drug funding. In the case of CoArtem, development partners have fully funded enough drugs for the country, yet stock outs remain. These stock outs indicate there may be

Chapter 3Medicines Stock Out Survey Results and Trends


problems in drug procurement, planning, management and distribution. There may also be challenges on the local level in forecasting, qualification and requisition stem-ming from lack of trained staff—a human resource challenge with clear health fund-ing implications, as shown here. Even if drug funding reaches 100%, Uganda must also ensure strong human resources, transport and systems for drug distribution, or risk massive stock outs.

Figures 1-3 show the percentage of health units that had antimalarials at the time of the visit. In all three figures, chloro is an abbreviation for chloroquine tablets.

Figure 1: Percentage of units with specific antimalarials

Percentage of units in Ibanda with specific antimalarials

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Figure 2: Percentage of health facilities in Isingiro with specific antimalarials

Figure 3: Percentage of health facilities in Lyantonde with specific antimalarials

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3.2 Availability of Antibiotics

Acute respiratory infection contributes substantially to morbidity and mortality in the three districts surveyed, coming in second behind malaria as the leading disease bur-dens. Moreover, RTIs and other opportunistic infections and illnesses like bacterial RTI (such as Streptococcus pneumoniae and pneumocystis carinii), TB, cryptococ-cal meningitis, and diarrhea which often can be treated with antibiotics are directly linked to illness and death among people living with AIDS in Uganda: indeed respi-ratory infection is the major cause of morbidity and mortality in children infected with human immunodeficiency virus (HIV) across much of Africa, including Uganda (Graham 2001; Abrams 2000). In an attempt to determine the stock outs for medi-cines used in the treatment of ARI and other opportunistic infections, the study veri-fied the stock outs for the antibiotics of amoxicillin, cotrimoxazole, erythromycin and ciprofloxacin.

Figures4-6showthepercentageofhealthfacilitiesthathadselectantibioticsatthetimeofthevisit.

The study found high levels of stock outs in antibiotics at health facilities in all three districts. For the first month of the study, 60-80% of health facilities in Ibanda had no access to the 4 major antibiotics traced by this study. In Isingiro district, access to any of the four antibiotics traced differed significantly, from less than 20% to 85%, but never reached 100% coverage for any medicines during the survey time. The most available antibiotics were amoxicillin and cotrimoxazole.

In Lyantonde, the percentage of health facilities with ciprofloxacin (between 25 and 50%) was much lower than in the other districts of Ibanda and Isingiro, where the medicines was available at between 35 and 100% of health facilities depending on the visit. Instead, at one time, erythromycin was in all health facilities, something which never occurred in the other districts during the period of the study.

These findings demonstrate that access to antibiotics varied widely over the course of the survey, depending on the visit, the district and the kind of antibiotic being mea-sured. Clearly there are major gaps in the drug procurement and distribution mecha-nism for critical antibiotics across the board, a major challenge that must be solved is health consumers in these new districts are to realize their right to health and have the weapons needed to fight the second biggest killer—RTIs, as well as other OIs that lead to illness and death, especially among those with HIV/AIDS.


Percentage of units in Isingiro with specific antibiotics

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Percentage of units in Ibanda with specific antibiotics

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Figure 4: Percentage of health facilities in Ibanda with specific antibiotics

Figure 5: Percentage of health facilities in Isingiro with specific antibiotics

Figure 6: Percentage of health facilities in Lyantonde with specific antibiotics


Procurement of medicines is a complex cycle that involves quantification, req-uisition, transport, storage and management of supplies at the point of supply. In all these stages, there is need for skilled human resources, adequate finances and a supportive health infrastructure. This study found weaknesses at every level of the procurement system. These weaknesses, combined with Uganda’s inadequate spending on essential medicines and human resources, have resulted in medicines stock outs in these new districts that threaten the realization of the right to health. This chapter highlights several of the key resource and systems challenges as out-lined by health workers in each district.

4.1 Health Centre StaffingThe new districts are grossly un-derstaffed, and this contributes to the medicines stock challenge by creating gaps in skills and cover-age that in turn affect quantifica-tion, requisition, storage, man-agement and utilization of the medicines. Although the number of health workers in the country is low generally, the new dis-tricts are severely understaffed. As one District Health Officer observed:

“Well, one of the biggest challenges is under staffing. Most of our units do not have enough personnel. In general the staffing levels are at 25%. You may find that the scope of the services that they service is small. You may find a unit with only nursing staff and some units have only a clinical officer”.

The numbers of health workers at the surveyed health facilities compared to the standard numbers according to HSSP are indicated in the tables below. The chal-lenges come from both huge deviations from the recommended staffing norms and significant gaps in the most critical cadres. As one DHO stated:

Chapter 4Challenges in medicines procurement

Qualified Health workers are key to maintaining accurate records, used to track and forecast medicine supplies


“Ifyoudon’thavecadreswhomyoucanreallycoordinatewithandyou aredealingwithnursingaides,coordinationbecomesaproblem.” (District Health Officer)

One unique challenge faced by these new districts is that health workers prefer to stay in the old districts where their retirement benefits have accumulated instead of risk-ing their pensions by being transferred to new districts, as depicted in the following quote:

“This is a new district and the government has revised staffing. This has leftthisplaceinaverysorrystateinthatwehavehadtogiveliberty accordingtoLocalGovernmentinstructionstopeopletoselectwhere theywanttobelong.Somanyofworkersselected(themotherdistrict) andtheywent.Forreasonsthatthepensionbusiness,thatwhenyouretire theLocalGovernmentshouldgiveyou(a)pension.Nowpeoplemaybe suspicious of a new district (being able to provide this pension). So staffing isaverybigproblemthroughoutthedistrict.” (District Health Officer).

Table 4: The staffing levels of visited health facilities in Ibanda

In Ibanda, the dual challenges of both not enough health workers and a lack of high level health workers combine in a perfect storm. In Ibanda, the proportion of health workers available at HC IV surveyed was 75% of the standard according to HSSP II, at HC IIIs surveyed, it was 37% of the standard while at HC IIs surveyed, it was 65% of the standard. Moreover, there is a complete dearth of clinical officers, leaving lower level cadres to provide all health care. And there is a frightening lack of midwives—for instance, at the HCIII level, there should be a total of 24 registered and enrolled nurse/midwives, but there are only 9—leaving expectant mothers without full access to qual-ity services. If a health facility has only lower cadre health workers, the clinic will only be able to offer services up to the training level of these workers: therefore patients may either get substandard diagnosis and treatment or not get treatment at all. In cases of substandard treatment, problems of resistances and death in the long run may be the consequences.

HC IV HC III HC II IBANDA PRESENT NORM PRESENT NORM PRESENT NORM MEDICAL OFFICER 0 2 0 0 0 0 CLINICAL OFFICER 1 2 3 8 2 0 COMPREHENSIVE NURSE 0 0 0 0 0 0 DOUBLE REGISTERED NURSE/MIDWIFE 0 1 0 0 0 0 REGISTERED NURSE/MIDWIFE 2 2 1 4 1 0 ENROLLED NURSE/MIDWIFE 7 6 8 20 3 10 LAB TECHNICIAN 2 1 0 4 0 0 LAB ASSISTANT 0 1 2 4 1 0 LAB ATTENDANT 0 0 0 0 1 0 NURSING ASSISTANT/AIDE 3 5 5 12 5 10 TOTAL 15 20 19 52 13 20


In Isingiro, the proportion of health workers available at HC IV was 50% of the stan-dard according to HSSP II, at HC III, it was 36% of the standard and at HC II, it was 58% of the standard. With such inadequate staffing it is clear that access to health care services is not fully achieved. The ratio of patient to health worker is too high, mean-ing that the few staff are overworked and may get fatigued and provide substandard services.

Table 6: The staffing levels of visited health facilities in Lyantonde

In Lyantonde, the proportion of health workers available at district hospital just previ-ously HC IV was 56% of the standard according to HSSP II, at HC III, it was 38% of the standard and at HC II, it was 83% of the standard.

Beyond these overall shortages, the study found that health centre III are particularly understaffed and lack the minimum required as established by the HHSSP as compared to HC IV and II. While health centre IIIs are supposed to have seven health workers namely; 1 clinical officer, 1 enrolled nurse, 2 enrolled midwives, 1 nursing assistant, 1 laboratory assistant and 1 records officer, the situation on the ground is far from ideal, with as low as 37% staffing compared to the goal of 75%. At these levels, it can be very difficult for health facilities to sustain the medicines supply mechanisms needed—nev-er mind actually provide patients with needed treatment.

HC IV HC III HC II LYANTONDE PRESENT NORM PRESENT NORM PRESENT NORM MEDICAL OFFICER 3 6 0 0 0 0 CLINICAL OFFICER 5 5 4 10 1 0 COMPREHENSIVE NURSE 2 0 0 0 0 0 DOUBLE REGISTERED NURSE/MIDWIFE 1 1 1 0 0 0 REGISTERED NURSE/MIDWIFE 9 2 0 5 1 0 ENROLLED NURSE/MIDWIFE 30 71 4 25 1 6 LAB TECHNICIAN 1 2 0 5 0 0 LAB ASSISTANT 3 1 3 5 1 0 LAB ATTENDANT 0 0 1 0 1 0 NURSING ASSISTANT/AIDE 4 15 12 15 5 6 TOTAL 58 103 25 65 10 12

HC IV HC III HC II ISINGIRO PRESENT NORM PRESENT NORM PRESENT NORM MEDICAL OFFICER 0 2 0 0 0 0 CLINICAL OFFICER 2 2 3 6 0 0 COMPREHENSIVE NURSE 0 0 0 0 0 0 DOUBLE REGISTERED NURSE/MIDWIFE 0 1 0 0 0 0 REGISTERED NURSE/MIDWIFE 2 2 1 3 1 0 ENROLLED NURSE/MIDWIFE 2 6 5 15 5 12 LAB TECHNICIAN 0 1 0 3 0 0 LAB ASSISTANT 1 1 2 3 2 0 LAB ATTENDANT 0 0 0 0 1 0 NURSING ASSISTANT/AIDE 3 5 3 9 5 12 TOTAL 10 20 14 39 14 24

Table 5: The staffing levels of visited health facilities in Isingiro


And while the staff levels are far from Ugandan government set norms, they are miles from WHO recommended ratios. The WHO recommends just under 2.5 skilled health providers per 1000 people. None of the districts come anywhere close to reaching this crucial recommendation. Lyantonde had only about one-third (32%) of the health pro-viders recommended by WHO, while Ibanda and Isingiro hovered around one-tenth of the WHO recommended number of provider (12% and 8% respectively)— low num-bers which have severely hampered the districts’ ability to provide quality services to their clients.

4.2 Medicines FundingHealth funding for the three districts surveyed was inadequate to meet the needs of patients and providers. The national government allocated funds to districts based on population: when the new districts were carved out, allocation remained based on pop-ulation and did not take into consideration the new infrastructure and staffing needs of these new districts. This has a direct impact on operations of the districts’ health centres as noted below,

“The funding we are relying mainly on (is) the PHC which is actually very little. For the current financial year, our PHC non wage allocation is184m.Ofcoursewedivideitbytwoandhalfgoestomedicineswhilewe remain with about 92m to do all sorts of things—to maintain HCs, maintain transport,topayportersandaskarisbecausetheyarenotpermanently employed by government. So basically at the end of the day you find that very little has been done vis a vis what is planned. So finances are in short supply.” (District Health Officer)

In a separate interview, another DHO expressed a similar concern.

“Formydistrictforexample,thefundingformedicinesfromprimaryhealth care is about 50 million a year. For the credit line facility it is about 90 million. And this one, compare to the population. We have a population of 360,000 people. You will find that the funding is not adequate for supplyingmedicinesforeveryoneduringtheyear.” (District Health Officer)

4.3 Medicine Quantification and Forecasting Health facility in-charges do not have the required training or capacity to quantify med-icines properly, and this too can lead to stock outs. In response to this lack of capacity, districts have instead begun placing orders for local health facilities after realizing that the local health facilities can not do it effectively. While this is a good interim measure, it has on the other hand created a new set of challenges.


This is well summarised by one of the DHOs:

“Ofcoursenumberone(challenge)westartwiththestaffwhoaresupposed to requisition for the medicines, they lack that expertise of quantifying what they need. Then of course when you fail to quantify what you need, you run a risk of either requesting for things which will not be enough or requesting too much of this and then you find you don’t have this. So that is actually whereIseeaverybigproblem.” (District Health Officer)

In response to the acute lack of capacity in the health in-charges at the lower level health facilities, the quantification is now done at the district level. This goes against the spirit of decentralization, which calls for medicine quantification to occur at the point of use. The following quotes from the DHO and the health unit in-charge points to this arrangement.

“In terms of quantification at lower level apart from one unit where you have worked from, we have been doing quantification basically for them, centrallyforthemandthentheyhadbeenprocured.” (District Health Officer)

One of the health in-charges had this to add:

“This (quantification) is solely done by the district. They just call us as the in-charges and tell us that this quarter you have been given so much, so you orderthemedicinesyouneedforyourfacilitybuttheamountvarieson quarterly basis.” (Health Unit In-Charge)

Although the HSSP II states that essential medicines and medical supplies have been shifted from a “push” to a “pull” system, the truth is that quantification in the district portrays a mixture of both systems. From the district, a push system is used with the lower health units, with decisions about medicine supplies made at the district level and “pushed” down to the health centres. At the same time, the National Medical Stores and the districts operate on more of a pull system, with districts placing orders for the essential medications and supplies needed in their district. Extending more training for staff—and indeed ensuring there is any staff at all—and truly following the decentralization model may help alleviate some of the misinformation which leads to medicines stock outs.

4.4 Medicines TransportMedicines are transported through several different systems, all susceptible to failure. Be-tween the national and the district level, medicines ordered from National Medical Stores are transported to districts by NMS, while districts must arrange transport for medicines from Joint Medical Stores. The next stage of transportation is from the district stores to the health units. Either the District Health Office transports medicines to the various health facilities, or the health units themselves come to the district headquarters to get the medicines. This system and the gaps therein, are illustrated in the following quotes:


“OfcoursefortransportwerelyontheNMStobringmedicines.Whenever we purchase from JMS we use the ambulance from HSD. We don’t have abigvehicleandevenifyouaretohire(avehicle),themoneywhichyou haveisverylittlesoyoucan’tbringallthemedicineslikeonalorry.” (District Health Officer)

“Wehaveonevehiclewhichisbasedatthehospital.Soatthedistrict we don’t have a vehicle. And you can’t use this vehicle to do so many thingsbecausesometimesyouarecalledtogovernmentmeetings,you dosupervision,therecanbeanemergencythenthevehiclehastotake somebody.Sotransportisabigproblem.” (District Health Officer)

These issues were re-echoed by the in-charges of the health facilities.

“Transportisaproblem,becausewe…areattheextreme(end)ofthe district.Soifourconsignmenthascomeatthedistrict,thentransporting themedicineshastohappensoon.Sometimesitbecomesaproblem. We wait until the vehicle from the headquarters is coming this way or when wefeelweareinneedofthemedicinesurgentlythenweresorttolocalor publictransport.” (Health Unit In-Charge)

4.5 National Medicine SuppliersThe government of Uganda has authorized only two institutions to procure medicines: the government-sponsored National Medical Stores and the NGO Joint Medical Stores. Districts are given three payment methods for medicines. First, districts have a cred-it line held by the central government to pay for medicines at NMS. The second is through PHC, where money is given to the district and they purchase the medicines when needed. Finally, for an amount not exceeding 10% of the medicines require-ments, districts can purchase medicines directly from local medicines providers instead of going through the two national stores.

However, districts point to several major challenges with the national medicine pro-curement system. First, the medicine funds held by the central government can be in-flexible and hard to access. For instance, if a district orders a medicine NMS does not have in store, the district can not get the money from the government to purchase that medicine elsewhere.

The mechanism of medicine payments has proven to be a major challenge, not only to local health units but to districts as well. For instance, one DHO said:


“We are supposed to first go to NMS for government institutions so we make our orders, process the cheques to NMS which in turn give us medicines.Whentheydonothavethemedicinesweneed,theyare supposed to give us a certificate of non availability. I think they have eithernevergivenusoriftheyhaveeveritisonlyonce.Eventhough theywillnotgiveyouthemoney,theywillgiveyouthepaper.Youwill haveputthemoneyintheirplace.Themoneyisretained(byNMS)so itdoesn’thelpmuch.Whatyouhaveisthepaper.Youhavetolookfor othermoney.” (District Health Officer)

The DHOs reported that the NMS sometimes sends medicines to them which they have not ordered in order to use monies on the credit line. This benefits NMS but does noth-ing help the health facilities to secure the medicines they need.

“Formostsuppliesinmydistrictweusethepullsystem.Wemakeour orderandbringthemtothemedicalstoreandtheysupplyaccordingto ourneeds.Occasionallyonthecreditlinetheremaybemedicinesthat are in stock so they find their ways of pushing it to us.” (District Health Officer)

Most critically, the funding from the national government is simply not enough at dis-trict level to meet all service needs:

“Thecontributionofthecentralgovernmenttohealthserviceshasalso beenreducing.Forexample,threeyearsagothehealthbudgetasa contribution of the government expenditure was about 8%, but this year it was only about 5%. The contribution has actually been declining.” (District Health Officer)

Moreover, districts consistently pointed to four major challenges in the medicine dis-tribution system, which include untimely/delayed medicine deliveries and deliveries which either have missing items, expired items, or unsolicited supplies. These chal-lenges were highlighted by both the DHOs and the health unit in-charges.

“WeusuallyprocuremedicinesuppliesfromNMSandtosomelittleextent fromJMS.NMSbringsthesupplies.Weputinourordersandtheybring thesuppliesbutthesuppliesdonotcomeintimeandevenwhentheydo supply you, they do not give you all that you requested. So you find that at timesyougetstockoutsofsomeimportantmedicineslikethat.” (District Health Officer)


The weaknesses at NMS also affect JMS, which must cover for shortages at NMS.

“JMSisalsobreakingdownbecausetheyhavebeenalsomissingcertain reagentsbecausenoweverybodyhasdivertedfromNationalMedicalStores tocometoJMSanditappearstheycannotaffordit.Weneeddextrose, weneedgloves,andwehavesomeproblemsthatareactuallyaffecting ourstocks.” (District Health Office)

The inadequacy of the NMS is even felt by the health unit in-charges as they pointed out that “At times we order for medicines we need but NMS sometimes doesn’t havethesemedicinesandthatmeanswemissthesemedicines.” (Health Unit In-Charge) “They (requisitions) are made the right way but when it comes to may be packingthemedicinesfromNMS,someareleftoutwhilesomearegiven whentheywerenotorderedfor.” (Health Unit In-Charge)

“At times we make orders from the NMS and they do not fulfill them e.g. you may order for 5 tins of quinine and they only deliver 3 tins. They even sendusmedicineswehavenotorderedfor.” (Health Unit In-Charge)

4.6 Medicines StorageMedicine storage is a critical health system infrastructure requirement for all districts. Once medicines are received from the suppliers, they must be stored appropriately in a safe place and properly recorded. As indicated in the Ministry of Health’s Ministerial Policy Statement 2007/2008, the creation of an additional 24 districts over the last two financial years means that for each new district a vaccine and medicines store has to be constructed. Indeed, this study found storage problems both at the district level and the health facility level.

Appropriate storage iscentralintrackingavailaibiltyofmedicines


“Storageofmedicines! Becausewedon’thaveacupboard,wekeep (themedicines)intheboxes.ThatisthemainproblemIface.” (Health Unit In-Charge)

This is re-iterated by one of the DHOs:

“Yesmostofourstoresareactuallyimprovised.Theimprovisedspace is inadequate and that one of course affects the medicine storage and the potency of the medicines. You find a small room like this, everything is thereyouknow.Youtrytoputinshelvesbutstillifit’ssmall,aerationwill notbeenough.Theotherthingisthedistrictmedicalstores.Wehave asmallroom…whichwearecurrentlyusingasadistrictmedicalstore.

Butitissmall.Wegetbulkysupplieslikesyringes.SoIthinkwehavea bigproblemespeciallyonthedistrictmedicalstores.” (District Health Officer)

The problems with storage go beyond infrastructure to record keeping. The inability to keep good records makes quantification very difficult and monitoring the use of medi-cines a major challenge.

“Yeswehaveactuallyabigproblemonthatespeciallyintheselower level units. You will find they get supplies and they can’t report or tell thereasonwhytheyhavegotthesesupplies,whytheyshouldrecord whatisgoingout.Wehavetriedtotrainthemonjobbutyouknow some of these things require some level of education. If you have a population full of nursing aides then you have a problem. So quite often we are fighting with them on stock cards there no dates for goodsreceived.Thosewhohavethemhavenotutilizedthem.” (District Health Officer)

If medicines are not stored in the right conditions, then health centres risk having spoiled medicines and dispensing them when they may not be good for human consumption. Lack of proper storage facilities means that health units may not be able to quantify what is and or is not available at a given time, thus contributing to stock outs.

4.7 Coordination Between Districts and Health CentresIndividual health facilities are allocated money to buy medications from NMS directly. However, because of transportation and cost issues, it most often makes sense for dis-tricts to purchase the medicines in bulk instead. This kind of system requires strong coor-dination and communication between individual health facilities and the district, which often does not happen, putting access to medicines in jeopardy:

“Theonlyproblemisthatwehavepoorcommunicationthisend. The networks are weak so we have to send SMS until he (DHO) gets themessages.” (Health Unit In-Charge)


ConclusionAs indicated above, there are a number of problems that have and will continue to lead to stock outs in health facilities in rural districts, if not addressed. While some prob-lems can be solved by administrative changes and coordination, the root of many of these challenges is the inadequate amount of money allocated to the health sector.

Limited finances have a great impact on most of the challenges listed above, including the amounts of medicines procured, transportation mechanisms, staff to quantify and dispense these medicines, medicine storage and communication systems. The Ugandan government must work towards the progressive realization of the right to health by ad-dressing the challenges identified above, aiming at meeting the AAAQ criteria. While it is appreciated that the resource envelope of the country is limited, health is a critical investment that can not be compromised. Essential medicines are a basic right that all Ugandans should be accessing at the shortest time possible, and with such problems and stock outs, this will only remain a dream.

5.1 ConclusionsThis study has shown significant gaps in health service delivery in three new districts in Southwestern Uganda. Health facilities in Ibanda, Lyantonde and Isingiro all experi-enced stock outs of essential malaria and antibiotic medicines during the study period. Especially problematic is the lack of CoArtem at some facilities: this is the government mandated first line medicines, is fully funded by development partners and should be available everywhere at all times. These medicines stock outs illustrate gaps in the medicines procurement system, in the health system in general, and in Uganda’s com-mitment to fulfilling the right to health for all Ugandans.

5.2 Policy RecommendationsBecause the medicines procurement system is complex and reaches from the interna-tional to the local level and across the health sector, AGHA has compiled a preliminary set of recommendations that address the top 5 challenges in medicine access as identi-fied by this survey, which include budget gaps, medicine purchasing and distribution, monitoring and evaluation, human resources for health and communication systems. This list of recommendations is not exhaustive, nor is it final. Through discussions with

Chapter 5Conclusions and recommendations


stakeholders, policy makers, and health workers about the study findings and its impli-cations for the health sector in Uganda, AGHA will refine these recommendations over time. All recommendations speak directly to solving the medicine stock out challenges faced by districts while also ensuring the health rights paradigm of accessible, available, acceptable and quality services is met by Uganda as soon as possible.

5.2.1 Budget GapsThe government of Uganda must immediately spend more money on health in order to provide the infrastructure and human resources needed to get quality care to those in the most remote places and to guarantee essential medicines are available for all. The cur-rent Health Sector Strategic Plan, HSSP II, is not fully funded and current projections do not indicate how the gaps in funding will be filled. The human resources situation is es-pecially dire in the districts that participated in this study, and the funding for medicines and health supplies is too low to meet the district’s need. Without increased funding for health services, the situation in these districts will not improve and thousands will con-tinue to be without access to essential medicines.

Scale up health spending: The Ministry of Finance supported by the Ministry of Health and Members of Par-liament must commit to rapidly scaling up health spending to 15% of the national budget by 2010. The 2007/2008 health budget remains at only 9% of the national budget, which is far below the 15% target.

Fully-fund the HSSP: HSSP I was only about 30% funded and current projections show that HSSP II will also be only partially funded. The Ministries of Health and Finance and the Parliament must commit to a fully funding future HSSPs..

Increase the budget ceiling for health: The Ministry of Finance must loosen any macroeconomic structures which pre-vent an expansion of the resource envelope for health, and allow full spending in order to fill the staffing gaps, improve the infrastructure of health facilities, and as-sure supplies and delivery of all essential medicines. Although some economists have claimed that health is not a productive sector, and therefore Uganda should not risk macroeconomic pitfalls like inflation to support health interventions, the government of Uganda must measure the impact of good health on her economics. A healthy workforce is a productive workforce, and many studies have shown that the positive impact of health spending outweighs macroeconomic concerns. Be-yond this economic argument, the Ugandan government has an obligation to pro-gressively realize the right to health by devoting the maximum available resources to the health sector, and meeting this 15% goal is a major indicator of progress and accountability towards this critical human rights marker.


5.2.2 Medicine Purchasing and DistributionSignificant reforms are needed in the medicine purchasing and distribution system in order to address medicine stock outs.

Allow for flexible purchasing: The current medicine purchasing system should be reformed to allow flexible pur-chasing from JMS or private companies when medicines are not available from NMS, without any penalty or loss of funds to the facilities or districts. If NMS does not have a medicine in stock, the district must be able to purchase it else-where immediately and without any caps on percentage of funds spent on outside purchases.

Increase funds available for transport: Funds should be allocated to make sure that NMS and the districts have a clear and efficient way to deliver medicines to the point of service. The NMS must deliver the needed medicines to the facilities in a timely and efficient manner, and the districts must have the funding available to transport the medicines to the health centres. With only a small percentage of the district budget available for administrative functions, districts struggle to find the funds to transport medicines from the district to the point of service.

5.2.3 Monitoring and EvaluationAlong with increasing the funding available for the health sector, Ministry of Health and Parliament must also ensure that those funds that are available for the procurement and distribution of essential medicines are being used as effectively as possible.

Strengthen the role of the Health Unit Management Committees: Each district is supposed to have a Health Unit Management Committee made up of knowledgeable community members that oversees medicine supplies and pro-vide independent oversight of the health system at the local level. The Ministry of Health with direct support and participation of District Health Directors should take responsibility for building the capacity of these committees to make sure they have the capacity to hold the health facilities accountable to the communities they serve.

Increase supervision and monitoring of medicine procurement and distribution by the Ministry of Health:

The Ministry of Health must have an effective and appropriate structure, be it the National Drug Authority or the Pharmaceutical Section of the Ministry of Health, to coordinate, supervise and monitor medicine procurement and distribution. Working closely with the NMS and the districts, the Ministry of Health should hold all parties accountable for delivery of the requested medicines to the point of service in a timely manner. By strengthening monitoring and oversight, the Ministry of Health will be better positioned to use the current funds efficiently and effectively.


Provide Regular Updates on Medicine Supply Levels: The Social Services Committee of Parliament should receive a medicines update from each district every six months in order to monitor stock outs of essential medicines and supplies on a regular basis. Ideally, this report would come from an independent structure like the Health Unit Management Committee, but if this is not possible then the districts themselves should be responsible for providing this information to Parliament on a semi-annual basis so that body can also monitor and hold accountable the health sector for medicine procurement.

Develop a system for inspecting medications to keep expired medications from be-ing delivered to districts and health centres:

The Ministry of Health must institute better inspection so that expired medicines do not reach districts or health centres. Health facilities should not accept medi-cines that have expired or are due to expire in the shortest time after and must have a straightforward mechanism for exchanging these medicines for ones which are still good.

5.2.4 Human ResourcesThe low numbers of health workers and the lack of qualified staff at many health fa-cilities is a huge barrier to addressing essential medicine stock outs. Parliament, the Ministry of Health, and the districts must all take responsibility for both increasing the capacity of the current health workforce and filling the staffing gaps.

Create practical strategies for meeting health facility staffing targets as outlined in the HSSP.

The Ministry of Health must have concrete and practical plans for how to fill the vacant positions country wide. If the government of Uganda keeps its promise to increase the budget for health, than the Ministry of Health must have realistic strat-egies ready for how to recruit and train health workers to fill vacant positions. Provide regular training to health centre staff on stock cards and medicine

forecasting. The Pharmaceutical Division of the Ministry of Health along side district leader-ship must provide training to health centre staff on how to use stock cards and how to forecast and quantify necessary medicines for their facilities. District leadership should then follow-up after the training to make sure that stock cards are being filled out correctly.

Provide incentives for health workers to join new districts. Health workers are currently hesitant to work in new districts due to uncertainty about access to pensions and other benefits. The Ministry of Health and the Dis-tricts must not penalize health workers that work in a new district, but instead provide them with incentives to work in the new district.


5.2.5 Communication SystemsSome of the challenges uncovered in this report point to a need for better communication systems between districts, health facilities, and central bodies such as the NMS and the Ministry of Health. Develop regular communication mechanisms between district offices and health facilities about medicine supplies and needs.

District offices must develop a functional way to communicate between health facilities and the district offices about medicine supplies and orders on a regular basis so that the correct supplies are ordered for the health centres. Health facili-ties must be held responsible for providing timely and accurate information about medicines, while district offices must be held responsible for ordering the correct supplies based on communicated needs from the health centres. Without accurate information from these health centres, improvements in national and district infra-structure will still not solve this crisis.

Improve communication between the Districts and the NMS about availability of medicines.

NMS must provide real-time information about medicines stocks in their storage facility to districts at the time of ordering, not waiting until delivery to inform a district if a medicine ordered is not available. This improved communication, coupled with a flexible purchasing system, would allow districts to secure needed medicines from an alternative supplier immediately.


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District Health Officer (Baseline): Key Informant Guide

I am …………………………….. I am representing the Action Group for Health, Human Rights and HIV/AIDS (AGHA) which is an indigenous Non-Governmental Organisation (NGO) founded in July 2003 to address issues of human rights as they relate to health with specific focus on HIV/AIDS. In this study, we are tracking medi-cines stocks at the health facilities in order to identify the availability and gaps so as to assist the districts and the policy makers with evidence for planning and advocacy.We would be interested in talking to you about this district and your experiences in providing health services especially types of services rendered in this district, types of providers and human resources available. Please be assured that the information is completely confidential. You may choose to stop the interview at any time.

Do you have any questions for me?Do I have your agreement to participate?

Types of services available1) What are the types of health services rendered in health facilities in this district? (Probe for preventive services, treatment and care and support)

2) What are the main challenges faced by the district in service delivery at health fa-cility level? (Probe for financial, human resource, logistic, coordination etc)

Medicines procurement1) What are the methods in which medicines are procured within the district? (Probe for credit line, open market purchasing, funding flow etc)

2) What are the challenges faced in the procurement and management of medicines at the health facilities? (Go through the procurement process: medicines quantification, requisitions and transport, storage, distribution, inventory control)

3) What are the on-going strategies to address these challenges?

Thank you for the time.

Appendix 1:


Records Review Tool: DHO (Baseline)

Ask the DHO for the person responsible for records to help you identify records for types of providers in the district and human resources. If not enough information is available to answer a question, mark NI (not enough information).

District: …………………………

Owner Hospital HC IV HC III HC II Non-facility based

Government

Faith based

NGO

Private for profit

Cadre Number posted as of 01/07/06

Medical officer Clinical officer Comprehensive nurse Double registered nurse / midwife Registered Nurse/ Midwife Enrolled comprehensive nurse Enrolled nurse / midwife Lab technician Lab assistant Lab attendant Nursing Assistant / Aide Porters

Appendix 2:


Data Collection Tool: Health Facility Survey (Baseline)

A. Seeking consentI am …………………………….. from the District services of ……………………..I am representing the Action Group for Health, Human Rights and HIV/AIDS (AGHA) which is an indigenous Non-Governmental Organisation (NGO) founded in July 2003 to address issues of human rights as they relate to health with specific focus on HIV/AIDS. In this study, we are tracking medicines stocks at the health facilities in order to identify the availability and gaps so as to assist the districts and the policy makers with evidence for planning and advocacy.We have discussed it with the DHO. (Produce letter from the DHO). We would be in-terested in talking to you about this facility and your experiences in providing health services especially medicines availability. Please be assured that the information is completely confidential. We shall be coming here twice every month for three months (January – March 2007). You may choose to stop the interview at any time.


B. General Information

C. Health Workers in the Facility

District: _________________________ Date: __ / __ / __ Facility Name:_____________________ Facility level: HC II, HC III, HC IV, Hospital ________________________ Research Assistant: _________________

Cadre Number posted as of 01/07/06

Medical officer Clinical officer Comprehensive nurse Double registered nurse / midwife Registered Nurse/ Midwife Enrolled comprehensive nurse Enrolled nurse / midwife Lab technician Lab assistant Lab attendant Dispenser Nursing aide in pharmacy Nursing Assistant / Aide Porters

Appendix 3:


D: Workload at the health facilityAsk the health worker responsible for records to help you identify records for all visits to the health facility. Use outpatient registers. Fill in the number of clients for the tracer condition for the months of October, November and December 2006. If not enough information is available to answer a question, mark NI (not enough informa-tion).

E. Referral facilities1) Where do you refer the severely-ill children?a. Hospital Specify name: ________________Distance from here_____________b. Health facility Specify name: ______________ Distance from here __________c. Private clinic ___________________ Distance from here __________________d. Other Specify name: _______________ Distance from here ________________

2) How long does it take for the patient to get to the referral center/physician using the most common local transport? ________ hours

F: Availability of medicinesAsk the health worker who is in charge of the medicines stores to give you the fol-lowing information and cross check physically.

October November December Under 5 Above

5 Under 5 Above

5 Under 5 Above 5

Tracer condition

M F M F M F M F M F M F Malaria

ARI not pneumonia

Pneumonia

Available Now

Tracer drug Did you at any time in Oct, Nov or Dec lack this drug?

Yes No

If yes, when did you get the last batch

How many tablets are available?

1. Chloroquine 2. Fansidar 3. Quinine 4. Co-Artem 5. Amoxycillin 6. Co-trimoxazole

7. Ampicillin 8. Erythromycin 9. Ciprofloxacin 10. Paracetamol 11. Ibuprofen 12. Aspirin 13. Mebendazole 14. Nalidixic acid


Health Unit In-Charge (Baseline): Key Informant Guide

I am …………………………….. I am representing the Action Group for Health, Human Rights and HIV/AIDS (AGHA) which is an indigenous Non-Governmental Organisation (NGO) founded in July 2003 to address issues of human rights as they relate to health with specific focus on HIV/AIDS. In this study, we are tracking medi-cines stocks at the health facilities in order to identify the availability and gaps so as to assist the districts and the policy makers with evidence for planning and advocacy.We would be interested in talking to you about this health unit and your experiences in providing health services especially types of services rendered in this health facil-ity, and medicines procurement. Please be assured that the information is completely confidential. You may choose to stop the interview at any time.


Types of services available1) What are the types of health services rendered in this health facility? (Probe for preventive services, treatment and care and support)

2) What are the main challenges faced by the health facility in service delivery? (Probe for financial, human resource, logistic, coordination etc)

Medicines procurement1) What are the methods in which medicines are procured by the health facility? (Probe for credit line, open market purchasing, funding flow etc)

2) What are the challenges faced in the procurement and management of medicines at this health facility? (Go through the procurement process: medicines quantification, requisitions and transport, storage, distribution, inventory control)

3) What are the on-going strategies to address these challenges?

Thank you for the time.

Appendix 4:


Data Collection Tool: Health Facility Survey (Follow-Up)

District: _________________________ Date: __ / __ / __Facility Name:_____________________ Facility level: HC II, HC III, HC IV, Hospi-tal ________________________ Research Assistant: ________________

Workload at the health facilityAsk the health worker responsible for records to help you identify records for all visits to the health facility. Use outpatient registers. Fill in the number of clients for the tracer condition for THE PRE-VIOUS TWO WEEKS. If not enough information is available to answer a question, mark NI (not enough information).

Availability of medicinesAsk the health worker who is in charge of the medicines stores to give you the following informa-tion and cross check physically

Appendix 5:

Under five Above five Tracer condition Male Female Male Female Malaria

ARI not pneumonia

Pneumonia

Available Now Tracer medicines

Yes No

If yes, when did you get the last batch

How many tablets are available?

1. Chloroquine 2. Fansidar 3. Quinine 4. Co-Artem 5. Amoxycillin 6. Co-trimoxazole 7. Ampicillin 8. Erythromycin 9. Ciprofloxacin 10. Paracetamol 11. Ibuprofen 12. Aspirin 13. Mebendazole 14. Nalidixic acid


Appendix 6:Map of Uganda Showing the new districts and the location of Ibanda, Isingiro and Lyantonde districts.


Health centres in the selected districts

1. Ibanda district: This district is composed of one county – Ibanda county with two health sub-districts.

Health Sub-district

Subcounty Health facility

Kikyenkye Kikyenkya HC III Rwengwe HC II Rugaaga HC II

Nyabuhikye Ruhoko HC IV Rubaya HC II Bwahwa HC II Rusaasi HC II Rwobuziizi HC II Nyamirima HC II

Nyamareebe Bihanga HC II Nyamareebe HC III

Rukiri Rukiri HC III Mpasha HC III Kigunga HC II Nyarukiika HC II

Bisheshe Bugarama HC II Bisheshe HC III Kakaasi HC II Kashangura HC II Kabale HC II Kalangala HC II Kikukyu HC II Nyakatookye HC III

Ibanda Town Council Bufunda HC III Ibanda Mission(NGO) HC II Ibanda Hospital ( NGO)

Ishongororo Birongo HC II Kakinga HC II Kashozi HC II Kijongo HC II Rwenkobwa ( NGO) HC III Ishongororo HC IV

Kikyuzi Irimya HC II Kanyambogo HC III Kikyuzi HC II

Appendix 7:


County / HSD Sub-county Health facility Ndinzi Ndinzi HC III

Lugaaga HC III Rwantaha HC II Busheka HC II Birunduma HC II Kashojwa HC II

Kashumba Kashumba HC III Murema HC II Buhungiro HC II ( NFP)

Ngarama Lwekubo HC IV Kagaga HC II Ngarama HC II Kabugu HC II

Birere Nyamuyanja HC IV Kikokwa HC II Kakoma HC II ( NFP)

Masha Nyarubungo HC III Nyakitunda HC III Rwentango HC II Kamubihizi HC II Kihihi HC II Ruhira HC II

Mbaare Mbaare HC III Nyamurungi HC II

Isingiro Town Council Isibuka HC II Kyeirumba HC II

Sub- county Health facility Lyantonde Town Council

Lyantonde Hospital Lyantonde Muslim hospital Kijukizo health centre

Lyantomde Rural Kabuyanda HC II Kariro Kariro HC III Mpummudde Mpumudde HC III Kinuuka HC III Kinuuka Ryakajura HC II Kasagama Kasagama HC III

Buyanja HC II

3. Lyantonde District: The district is composed of one county called Kabula county and has one health sub-district with the head quarters at Lyantonde.

2. Isingiro District: The district is composed of two counties – Isingiro and Bukanga – and three health sub-districts.

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