Uganda - Demographic and Health Survey - 2003

Publication date: 2003

Uganda Health Facilities Survey 2002 Ministry of Health Kampala, Uganda ORC Macro MEASURE DHS+ Calverton, Maryland, USA John Snow, Inc./DELIVER Arlington, Virginia, USA JSI Research & Training Institute, Inc./ Uganda AIDS/HIV Integrated Model District Programme (AIM) Kampala, Uganda June 2003 Contributors: John Snow, Inc./DELIVER Dana Aronovich Allison Farnum Cochran Erika Ronnow ORC Macro Gregory Pappas JSI Research and Training Institute, Inc./AIM Evas Kansiime Maurice Adams Ministry of Health F. G. Omaswa H. Kyabaggu Eddie Mukooyo Martin O. Oteba This report presents findings from the 2002 Uganda Health Facilities Survey (UHFS 2002) carried out by the Uganda Ministry of Health. ORC Macro (MEASURE DHS+) and John Snow, Inc. (DELIVER) provided technical assistance. Other organizations contributing to the project were the U.S. Centers for Disease Control and Prevention (CDC/Uganda), the U.S. Agency for International Development (USAID/Uganda), and the JSI Research and Training Institute, Inc., AIDS/HIV Integrated Model District Programme (AIM). MEASURE DHS+, a USAID-funded project, assists countries worldwide in the collection and use of data to monitor and evaluate population, health, and nutrition programs. Information about the Uganda Health Facilities Survey or about the MEASURE DHS+ project can be obtained by contacting: MEASURE DHS+, ORC Macro, 11785 Beltsville Drive, Suite 300, Calverton, MD 20705 (Telephone 301-572-0200; Fax 301-572-0999; E-mail reports@orcmacro.com; Internet: www.measuredhs.com). DELIVER, a worldwide technical assistance support project, is funded by the Commodities Security and Logistics Division (CSL) of the Office of Population and Reproductive Health of the Bureau for Global Health (GH) of the U.S. Agency for International Development (USAID). Implemented by John Snow, Inc. (JSI), (contract no. HRN-C- 00-00-00010-00), and subcontractors (Manoff Group, Program for Appropriate Technology in Health [PATH], Social Sectors Development Strategies, Inc., and Synaxis, Inc.), DELIVER strengthens the supply chains of health and family planning programs in developing countries to ensure the availability of critical health products for customers. DELIVER also provides technical support to USAID’s central contraceptive procurement and management, and analysis of USAID’s central commodity management information system (NEWVERN). Additional information about DELIVER can be obtained by contacting: DELIVER, John Snow, Inc., 1616 North Fort Myer Drive, 11th Floor, Arlington, VA 22209 (Telephone 703-528-7474; Fax 703-528-7480; E-mail deliver_info@jsi.com; Internet: deliver.jsi.com). AIM, the Uganda AIDS/HIV Integrated Model District Programme, is a five-year initiative jointly funded by the U.S. Agency for International Development (USAID) and the Centers for Disease Control and Prevention (CDC). The Programme was devised in consultation with the Ministry of Health, the Uganda AIDS Commission, international agencies, non-governmental organizations (NGOs), community-based organizations (CBOs), and those affected by HIV/AIDS. JSI Research and Training Institute and its partners, World Education and World Learning, are carrying out the AIM Programme in Uganda, working with organizations and individuals to increase the provision of HIV/AIDS services at the district and sub-district level resulting in broader access to quality HIV/AIDS prevention, care and support services. Additional information about the AIM Programme in Uganda can be obtained by contacting: Uganda AIDS/HIV Integrated Model District Programme, Nakawa House, 1st Floor, Plot 3-7 Port Bell RD, Kampala, Uganda (Telephone 041-222-011). The opinions expressed herein are those of the authors and do not necessarily reflect the views of the U.S. Agency for International Development. Recommended citation: Ministry of Health (MoH) [Uganda], ORC Macro, and John Snow, Inc./DELIVER. 2003. Uganda Health Facilities Survey 2002. Calverton, Maryland and Arlington, Virginia, USA: ORC Macro and John Snow, Inc./DELIVER. Contents Tables and Figures .vii Preface . xi Acknowledgements.xii List of Acronyms . xv Summary of Findings .xvii Introduction.xviii Physical infrastructure. xix Infection control. xx HIV/AIDS services . xxi Government laboratory capacity .xxii Non-government laboratory capacity.xxiii Stockout rates. xxiv Stock status . xxv Evaluation criteria for HIV/AIDS services . xxvi Findings, conclusions, and recommendations. xxix Map of Uganda . xxxiv Chapter 1 Introduction. 1 1.1 Structure of the health care delivery system . 1 1.2 Public health commodity logistics system. 2 1.3 National Strategic Framework for HIV/AIDS. 3 1.4 Health Sector Strategic Plan . 5 Chapter 2 Survey Objectives and Methods . 2 2.1 Survey objectives. 7 2.2 Methodology. 7 2.3 Sample design . 8 2.3.1 Sample description . 9 2.3.2 Weights and minimum sample sizes for stable estimates. 9 2.4 Data collection teams. 10 2.5 Survey instrument . 10 Contents | iii 2.6 Tabulation and key outcome indicators . 11 Chapter 3 Health Commodity Management and Logistic System Performance . 13 3.1 Commodity availability . 13 3.1.1 Commodity management. 14 3.1.1.1 HIV test kits . 14 3.1.1.2 Contraceptives and condoms. 15 3.1.1.3 Drugs to treat opportunistic infections . 16 3.1.1.4 Malarial drugs . 17 3.1.1.5 Drugs to treat sexually transmitted infections. 17 3.1.1.6 Anti-retroviral drugs. 18 3.1.1.7 Tuberculosis drugs . 18 3.1.1.8 Essential drug kits . 19 3.1.2 Stockouts and stock availability . 20 3.1.3 Stockout duration, December 1, 2001–May 31, 2002 . 22 3.1.4 Record keeping in relation to stockouts. 22 3.1.5 Reasons for stockouts . 23 3.2 Inventory management . 23 3.2.1 Stock status. 23 3.2.2 Expired products. 25 3.3 Health Management Information System . 25 3.4 Training in logistics and human resources. 27 3.5 Supervision in logistics . 29 3.6 Forecasting, ordering, and procurement . 31 3.7 Distribution and transportation . 33 3.8 Storage conditions. 34 Chapter 4 Service Provision. 37 4.1 HIV/AIDS Support Services. 37 4.1.1 Voluntary counseling and testing . 38 4.1.2 Prevention of mother-to-child transmission . 39 4.1.3 Services to improve the quality of life for the HIV-positive client . 40 4.1.4 Management and treatment of opportunistic infections . 40 iv | Contents 4.1.5 Social, economic, and psychological support. 41 4.1.5.1 Targeted activities for orphans and vulnerable children . 41 4.1.5.2 Youth-friendly programs. 42 4.1.5.3 Home-based care . 42 4.1.5.4 Social support/post-test services targeted to HIV-positive clients and family . 43 4.1.6 Sexually transmitted infections . 43 4.1.7 Diagnosis and treatment of tuberculosis. 44 4.2 Facility infrastructure and resources . 45 4.2.1 Provider training and supervision. 45 4.2.1.1 Training and experience . 45 4.2.1.2 In-service training . 45 4.2.1.3 Supervision. 46 4.2.2 Laboratory capacity and facilities. 47 4.2.2.1 Indicators for laboratory diagnostics. 47 4.2.2.2 HIV diagnosis. 48 4.2.2.3 TB diagnosis. 49 4.2.2.4 Syphilis laboratory diagnosis . 50 4.2.3 Infection control . 51 4.2.3.1 Capacity to disinfect equipment . 51 4.2.3.2 Infection prevention in the service delivery area . 52 4.2.3.3 Laboratory infection control. 54 4.2.3.4 Management and disposal of hazardous health care waste . 55 4.2.3.5 Management and disposal of sharps. 55 Chapter 5 Commodity, Equipment, Training, and Services Availability. 57 5.1 Definitions of evaluation criteria . 57 5.2 Availability of trained staff and commodities/equipment for selected services . 58 5.2.1 Voluntary counseling and testing . 59 5.3 Prevention of mother-to-child transmission. 60 5.4 Treatment of opportunistic infections. 61 5.5 STI diagnosis and treatment. 61 5.6 Tuberculosis diagnosis and treatment . 62 Contents | v 5.7 Limitations . 63 Chapter 6 Conclusions and Recommendations. 65 6.1 Health Commodity Management and Logistics System Performance . 65 6.1.1 Conclusions . 65 6.1.2 Recommendations . 66 6.2 Service Provision . 67 6.2.1 Conclusions . 67 6.2.2 Recommendations . 67 6.3 Commodity Management and Service Provision: Summary Conclusions . 68 References . 71 Appendix A Selected Estimates of Sample Errors . 73 Appendix B Data Quality . 75 Appendix C Survey Personnel. 77 Appendix D Commodities Surveyed. 79 Appendix E Facilities Surveyed and Facility Type . 81 Appendix F Survey Instrument . 87 Appendix G Full Tabulation of Data . 153 Appendix H Collaborating Agencies. 207 Appendix I Letter of Introduction. 211 vi | Contents Tables and Figures Chapter 1 Introduction Figure 1.1 Public health commodity logistics system in Uganda . 4 Chapter 2 Survey Objectives and Methods Table 2.1 Sample of facilities . 9 Chapter 3 Health Commodity Management and Logistics System Performance Table 3.1 Management of HIV test kits. 15 Table 3.2 Management of contraceptives and condoms . 16 Table 3.3 Management of drugs to treat opportunistic infections . 17 Table 3.4 Management of malarial drugs . 17 Table 3.5 Management of STI drugs . 18 Table 3.6 Management of TB drugs . 19 Table 3.7 Stock availability on day of survey. 22 Table 3.8 Data quality: median percent discrepancy . 27 Table 3.9 Availability of staff trained in logistics . 28 Table 3.10 Distribution . 33 Figure 3.1 Stockouts over the six-month period December 1, 2001–May 31, 2002. 21 Figure 3.2 Stock on hand (government facilities) . 24 Figure 3.3 Reported use of stock cards for commodity management . 26 Figure 3.4 Actual use of stock cards by commodity category . 26 Figure 3.5.1 Training in completing logistics forms (government facilities). 28 Tables and Figures | vii Figure 3.5.2 Training in completing logistics forms (non-government facilities) . 29 Figure 3.6.1 Most recent supervisory visit (government facilities). 29 Figure 3.6.2 Most recent supervisory visit (non-government facilities) . 30 Figure 3.7.1 Supervision of logistics practices (government facilities) . 30 Figure 3.7.2 Supervision of logistics practices (non-government facilities). 30 Figure 3.8 Push vs. pull ordering practices (government facilities). 32 Figure 3.9 Frequency of orders placed in past year (government facilities) . 32 Figure 3.10 Most frequently used mode of transport . 34 Figure 3.11.1 Compliance to minimum storage criteria (government facilities) . 35 Figure 3.11.2 Compliance to minimum storage criteria (non-government facilities) . 35 Figure 3.12 Compliance with individual storage conditions. 36 Chapter 4 Service Provision Table 4.1 Youth-friendly services. 42 Table 4.2 In-service training of staff. 46 Table 4.3 Outside supervision of providers . 46 Table 4.4 Qualifications of laboratory staff . 48 Table 4.5 Reported laboratory testing capacity . 48 Table 4.6 Staff trained in HIV laboratory diagnosis . 49 Table 4.7 Equipment disinfection . 52 Table 4.8 Infection control amenities . 53 Figure 4.1 Facilities providing HIV/AIDS services, government and non-government. 38 Figure 4.2 Facilities providing VCT, by ownership and facility type. 39 Figure 4.3 Availability of PMTCT, by ownership and facility type . 40 viii | Tables and Figures Figure 4.4 Availability of OI management services, by ownership and facility type . 41 Figure 4.5 Availability of STI services, by ownership and facility type. 44 Figure 4.6 Availability of tuberculosis diagnosis and treatment, by ownership and facility type . 44 Figure 4.7 In-service training in HIV/AIDS–related topics in the past three years . 46 Figure 4.8 Availability of laboratory staff trained in testing for HIV, by ownership and facility type . 49 Figure 4.9 Availability of laboratory staff trained in testing for tuberculosis, by ownership and facility type . 50 Figure 4.10 Availability of laboratory staff trained in testing for syphilis, by ownership and facility type . 50 Figure 4.11 Facilities with electricity available, by ownership and facility type. 52 Figure 4.12 Facilities with electricity, water source, and latrines available. 54 Figure 4.13 Laboratory facilities with infection control commodities, by ownership . 54 Chapter 5 Commodity, Equipment, Training, and Services Availability Table 5.1 VCT services. 60 Table 5.2 PMTCT services . 61 Table 5.3 OI treatment services . 61 Table 5.4 STI services. 62 Table 5.5 TB diagnostic services . 62 Table 5.6 TB treatment services . 63 Figure 5.1 Evaluation criteria for HIV/AIDS support services (all facilities). 58 Figure 5.2 Evaluation criteria for HIV/AIDS support services (district hospitals and health center IVs). 59 Appendix A Selected Estimates of Sample Errors Table A.1 Selected estimates of sample errors . 73 Tables and Figures | ix Appendix G Full Tabulation of Data Table G.1 Management of HIV test kits. 153 Table G.2 Management of contraceptives . 154 Table G.3 Management of drugs to treat opportunistic infections . 154 Table G.4 Management of malarial drugs . 155 Table G.5 Management of STI drugs . 155 Table G.6 Management of TB drugs . 156 Table G.7 Stockouts over the six-month period . 157 Table G.8 Stockout on day of survey: HIV test kits . 158 Table G.9 Stockout on day of survey: contraceptives . 158 Table G.10 Stockout on day of survey: Drugs to treat opportunistic infections. 159 Table G.11 Stockout on day of survey: Malarial drugs . 159 Table G.12 Stockout on day of survey: STI drugs. 160 Table G.13 Stockout on day of survey: TB drugs . 160 Table G.14 Stock on hand: HIV test kits . 161 Table G.15 Stock on hand: Contraceptives. 161 Table G.16 Stock on hand: Drugs to treat opportunistic infections. 162 Table G.17 Stock on hand: Malarial drugs . 162 Table G.18 Stock on hand: STI drugs. 163 Table G.19 Stock on hand: TB drugs . 163 Table G.20 Reported use of stock cards . 164 Table G.21 Actual use of stock cards . 164 Table G.22 Data quality. 165 Table G.23 Availability of staff trained in logistics . 166 x | Tables and Figures Table G.24 Training in completing logistics forms . 166 Table G.25 Most recent supervisory visit . 167 Table G.26 Supervision of logistics practices. 167 Table G.27 Push vs. pull ordering practices . 168 Table G.28 Frequency of commodity orders placed in the past year . 168 Table G.29 Distribution of commodities . 169 Table G.30 Most frequently used modes of transport. 169 Table G.31 Compliance with minimum criteria for storage conditions . 170 Table G.32 Compliance with individual criteria for facility storage conditions. 171 Table G.33 Facilities providing HIV/AIDS services . 172 Table G.34 Availability of VCT service components . 173 Table G.35 Availability of VCT services on the day of the visit. 174 Table G.36 Availability of PMTCT service components . 175 Table G.37 Availability of PMTCT services on the day of the visit . 176 Table G.38 Availability of OI service components . 177 Table G.39 Availability of OI services on the day of the visit . 178 Table G.40 Availability of OVC service components . 179 Table G.41 Availability of OVC services on the day of the visit . 180 Table G.42 Availability of youth-friendly service components . 181 Table G.43 Availability of youth-friendly services on the day of the visit. 182 Table G.44 Availability of home-based care service components. 183 Table G.45 Availability of home-based care services on the day of the visit. 184 Table G.46 Availability of social support/post-test service components. 185 Table G.47 Availability of social support services on the day of the visit . 186 Tables and Figures | xi Table G.48 Availability of STI services on the day of the visit. 186 Table G.49 Availability of TB diagnosis service components . 187 Table G.50 Availability of TB diagnosis services on the day of the visit . 188 Table G.51 Availability of TB treatment service components . 189 Table G.52 Availability of TB treatment services on the day of the visit . 190 Table G.53 In-service training of staff. 191 Table G.54 Availability of trained service providers. 192 Table G.55 Outside supervision of providers . 193 Table G.56 Reported laboratory capacity . 193 Table G.57 Qualifications of laboratory staff . 194 Table G.58 Reported laboratory testing capacity . 194 Table G.59 Availability of equipment for an HIV test . 195 Table G.60 Availability of sufficient power source to run refrigerator . 195 Table G.61 Availability of trained laboratory staff . 196 Table G.62 Staff trained in HIV laboratory diagnosis . 196 Table G.63 Principal use of HIV test kits . 197 Table G.64 Availability of equipment for TB sputum test . 198 Table G.65 Availability of equipment for a syphilis test. 198 Table G.66 Equipment disinfection . 199 Table G.67 Availability of electricity, water and latrines for infection control. 200 Table G.68 Infection control amenities in service delivery area . 201 Table G.69 Laboratory facilities with infection control commodities. 201 Table G.70 Sharps management and disposal practices . 202 Table G.71 Contaminated waste management and disposal practices. 203 xii | Tables and Figures Table G.72 VCT services. 204 Table G.73 PMTCT services . 204 Table G.74 Opportunistic infection services . 205 Table G.75 STI services. 205 Table G.76 TB diagnostic services . 206 Table G.77 TB treatment services . 206 Tables and Figures | xiii Preface Access and quality of health care in Uganda continue as major challenges to the Ministry of Health and its partners working to improve the health of the population. Physical access to health facilities varies enormously, and rural communities are particularly affected. There are variations in access to health care both within and between districts. In addition, the HIV/AIDS epidemic has placed new demands on the health care delivery system and Uganda has responded rapidly and effectively to address this crisis. The Ministry of Health of Uganda conducted a national survey of health facilities to evaluate HIV/AIDS-related services in the country. The Uganda Health Facilities Survey 2002 is a nationally representative survey of government and non-government health facilities throughout Uganda. This report describes the objectives, methods, results, conclusions, and recommendations of this survey. The survey evaluated health commodity management and the performance of the national logistics system for health commodities. This report includes results on the status of health commodity availability in the country as they relate to HIV/AIDS, sexually transmitted infections, opportunistic infections, family planning, and infection control. A chapter presents findings on commodity management, stock availability and stock status, inventory management, information systems, training, supervision, and other logistics system functions. HIV/AIDS-related services have also been evaluated, including the availability of prevention, care and support services, laboratory capacity, infection control, and infectious waste (including sharps) management in health care facilities. Data was collected on types of services, frequency of service availability, staff training related to services, and infrastructure (infection control, protocols, laboratory capacity) relevant to providing good quality services for HIV/AIDS. The report attempts to bring together various findings in the study by creating composite indicators that include a measure of service availability, staff training, and availability of commodities and equipment in HIV/AIDS and related service areas. A chapter in the report uses a set of evaluation criteria for HIV/AIDS services including voluntary counseling and testing, prevention of mother-to-child transmission, management of opportunistic infections, treatment of sexually transmitted infections, and diagnosis and treatment of tuberculosis. The assessment will help the Ministry of Health and other stakeholders in Uganda to identify strengths and weaknesses of the Ugandan health care system. The results provide information for planning interventions and baseline data for future evaluation. Preface | xv Acknowledgements This report is the result of a collaborative effort between the Ugandan Ministry of Health, the U.S. Agency for International Development (USAID)/Uganda, the Centers for Disease Control and Prevention (CDC)/Uganda, John Snow, Inc. (JSI)/DELIVER project, JSI Research and Training Institute (JSI R&T)/AIM project, and ORC Macro. We would like to express our sincere appreciation to the numerous people that contributed to the completion and success of this survey and report. In particular, we would like express our gratitude to Dr. Martin Oteba and Dr. Eddie Mukooyo for their leadership and guidance in carrying out this survey and for their assistance with the coordination of the fieldwork. We would also like to thank all of the dedicated Ministry of Health staff that contributed to making the data collection run smoothly as well as the enthusiastic data collectors who worked tirelessly to complete the survey at sites around the country. We would particularly like to thank district administrators and technical staff, including the many health facility workers who graciously opened their doors to our survey teams and took the time to answer the survey questions openly and honestly. We are also grateful to USAID and CDC for their financial support of this survey. For their contributions in the conception, design, and ongoing support of this survey, we would like to thank Elise Ayers, Suzzane McQueen, and Dr. Jessica Kafuko of USAID/Uganda, and Dr. Rebecca Bunnell and Dr. Donna Kabatesi of CDC/Uganda. We would also like to thank Ray Ransom and the data entry team at CDC/Uganda for their tremendous and tireless efforts in designing data entry screens, completing the data entry for the entire survey, and carrying out preliminary analysis of the data. Keith Purvis of ORC Macro carried out the tabulation of the data and the documentation of the data set. In the area of planning and implementation of the fieldwork, we would like to thank Steve Wilbur, JSI/DELIVER Resident Logistics Advisor to Uganda, Dr. Maurice Adams, Chief of Party for the AIM project, and Hanif Nazerali, UHSSP Technical Advisor. We would also like to thank the entire staff at AIM, especially Evas Kansiime, Monitoring and Evaluation Advisor, whose technical and administrative support was invaluable to the success of the survey. For her extensive work in the design of the survey instrument, we would like to thank Dr. Nancy Fronczak of ORC Macro. Also from ORC Macro, Dr. Sidney Moore edited the final report, Noah Bartlett assisted in the design of the figures, and Katherine Senzee designed the report and prepared the document for publication. Finally, we would like to express our appreciation to those who thoughtfully reviewed this report. This includes Timothy Williams, Edward Wilson, and Rebecca Copeland of John Snow, Inc., and Dr. Nancy Fronczak and Dr. Sidney Moore of ORC Macro. Dana Aronovich, John Snow, Inc./DELIVER Allison Farnum Cochran, John Snow, Inc./DELIVER Erika Ronnow, John Snow, Inc./DELIVER Gregory Pappas, ORC Macro Acknowledgements | xvii List of Acronyms ACP AIDS Control Programme AHSPR Annual Health Sector Performance Report, Financial Year 2000/2001 (September 2001) AIDS acquired immune deficiency syndrome AIM AIDS/HIV Integrated Model District Programme ARV anti-retroviral drugs CBO community-based organizations CDC Centers for Disease Control and Prevention CMS Commercial Market Strategies project DANIDA Danish International Development Agency DFID British Department for International Development DHS Demographic and Health Surveys DOTS directly observed treatment, short-course (for tuberculosis) ED essential drugs EDL essential drug list FEFO first-to-expire, first-out FP family planning FPAU Family Planning Association of Uganda GFATM Global Fund to Fight AIDS, Tuberculosis, and Malaria GoU Government of Uganda HBC home-based care HC II Health Center Grade II HC III Health Center Grade III HC IV Health Center Grade IV HIV human immunodeficiency virus HLD high-level disinfection HMIS health management information system HSD health sub-district HSSP Health Sector Strategic Plan 2000/01–2004/5 (Uganda Ministry of Health) IDA International Development Association IGP income-generating projects IPPF International Planned Parenthood Federation JMS Joint Medical Stores JSI John Snow, Inc. KfW Kreditanstalt für Wiederaufbau (German Bank for Reconstruction and Development) KPI Kampala Pharmaceutical Industries, Ltd. LIAT Logistics Indicators Assessment Tool LMIS logistics management information system MACA Multi-sectoral Approach to the Control of HIV/AIDS MAP Multi-Country HIV/AIDS Program MCH maternal and child health MoH Ministry of Health MSI Marie Stopes International NCPA National Committee for the Prevention of AIDS NDA National Drug Authority List of Acronyms | xix xx | List of Acronyms NDP National Drug Policy NEWVERN USAID’s central commodity management information system NGOs non-governmental organization NMS National Medical Stores OI opportunistic infection OVC orphans and vulnerable children PHC primary health care PLHA people living with HIV/AIDS PMTCT prevention of mother-to-child transmission RH reproductive health SDP service delivery point SP sulfadoxine/pyrimethamine SPA Service Provision Assessment STI sexually transmitted infection SWAp Sector-Wide Approach TB tuberculosis TG/CWG Technical Guidance and Competence Working Group UAC Uganda AIDS Commission UAPC Uganda HIV/AIDS Control Project UNAIDS Joint United Nations Programme on HIV/AIDS UNEPI Ugandan National Expanded Program for Immunization UNFPA United Nations Population Fund UNICEF United Nations Children’s Fund UNMHCP Uganda National Minimum Health Care Package USAID United States Agency for International Development VCT voluntary counseling and testing WB World Bank Summary of Findings | xvii Summary of Findings xviii | Summary of Findings In recent years, Uganda has been cited as a model throughout the world for its rapid and effective re- sponse to addressing the HIV/AIDS epidemic. Prevalence rates have re- portedly fallen in Uganda. This is fre- quently credited to the government providing direct and open informa- tion and leadership in curbing the epidemic, a delay in sexual debut and an increase in condom use, par- ticularly with non-regular sexual partners (Uganda Epidemiological Fact Sheet on HIV/AIDS and Sexu- ally Transmitted Infections, 2002 Update, UNAIDS, UNICEF, WHO). To continue these successes, compre- hensive HIV/AIDS prevention, care, and support services are critical. This includes services ranging from test- ing and counseling; to diagnosis and treatment of sexually transmitted in- fections (STI), tuberculosis (TB) and other opportunistic infections (OI); to treatment with anti-retroviral therapy; to a range of social and com- munity-based support services. Be- cause of Uganda’s successes, interna- tional donor funding has increased in recent years to support the expan- sion of services and for procurement of the health commodities required to offer comprehensive HIV/AIDS services. The Ministry of Health (MoH) of Uganda conducted the Uganda Health Facilities Survey (UHFS) in June 2002 to evaluate the current availability of HIV/AIDS support ser- vices and the health commodities required to offer these services, in addition to assessing the perfor- mance of the logistics system, labo- ratory services, and infection control Introduction and waste management procedures. The U.S. Agency for International Development (USAID) and the U.S. Centers for Disease Control and Pre- vention (CDC) provided financial assistance for the survey. Technical assistance was provided by John Snow, Inc./DELIVER, JSI Research and Training Institute, Inc./AIDS/ HIV Integrated Model District Programme (AIM), CDC/Uganda, and ORC Macro/MEASURE DHS+. The general objectives of the survey were as follows: • Provide the MoH with current information on logistics system performance and stock status of key health commodities prior to the introduction of the new “pull” request and distribution system for the health commodi- ties. • Provide the MoH with current information on the availability of HIV/AIDS prevention, care, and support services, including other STIs, TB, and other OIs. • Provide the MoH with informa- tion on the training of staff who manage and/or provide these services. • Provide a baseline to measure the improvements in the logis- tics system for health commodi- ties from USAID’s support to the MoH through the DELIVER project and other USAID projects. • Provide a baseline for measur- ing the improvements in HIV/ AIDS support services from USAID and CDC support to the MoH through the AIM program. A nationally representative sample of 238 health care facilities was selected from the 2000 Inventory of Health Institutions in Uganda. Facilities at all levels were selected from both the public and private sectors. Twelve government warehouses were also included in this study. The study used a questionnaire to survey clinic managers, clinic staff, laboratory staff, and logistics managers, and to observe clinic infrastructure, labora- tory equipment, and availability of commodities. This document pre- sents a summary of the key findings, conclusions, and recommendations from the survey. The final report con- tains more extensive details about the survey and the findings. This survey will provide the MoH, USAID and its partners and other stakeholders in Uganda with infor- mation on the characteristics and the performance (strengths and weak- nesses) of the logistics system and service delivery at all levels of health care in the country. The results will provide information for planning in- terventions that address problem areas and will provide baseline data, allowing the MoH to monitor progress over time, in order to ad- just strategies as appropriate. Note: The indicators for evaluation of health services used in this report evaluate the systems and cannot be used as a replacement for certifica- tion or needs assessment of particu- lar facilities. Summary of Findings | xix Physical infrastructure Availability of electricity, an on-site water source, and functional latrines are basic components of physical in- frastructure that support infection control at clinical facilities. Figure 1 shows the percentage of all health care facilities in the country (govern- ment and non-government facilities) that have electricity from any source, any on-site water source, and la- trines. Almost 20 percent of facilities have electricity, which is important for op- erating some disinfecting and steril- ization equipment. However, 66 per- cent of facilities have an on-site wa- ter source. The majority of facilities have latrines available (over 90%). Figure 1 Physical infrastructure of health care facilities: Percentage of clinical facilities with electricity, water source, and latrines 0 20 40 60 80 100 LatrinesWaterElectricity Source: UHFS 2002Note: Based on observation at time of survey Electricity is available in less than 20 percent of health facilities in the country. xx | Summary of Findings Infection control “Universal precautions” for infec- tion control at all facilities is the goal of the Ministry of Health of Uganda. This survey has assessed a subset of “universal precautions” that in- cludes availability of soap and wa- ter for hand washing, disposable syringes and sharps containers, dis- infectant soaking of contaminated equipment, and a final process of sterilization or high level disinfect- ing (HLD) procedures (dry heat, autoclave, steam, boiling, or chemi- cal). These items had to be either observed or reported at the facility at the time of the survey. Only 26 percent of clinical facilities in the country met all of the criteria. Figure 2 shows the proportion of fa- cilities that have infection control in place (according to the definition), by ownership and type of facility. Less than 40 percent of hospitals have infection control provisions in place. Non-government facilities are more likely than government facili- ties to have infection control in place (31% and 24%, respectively). The most common reason that fa- cilities do not meet the infection control criteria is that sharps con- tainers were not available (51% of facilities). Figure 2 Percentage of clinical facilities that have soap, water for hand washing, disposable syringes, sharps boxes, disinfectant, and sterilization or HLD capacity, by ownership and type of facility 0 20 40 60 80 100 HC IIHC IIIHC IVDistrict hospital Non- govern- ment Govern- ment Source: UHFS 2002 Note: Based on observation or reports at time of survey Sharps containers were not available in 51 percent of facilities. Summary of Findings | xxi HIV/AIDS services The survey also investigated the com- ponents of each type of service, in- cluding outreach, partnerships, avail- ability of guidelines, and existence of a register to record program in- formation. More detailed findings on the availability of HIV/AIDS sup- port services are available in the full report. Figure 3 shows the proportion of fa- cilities that reported offering services related to HIV/AIDS according to ownership (government versus non- government). These results do not describe the quality of services, only the reported availability of services at each facility. The survey asked about the availability of voluntary counseling and testing (VCT) ser- vices, prevention of mother-to-child transmission (PMTCT) services, management of opportunistic infec- tions (OIs), treatment of sexually transmitted infections (STIs), and diagnosis and treatment of tubercu- losis (in separate bars). The survey also evaluated other HIV/AIDS sup- port services not shown here. Only 7 percent of government facili- ties reported offering VCT services compared with 21 percent of non- government facilities. Very few facili- ties reported offering PMTCT. OI and STI services were more readily available than the other services. Sixty percent of government hospi- tals and clinics reported managing OIs, and a slightly higher percentage of non-government hospitals and clinics. STI services were reportedly available at 67 percent of govern- ment and 85 percent of non-govern- ment clinics. Between 20 and 30 percent of the clinics reported offer- ing diagnosis and treatment of TB. Figure 3 Percentage of clinical facilities reporting HIV/AIDS services, by ownership 0 20 40 60 80 100 Non-governmentGovernment TB RxTB DxSTIOIPMTCTVCT Source: UHFS 2002Note: As reported by facilities xxii | Summary of Findings Government laboratory capacity Figure 4 Percentage of government facilities with laboratory capacity to conduct HIV, TB, and syphilis tests, by type of facility 0 20 40 60 80 100 HC IIIHC IVDistrict hospital Syphilis testTB testHIV test Source: UHFS 2002Note: As reported by facilities testing, with 79 percent of the dis- trict hospitals and 56 percent of the HC IVs reporting the ability to test for HIV. Less than one-quarter of the HC IIIs could conduct any of these tests. It is important to note that, with syphi- lis, many practitioners at lower-level facilities rely on syndromic diagno- sis. The current target of the MOH is for all facilities to have a function- ing laboratory support system. At present, clients seeking laboratory services in the public sector will have to go to urban or semi-urban areas to receive a clinical diagnosis. The 2002 UHFS also looked at spe- cific indicators to measure laboratory capacity to diagnose HIV, TB, and STIs. These indicators are the follow- ing: a) trained laboratory personnel; b) laboratory equipment to conduct the tests including availability of at least one test kit and reagents, a func- tioning microscope, glass slides, and a functioning refrigerator, as appro- priate; c) sufficient power source for refrigerator; and d) infection control items such as soap and water for hand washing, sharps container, dis- posable syringes, and waste recep- tacle with lid and liner. A maximum of two laboratory staff were inter- viewed at each facility to gather in- formation on in-service training for conducting each of the tests. Detailed findings are available in the full re- port. According to the 2000 MOH Inven- tory of Health Institutions in Uganda, all HC IIIs, HC IVs, and hospitals should have the capacity to provide laboratory services for HIV, TB, and syphilis testing. Although laboratory capacity was reviewed in the HC IIs visited, only a small num- ber were found to offer laboratory services for these three diseases and were therefore excluded from the analysis. Among the facilities sur- veyed for the 2002 UHFS, only 27 percent of government facilities re- ported laboratory capacity to con- duct any tests related to HIV/AIDS, TB, or STIs. Overall, laboratory ca- pacity in government facilities was most frequently reported at district hospitals (97%), followed by HC IVs (88%); only 26 percent of HC IIIs reported laboratory capacity for test- ing. Figure 4 shows the percentage of gov- ernment facilities that reported hav- ing the capacity to conduct each of the specified tests by type of facility. Almost all of the district hospitals (97%) reported the ability to test for TB and syphilis, while at the HC IV level, 88 percent could test for TB and 71 percent could test for syphi- lis. The numbers are lower for HIV Summary of Findings | xxiii Non-government laboratory capacity At non-government facilities, 100 percent of HC IVs and 31 percent of HC IIIs reported having the capacity to test for at least one of the three diseases (HIV, TB, and syphilis). Overall, 46 percent of all non-gov- ernment facilities reported the capac- ity to test for at least one of the three diseases. Figure 5 shows the percentage of non-government facilities that re- ported having the capacity to con- duct HIV, TB, and syphilis testing. One hundred percent of the HC IV facilities reported that they could conduct a TB sputum test and a syphilis test. Ninety-five percent of HC IV facilities reported that they could test for HIV. Almost none of the HC IIIs reported the capacity to test for HIV; 26 percent could test for TB and 22 percent could test for syphilis. The specific indicators used to mea- sure laboratory capacity at non-gov- ernment facilities can be found in the full report. Figure 5 Percentage of non-government facilities with laboratory capacity to conduct HIV, TB, and syphilis tests, by type of facility 0 20 40 60 80 100 HC IIIHC IV Syphilis testTB testHIV test Source: UHFS 2002Note: As reported by facilities In government facilities, almost 80 percent of district hospitals and over half of HC IVs had laboratory ca- pacity to test for HIV. In non-government facilities, 95 percent had laboratory capacity to test for HIV. xxiv | Summary of Findings Stockout rates Figure 6 Percentage of facilities at which specific commodities were not available sometime during December 1, 2001–May 31, 2002, by ownership 0 20 40 60 80 100 Non-governmentGovernment TB b lis te r p ac k Be nz at hi ne pe ni cil lin Ch lo ro qu in e Co -tr im ox az ol e De po -P ro ve ra Co nd om s M icr og yn on Source: UHFS 2002Note: Stockouts are defined as observed missing commodities on the day of the survey or a report of missing commodities during the specified period. commodity stockout during the six- month period, among facilities that are supposed to manage the speci- fied commodities. This is shown for all facility types combined (all lev- els, all districts), according to own- ership. In the past six months, a larger pro- portion of facilities had a stockout of Microgynon than the other two contraceptive methods shown (condoms and Depo-Provera). Only about 20 percent of facilities experi- enced a stockout of condoms or Depo-Provera during this period. Over 50 percent of government fa- cilities experienced a stockout of co- trimoxazole, 29 percent of chloro- quine, 46 percent of benzathine penicillin, and 50 percent of TB blis- ter packs. For Microgynon, condoms, and TB blister packs, non-govern- ment facilities were more likely to have stockouts than government fa- cilities. For the essential drugs dis- tributed (co-trimoxazole, chloro- quine, and benzathine penicillin), government facilities were more likely to experience a stockout than non-government facilities. Contra- ceptive methods and TB drugs are supposed to be kept in full supply to meet the needs of all clients. All hospitals, HC IVs, and HC IIIs are supposed to have co-trimoxazole, chloroquine, and benzathine peni- cillin in stock. As can be seen in the figure, this is not happening in prac- tice. Logistics managers at clinical facili- ties strive to ensure a consistent and reliable supply of the commodities required for delivery of health ser- vices. A key indicator used to mea- sure whether a logistics system has achieved this goal is stockout rates or, the opposite, stock availability rates. For this analysis, a stockout occurs when a facility has no supply of a particular brand although there may be supplies of other brands that can be used for the same purpose. When facilities experience stockouts, they are unable to serve clients with a comprehensive range of health commodities or services. At each facility visited for this sur- vey, data collectors interviewed facil- ity staff and reviewed stock records to collect information on stock avail- ability on the day of the visit and for the six-month period preceding the survey (December 1, 2001 to May 31, 2002). A six-month period is re- viewed to capture a more accurate picture of stock availability and to al- low for seasonal trends in consump- tion (e.g., malarial drug use increases during the rainy season) and avail- ability (e.g., periodic shipments of supplies). Figure 6 shows the percentage of fa- cilities that experienced at least one Summary of Findings | xxv Stock status Figure 7 shows the levels of stock available (average number of months of stock on hand) at each type of government facility for a se- lected number of commodities. An assessment of the stock status of health commodities is an important complement to stockout rates and offers an estimate of how long the commodities will be available. Re- viewing stock status provides a more comprehensive picture of how com- modities are being managed by the logistics system. To ascertain whether stock levels of health commodities are adequate, the average number of months of stock on hand is calculated. To do this, data collectors must first calcu- late a rate for the average monthly consumption or issues of products. This rate is then compared with the physical inventory at each facility on the day of the visit to establish the number of months of stock available to be dispensed to clients or issued to other facilities. The indicator shows how many months the current stock will last to serve clients. It can also identify situations where com- modities are overstocked, which can lead to commodity expiration and wastage, or understocked, which can lead to rationing of commodities or stockouts. Figure 7 shows the average number Figure 7 Average number of months of stock on hand (for specified health commodities) at government facilities on the day of the survey, by type of facility of months of stock on hand at each type of facility. Two of the contracep- tive methods, Microgynon and con- doms, were significantly overstocked on the day of the visit, with 12 months or more of stock at all of the facilities. For condoms, these high stock levels were likely due to a year's supply of condoms being distributed to facilities between March and July 2002, during the period the survey was being carried out. For most of the remaining commodities, the stock levels were low at the higher level facilities, such as warehouses, and high at the lower level facilities, where they need to be to serve cli- ents. Most of these commodities were stocked according to the estab- lished inventory control levels, with the exception of co-trimoxazole, which was understocked at all lev- els, and TB blister packs, which were overstocked at the HC III level. 0 2 4 6 8 10 12 HC II HC III HC IV District hospital District warehouse TB b lis te r p ac k Be nz at hi ne pe ni cil lin Ch lo ro qu in e Co -tr im ox az ol e De po -P ro ve ra Co nd om M icr og yn on Source: UHFS 2002 Stock levels were low at the higher-level facilities, such as warehouses, and high at the lower-level facilities, where they need to be to serve clients. xxvi | Summary of Findings Evaluation criteria for HIV/AIDS services VCT PMTCT OI STI TB Dx TB Rx 0 20 40 60 80 100 Training, commodities, and equipment Training Commodities and equipment Total facilities offering specified service Source: UHFS 2002 cility had at least two HIV test kits available for use and a func- tioning refrigerator to store cer- tain HIV test kits—with a suffi- cient and consistent power source—on the day of the visit. • For STI and OI services, the fa- cility had at least one dose of any of the drugs that the survey looked at for the treatment of STIs or OIs on the day of the visit. The STI drugs included ciprofloxacin (Cipro), benza- thine penicillin, doxycycline, and metronidazole (Flagyl). The OI drugs included fluconazole (Diflucan), co-trimoxazole (Sep- trin), and acyclovir (Zovirax/ Cyclovax). • For TB diagnostic services, the fa- cility had a functioning micro- scope and slides on the day of the visit. • For TB treatment services, the fa- cility had any stock of TB blister packs for the treatment of TB on the day of the visit. Figure 8 shows the percentage of all health care facilities (government and non-government) visited that re- ported offering specific HIV/AIDS support services. Facility staff re- ported that OI and STI services are available at more than half the fa- cilities. TB diagnosis and treatment are available at approximately one- third of the facilities, and VCT and PMTCT services are available at only a small proportion of the facilities. The lines on the bars show the ac- tual availability of these services. Figure 8 Percentage of facilities offering specific HIV/AIDS services, and percentage meeting evaluation criteria for training, commodities, and equipment necessary to offer the services Quality health care must include a minimum level of commodities, ap- propriate equipment, and trained staff. The figure evaluates selected HIV/AIDS services at facilities in Uganda by applying a set of criteria created for this study. The services evaluated include voluntary testing and counseling (VCT), prevention of mother-to-child transmission (PMTCT), management of opportunistic infec- tions (OI), treatment of sexually transmitted infections (STI), and tu- berculosis diagnosis (TB Dx) and treatment (TB Rx). The evaluation criteria for offering each service, as defined here, include the presence of trained staff and the availability of the commodities and equipment necessary for offering each service. Training is measured by the presence of a staff person working in each ser- vice area who has received in-service training in the past three years re- lated to that service. For service ar- eas where laboratory capacity is re- quired (VCT, PMTCT, and TB diag- nosis), the criteria require facilities to also have at least one laboratory staff person who has received in-ser- vice training in laboratory diagnosis using (where applicable) HIV test kits or TB sputum testing procedures in the last three years. The criteria for commodities and equipment are defined for each ser- vice as follows: • For VCT/PMTCT services, the fa- Summary of Findings | xxvii The lines with squares on the bars show the percentage of facilities that have a staff person trained to offer the specified service. The majority of facilities offering OI, STI, TB treat- ment, and VCT services have a staff person trained to offer the services, while less than half the facilities of- fering PMTCT and TB diagnosis have a staff person trained to offer those services. The lines with circles show the per- centage of facilities that have the commodities and equipment neces- sary to offer the specified service on the day of the survey. Fifty percent or more of the facilities that reported offering VCT, OI, STI, TB diagnosis, and TB treatment services also had the commodities and equipment needed to provide the service on the day of the visit. However, those that reported offering PMTCT services were usually lacking the commodi- ties and equipment needed. Finally, the lines with diamonds show the percentage of facilities that have both trained staff and the com- modities and equipment needed to provide the specified service, i.e., the minimum requirements to offer the service. Without trained staff and the required commodities and/or labo- ratory equipment needed to provide the service, a facility is not, in fact, able to offer the service. Approxi- mately half the facilities that re- ported offering OI, STI, and TB treat- ment meet the evaluation criteria of this study. Only a minority of the fa- cilities offering other services meet the evaluation criteria. Among all of the facilities, less than 5 percent can offer VCT with the training, commodities, and equip- ment criteria used here. Less than 35 percent can offer an OI service ac- cording to this definition. Among all the facilities in the country, less than half offer STI services that meet the evaluation criteria. TB diagnosis and treatment are offered at less than 20 percent of all facilities. It is important to note that the crite- ria shown in the figure are very le- nient. A stricter set of criteria could be applied to represent the actual availability of services. Facility staff reported that OI and STI services are avail- able at more than half the facilities. TB diagnosis and treatment are available at one-third of the facilities. VCT and PMTCT services are available at a small pro- portion of facilities. Summary of Findings | xxix Findings, conclusions, and recommendations A. Findings 1. The Ministry of Health (MoH) has set a target that all health units provide HIV voluntary counseling and testing (VCT) services. Currently, about 11 percent of all facilities report that they provide VCT services. However, less than half these fa- cilities have trained staff (re- ceived in-service training in the past three years) and equipment for services, i.e., at least two HIV test kits and a working refrigera- tor (4% of all facilities). 2. Effective management of STIs and opportunistic infections in all health units is another target of the MoH Strategic Plan. Cur- rently, 72 percent of all facilities report that they provide STI ser- vices. Staff trained in syndromic management (received in-ser- vice training in the past three years) are present in 71 percent of facilities. Medication for at least one of the common STIs is available in only 82 percent of facilities. Both trained staff and commodities are available in only 60 percent of facilities. Similar findings were reported for OI management. 3. The report defined infection control as the presence of soap and water for hand washing, dis- posable syringes, ability to soak equipment in a disinfectant, and some method of high level dis- infection (e.g., boiling). Less than half of all hospitals met these criteria, and only a few small facilities were found able to control infection according to this defi- nition. 4. A national target for tuberculosis control is 100 percent national coverage with community DOTS. Cur- rently in Uganda, 28 percent of facilities provide diagnosis of TB by trained personnel and have adequate laboratory facili- ties. Regarding treatment for tuberculosis, only 45 percent of facilities have trained personnel and any medication. 5. Capillus and Serocard were found to be the most commonly used HIV test kits. Capillus was used most often as the primary test. Use of the other six test kits studied was inconsistent. B. Conclusions 1. The Health Sector Strategic Plan lays out a number of important goals for 2005. The 2002 Uganda Health Facilities Survey measures progress towards these goals. For the goals that can be evaluated by this study, it was found that most health facilities in Uganda are far from reaching the targets. 2. Training remains an important challenge, especially in areas of clinical care such as HIV that are changing rapidly. There is a need for in-service training in all areas of HIV, STI, and TB ser- vices. 3. Availability of services is strong at the district level but weak at smaller facilities (HC II and III). New services such as VCT and PMTCT are available at very few of the smaller facilities. Even for long-standing programs like tu- berculosis treatment and con- trol, most small facilities do not provide services. 4. While this study provides a na- tional picture of provision of care in the government and non- government health care delivery system, it does not examine the utilization of services. Commer- cial pharmacies provide medica- tion, especially in towns, but were not covered in this study. I. Service Provision It is thought that there are serious financial barriers to the purchase of medications and commodities in Uganda. Universal precautions for infection control are not being followed in most health care facilities. xxx | Summary of Findings Access to medication through these pharmacies should im- prove the health care picture provided by this report. How- ever, it is thought that there are serious financial barriers to the purchase of medications and commodities in Uganda. 5. Universal precautions for infec- tion control are not being fol- lowed in most health care facili- ties. C. Recommendations 1. Efforts to improve the quality of and access to care for deadly and highly prevalent infectious dis- eases such as syphilis and tuber- culosis should receive the highest A. Findings 1. Less than 50 percent of Ugandan health facilities had stockouts of the commodities surveyed in the six-month period preceding the survey. However, at district hos- pitals, HC IVs, and HC IIIs, many of the stockouts were of long duration. Furthermore, many of the facilities that had stockouts during the survey pe- riod were not keeping their stock priority as the country moves toward develop- ment of the health sys- tem and health care reform. While efforts to extend PMTCT and anti-retroviral therapy to the en- tire population are important, deadly and debilitating diseases like syphilis and tuberculosis are endemic and under-treated in the country. 2. Policy guidelines for the provision of VCT and PMTCT services must be established. This includes the selection of HIV test kits and anti-retroviral drugs and the de- velopment of protocols for their distribution and management (with consideration for electric- ity and refrigeration limita- tions). 3. Laboratory capacity to manage and conduct the tests to support VCT and PMTCT services will also need to be improved. 4. Service providers will need to be trained in the provision of VCT and PMTCT services, which in- volve new protocols, procedures, and skills. II. Health Commodity Management and Logistics System Performance cards up to date, particularly re- garding contraceptive methods. The most common reason given by facilities for the occurrence of stockouts was that a higher level facility did not send the com- modities in time. 2. Microgynon and condoms were significantly overstocked at all levels. Co-trimoxazole, fluco- nazole, metronidazole, doxycy- cline (at all but HC IIs), and ciprofloxacin (at all but HC IIs) were understocked at all levels. TB blister packs were overstocked at the HC III level. Other commodities were stocked appropriately on the day of the survey, with lower stock levels at the higher level facilities and higher stock levels at the lower level facilities. 3. Although the majority of facili- ties reported using stock cards, a smaller percentage of facilities were actually found to be using the cards on the day of the sur- vey. 4. Approximately one-quarter of the facilities place commodity orders about every two months, which is the same frequency as the new pull system protocol. These facilities are, to some de- Deadly and debilitating diseases like syphi- lis and tuberculosis are endemic and under- treated in the country. Some facilities are, to some degree, already assessing their commodity needs to place orders. Summary of Findings | xxxi gree, already assessing their com- modity needs to place orders. 5. In both government and non- government facilities, at all lev- els of the system except district warehouses and some district hospitals, health commodities are not routinely managed by staff trained in logistics. How- ever, staff at higher levels of the logistics system are more likely to have received formal training in logistics management than staff at lower levels. Many staff learn to perform daily logistics tasks informally on the job. 6. Supervisory visits occur regularly and include limited monitoring of logistics tasks such as record keeping and stock management. Supervision is more routine at the lower levels of the health care system—the majority of HC IIs and HC IIIs received supervi- sory visits during the month pre- ceding the survey. B. Conclusions 1. The frequency of stockouts in the public sector is high, includ- ing full-supply products. These stockouts include critical drugs required for contraception and disease prevention and to treat STIs, TB, and other infectious diseases. 2. Commodity availability in the public sector is inconsistent and insufficient. The data on levels of stock on hand show that in- ventory management practices have led to over- and under- stocked facilities. This can lead to stockouts and product wast- age through expira- tion and the inability of facilities to meet cli- ents’ needs. 3. Health commodity security is additionally threatened by inad- equate record keeping and infor- mation systems. 4. The district warehouses do not maintain large quantities of health commodities in stock and serve primarily as pass- through points from the Na- tional Medical Stores (NMS) at the central level to the store- rooms at the health sub-districts (HSD). 5. Performance improvement in- terventions in logistics manage- ment are needed to ensure a smooth transition to a pull sys- tem. In light of the rapidly changing MoH logistics system, the information and processes taught to these staff may be in- consistent or outdated, particu- larly for ordering and inventory management. C. Recommendations 1. Improve product availability by collecting key logistics data through the health management information system (HMIS). In- formation at the facility level is needed to evaluate and justify the orders placed. To ensure that the logistics data needed to make forecasting, ordering, and procurement decisions are col- lected through the existing infor- mation system, the commodity order forms should be rede- signed to include stock on hand at the facility level. (Note: since the survey was conducted, the order forms have been re- worked, in part due to the pre- liminary findings from this sur- vey.) 2. Analyze data collected through the HMIS and use data for deci- sionmaking at the central level (e.g., for forecasting and procure- ment). At present, the data are not systematically collected and analyzed at the central level. As NMS takes over forecasting and procurement functions for health commodities, they will need logistics data to forecast future needs. The MoH will also need this information for bud- geting purposes. 3. Establish protocols for transfer- ring overstocked commodities and Health commodities are not routinely man- aged by staff trained in logistics. Stockouts are reported most frequently be- cause a higher-level facility did not send the commodities in time. xxxii | Summary of Findings disposing of expired products. A preliminary recommendation of the survey was to schedule a na- tional “dejunking” of ware- houses and health centers. This has been scheduled for 2003. Protocols should be established to create a mechanism for facili- ties to transfer stocks between facilities to avoid stock imbal- ances. 4. Decentralize the transportation of health commodities. NMS and the MoH should investigate the cost-benefit of delivering sup- plies directly to the HSD level, rotating through districts every two months. (Note: Since the survey was conducted, DELIVER carried out a cost study in De- cember 2002 to evaluate this option. Detailed findings are available from DELIVER.) 5. Establish a human resources plan to identify staff needs and fund- ing to meet these needs. Staff shortages have affected product availability, reporting, and over- all logistics system performance. 6. Create a performance improve- ment plan of action for logistics management to ensure commod- ity security and quality of care. This activity can be imple- mented largely through on-the- job training and during super- vision visits by reinforcing good commodity management prac- tices. The plan should include an added emphasis on monitoring and evaluation of logistics activi- ties and system performance. Su- pervisory visits should be used as a cost-effective means of re- inforcing skills and for on-the- job training of staff. Because routine supervision is already taking place, it can be used as a tool for monitoring logistics sys- tem performance in order to re- solve problems quickly and for performance improvement in- terventions for staff. xxxiv | Map of Uganda Chapter 1 Introduction This report outlines the design, implementation, findings, conclusions, and recommendations of the Uganda Health Facilities Survey conducted in June 2002. This survey and report are a result of collabora- tive efforts of the Uganda Ministry of Health (MoH), the U.S. Centers for Disease Control and Prevention (CDC)/Uganda, the U.S. Agency for International Development (USAID)/Uganda, John Snow, Inc.’s DELIVER Project, JSI Research and Training Institute, Inc.’s AIDS/HIV Integrated Model District Pro- gramme (AIM), and ORC Macro’s MEASURE DHS+ Project. Further description of each partner can be found in Appendix H. This introductory chapter provides background information on the health care delivery system in Uganda. This background includes: • Structure of the health care delivery system • Public health commodity logistics system • National Strategic Framework for HIV/AIDS • Health Sector Strategic Plan 1.1 Structure of the health care delivery system The Government of Uganda (GoU) and the MoH are currently implementing changes to their health care delivery system to reduce morbidity and mortality from major health problems. Most significantly, they are in the process of decentralizing financial and decision-making authority for the provision of basic health services. This includes many logistics functions and control over medical personnel from the MoH to the districts, health sub-districts (HSD), and service delivery points (SDP) throughout the country. The Constitution and Local Government Act of 1997 allocated the responsibility and authority for delivery of health services to the level of the district and other local authority entities such as municipali- ties. Since that time, the MoH has been downsized and restructured. As part of the reform process in gov- ernment, the MoH introduced a Sector Wide Approach (SWAp) as the guiding principle in health planning and resource mobilization. The purpose of SWAp is to provide much-needed funds to the MoH while developing MoH capacity in making procurement decisions based on their priorities. Planning and management of health services is now being done by the MoH together with districts, other government ministries and development partners. The MoH Health Sector Strategic Plan (HSSP) 2000/01–2004/5 was launched in August 2000. Dur- ing the first year of the HSSP, the emphasis was to establish policies, structures, and systems for imple- menting activities in the HSSP. The recent Annual Health Sector Performance Report (AHSPR) (September 2001) indicates that this has been achieved. The same report also states that the health sector is under-funded, operating with less than half of the required funds to deliver the Uganda National Mini- mum Health Care Package (UNMHCP), a set of technical health care programs that are “considered to have a high impact on reducing morbidity and mortality from the major contributors to the disease burden using existing resources.” According to the MoH Inventory of Health Institutions in Uganda (March 2000) and the HSSP, na- tional health service outlets include 1,738 facilities, of which 1,226 are government-managed, 465 are Introduction | 1 managed by non-governmental organizations (NGO), and 47 are private. The facilities include 104 hospi- tals (57 government, 44 NGO and 3 private), 250 health centers (179 government, 68 NGO and 3 pri- vate), 2 palliative care facilities (1 government, 1 NGO), and 1,382 others1 (989 government, 352 NGO and 41 private). The health centers throughout the country are categorized as Health Center II, Health Center III, and Health Center IV. Each facility category depends on the administrative zone served (i.e., parish, sub- county, and health sub-district) and the different types of services they provide. A Health Center Grade II (HC II) serves a parish with a population of approximately 5,000 people. It provides outpatient care, antenatal care, immunization, and outreach. An HC II is supposed to be staffed by one enrolled nurse, one enrolled midwife, and two nursing assistants. According to the HSSP, all HC IIs provide community-based preventive and promotive health service. A Health Center Grade III (HC III) serves a sub-county with a population of approximately 20,000 people. It provides all the services of an HC II plus inpatient care and environmental health. It is usually staffed by one clinical officer, one enrolled nurse, two enrolled midwives and one nursing assistant, one health assistant, one laboratory assistant, and a records officer. According to the HSSP, all HC IIIs pro- vide the services offered in an HC II plus maternity services, inpatient health services, and laboratory ser- vices. A Health Center Grade IV (HC IV) serves a health sub-district with a population of approximately 100,000 people. It is the headquarters unit of the health sub-district. It provides all the services of an HC III, plus surgery, supervision of the lower-level units, collection and analysis of data on health, and devel- opment of plans for the health sub-district. Each HC IV should have at least one medical officer, two clinical officers, one registered midwife, one enrolled nurse, one enrolled midwife, one registered com- prehensive nurse, two nursing assistants, one laboratory technician, one laboratory assistant, one health inspector, one dispenser, one public health dental assistant, one anesthetic officer, one assistant health educator, one records assistant, one accounts assistant, and two support staff. The HSSP calls for all HC IVs to provide emergency surgery and blood transfusion services as well as all the services offered at HC IIIs. Government hospitals are divided into three categories: national referral, regional referral, and dis- trict/rural/general hospitals. District/rural/general hospitals are staffed with general doctors. The goal for 2005 outlined in the HSSP lists services to be provided as all services offered at the HC IV level plus in- service training, consultation, and research for community-based health care programs. Regional referral hospitals have specialists in a limited number of fields and are also teaching hospitals. The HSSP states that they will offer services as described for the general hospital plus specialist services in psychiatry, ear, nose, and throat (ENT), ophthalmology, dentistry, intensive care, radiology, pathology, and higher level surgical and medical services. Finally, there are two national referral hospitals located in Kampala dis- trict. These are also teaching/research hospitals and provide comprehensive specialist services. 1.2 Public health commodity logistics system To ensure that the Uganda National Minimum Health Care Package (UNMHCP) can be provided throughout the health care delivery system, it is essential to have health commodities available at all lev- els of the system. Currently, in Uganda, procurement of health commodities is carried out through private vendors, donors, and faith-based organizations. This process begins with arrival at the port of entry (En- tebbe or by train from Mombasa) where the consignments are approved by the National Drug Authority (see Section 3.1.1 for further discussion on inputs according to commodity type). The approval time for 1 Others includes dispensaries, maternity units, sub-dispensaries, and dispensary-maternity units. 2 | Introduction consignments that enter the country varies from one day to one month (Raja, Wilbur, Blackburn, 2000). For the public sector supplies, the commodities are then moved to the National Medical Stores (NMS) in Entebbe. Various vertical programs utilize the NMS to pack and deliver commodities to the district ware- houses (N=56). The district warehouses are responsible for delivering to the health sub-district (N=214). Individual service delivery facilities (N=1,226) then collect their supplies from the health sub-district store that is commonly housed in the sub-district hospital. The flowchart in Figure 1.1 illustrates the flow of commodities and the number of levels that exist in the supply chain for public health commodities. This chart also shows the large number of parallel supply chains that currently exist. Further discussion of the logistics system can be found in Chapter 3. 1.3 National Strategic Framework for HIV/AIDS Uganda has made important progress in creating awareness of HIV/AIDS, promoting testing, and facili- tating care for those infected. However, more needs to be done to further reduce HIV infection and miti- gate the socio-economic impact of the epidemic at individual, household, and community levels. This section provides a context for the findings of this report by providing a history of the HIV/AIDS planning and health care services in Uganda. Various sectors and line ministries have played an important role in HIV/AIDS prevention and care and in mitigating the socioeconomic impact of HIV/AIDS during the last decade. The National Strategic Framework recognizes that HIV/AIDS should be integrated into all aspects of development work, service provision, planning, and implementation by line ministries, local governments, religious and cultural or- ganizations, the private sector and NGOs/CBOs (community-based organizations). The framework is the national guideline and source of inspiration for sector-wide HIV/AIDS planning and implementation and emphasizes collaboration and co-ordination among all stakeholders working towards HIV/AIDS preven- tion and care. Openness, political support, and commitment at the highest level of government have char- acterized the national response to the epidemic. The first response of the GoU was the establishment of the National Committee for the Prevention of AIDS (NCPA) in 1985. In October 1986, the AIDS Control Programme (ACP) was established in the MoH. This report provides information on activities and services that are under the responsibility of the ACP and that are frequently based from health facilities. These include the provision of HIV/AIDS in- formation, education and communication; provision of patient care and counseling; and prevention and control of other STIs. In 1990/91, the government adopted a Multi-sectoral Approach to the Control of HIV/AIDS (MACA) for dealing with the epidemic. This approach emphasized the notion of collective responsibility of individuals, community groups, different levels of government and other agencies for the prevention of HIV infection. It also emphasized building and strengthening organizational capacity among government sectors and non-governmental organizations to sustain AIDS activities. The Uganda AIDS Commission was established in 1992 by an act of Parliament to address the HIV/AIDS problem in this broad context. The National Operational Plan for HIV/AIDS prevention, care, and support (1994–1998) was drawn up to provide guidance for agencies involved in HIV/AIDS-related work. Introduction | 3 Figure 1.1 Public health commodity logistics system in Uganda Freight Forwarders USAID DFID UNFPA KfW IPPF FP KfW Italy WB TB DANIDA GoU Churches ED IDA/WB STI UNICEF Rotary Int’l GoU Vaccines Vitamin A Anti-retroviral drugs Port of Entry Mombasa Entebbe NDA CUSTOMERS FPAU MSI KPI/CMS Private Vendors NMS (Entebbe) NMS (Kampala) JMS UNEPI Private Vendors RH Office HEALTH FACILITIES GoU and NGO DISTRICTS UNAIDS UNICEF Source: Raja, Wilbur and Blackburn, DELIVER Uganda Logistics Systems for Public Health Commodities: An Assessment Report, May 2000. Note: See pp. xv–xvi for explanation of acronyms. 4 | Introduction The Strategic Framework for HIV/AIDS prevention and care for the 1998–2002 period has seven goals: • Stop the spread of HIV infection; • Mitigate the adverse health and socio-economic impact of the HIV/AIDS epidemic; • Strengthen the national, district, and lower level capacity to respond to the HIV/AIDS epidemic; • Establish the national information base on HIV/AIDS; • Strengthen the national capacity to undertake research relevant to HIV/AIDS; • Provide care, support, and protection of rights of PLHAs; and • Reduce the vulnerability of individuals and communities to HIV/AIDS, with a focus on children, youth, and women. Following a period of implementation, the current Strategic Framework was revised to minimize duplication of efforts, engender more focused interventions, and simplify monitoring and evaluation. The present document also places HIV/AIDS in the broader context of social and economic development. The original seven goals were therefore regrouped as follows: • Reduce the rate of HIV infection; • Mitigate the health and socio-economic impacts of HIV/AIDS at individual, household and community levels; and • Strengthen the national capacity to respond to the epidemic. 1.4 Health Sector Strategic Plan Based on the Poverty Eradication Action Plan, health sector policy, and inputs from stakeholders and re- lated ministries, the MoH developed the Health Sector Strategic Plan for 2000/1–2004/5 (HSSP). The goals and objectives outlined in the plan are intended to reduce morbidity and mortality in Uganda. The plan provides a framework for work planning, financing, and integrating the activities in the plan with related support services. Monitoring and evaluation of the plan will be conducted by the National Health Assembly and will track 45 input, process and output indicators. The plan outlines objectives, indicators, and means of verification in a logframe format in the areas of implementing the National Minimum Health Care Package, developing the health care delivery system, integrating support systems, calculating costs, securing financing, and implementing the plan itself. Although the HSSP is a detailed and comprehensive plan for the entire health sector, this report highlights HIV/AIDS, STI, and tuberculosis (TB) services. The HSSP’s overall objective for STI and HIV/AIDS is “to prevent and control STD/HIV/AIDS transmission and mitigate the personal effects of AIDS.” The national targets associated with the STI/HIV/AIDS objective that are addressed by the results of this survey include the following: • Providing HIV voluntary counseling and testing services in all health units (HC III and above); • Providing effective management of STIs and opportunistic infections in all health units; • Achieving 100 percent compliance with universal infection control procedures in all health units, public and private; • Providing counseling and psychosocial support to individuals and families affected by HIV (MOH, 2000). Introduction | 5 6 | Introduction For tuberculosis, the overall objective laid out in the HSSP is the “control of TB through early diagnosis and treatment.” The national targets (which are addressed by the results of this survey) to be achieved by the end of the plan period include the following: • Achieving 100 percent national coverage with community DOTS (Directly Observed Treatment, Short-course) strategy; and • Achieving an increase in TB treatment and cure rate (TB success rate) from 60 to 80 percent (MOH, 2000). The HSSP provided the framework for the development of the survey instrument and for the report- ing of the data in this report. Chapter 2 Survey Objectives and Methods 2.1 Survey objectives This nationally representative survey of government and non-governmental facilities serves to help the Ministry of Health (MoH) monitor and evaluate their HIV/AIDS care and support programs. The general objectives of the survey were as follows: • Provide the MoH with current information on logistics system performance and stock status of key health commodities prior to the introduction of a new “pull” request and distribution system for health commodities; • Provide the MoH with current information on the availability of HIV/AIDS prevention, care, and support services, including other STIs, TB and other opportunistic infections (OIs). • Provide the MoH with information on the training of staff who manage and/or provide these services. • Provide a baseline to measure the improvements in the logistics system for health commodities from USAID’s support to the MoH through the DELIVER project and other USAID projects. • Provide a baseline for measuring the improvements in HIV/AIDS support services from USAID and CDC support to the MoH through the AIM (AIDS/HIV Integrated Model Programme) Project. The Commodity Management section of the survey was designed to assess the performance of the logistics systems that manage key health commodities and the availability and current stock of a selected list of health commodities. It involved the collection of quantitative and qualitative data about the per- formance of the logistics system, the quality and flow of information through the system, and commodity availability at all levels of the health care system. The quantitative data are used to calculate key logistics indicators that are described in Section 2.6. The survey also assessed certain activities (i.e., training, or- dering, distribution, transportation, supervision, etc.) within the system so that recommendations could be generated to improve services and commodity availability at the district level and service delivery points (SDPs). The Service Provision section of the survey was designed to assess availability and management of key HIV/AIDS services, infection control in health care facilities, and laboratory capacity. Data was col- lected on the types of services offered, staff training, and infrastructure (infection control, protocols, labo- ratory capacity) relevant to providing good quality services for HIV/AIDS. 2.2 Methodology A literature review was carried out to evaluate the types of surveys that had recently been conducted in Uganda and to review the current status of HIV/AIDS activities in Uganda. This information informed the development of the survey objectives and instrument. A survey manual was also developed to accompany the instrument, both to assist with the training of data collectors and to serve as a resource document for Survey Objectives and Methods | 7 collectors while in the field. Data collectors were recruited in Uganda, and a total of 27 MoH staff and independent consultants were selected to carry out the survey at sampled sites throughout the country. After the initial reviews and revisions of the instrument, a four-day training session was carried out for all data collectors to explain the objectives of the survey and to train collectors on how to use the in- strument, including general information on logistics and HIV/AIDS support services. The group also made additional revisions and adaptations to the instrument and manual to meet local needs. The entire team then carried out a field test of the instrument at health facilities in Kamuli district, near Kampala. The experiences of the field test were discussed extensively and final revisions were made to the instru- ment and the accompanying manual for the actual data collection. The Director General of Health Ser- vices of the MoH sent a letter of introduction to each of the survey sites selected in the sample (see Ap- pendix I) in advance of the teams’ arrival. Each team presented themselves at the District Health Office to introduce the survey and to plan the logistics necessary to visit the selected facilities. Each District Health Office was asked to assign a district representative to accompany the data collection teams to facilitate the survey. Key informant interviews were also carried out with certain MoH staff at the central and periph- eral levels to provide a more thorough understanding of the MoH’s strategic plans in the areas of HIV/AIDS services, logistics management, and health commodity security. Each questionnaire completed by the teams was carefully reviewed as they returned to Kampala prior to data entry. Data entry screens were developed using the CDC’s Epi Info software. Each question- naire was entered twice in order to clean the data and correct any data entry errors. Upon completion of the fieldwork and data entry and cleaning, the final sample of facilities was reviewed and weighted within each district. A final cleaning of the data was completed to support data analysis. 2.3 Sample design The sample was designed to produce national estimates that describe the health care facilities in the coun- try. The sampling frame was designed to include approximately 200 facilities, including 80 non- governmental facilities, in 12 districts. The 12 sampled districts included six AIM-designated districts and six non-AIM districts, in order to allow for comparisons to be drawn over time between those districts receiving technical assistance from AIM and those that do not. AIM districts were separated from the non-AIM districts and random samples of districts were selected within each group. AIM districts were over-sampled in such a way as to produce stable estimates for the strata.1 Within each of the selected districts, representative numbers of governmental and non- governmental facilities were selected to represent the services and health commodities available in each district. Also within each district, health facilities were stratified by type of facility (district hospitals and health center IVs, IIIs, and IIs), and proportional numbers of each type were selected to provide a com- plete picture of the facilities serving clients in each district. The district warehouse, where products and supplies are stored while in transit from the National Medical Stores in Entebbe to the health sub-districts, was also visited in each district. Only the commodity management section of the instrument was com- pleted at the warehouses since no services are offered there. 2.3.1 Sample description This section describes the sample design procedures implemented in the Uganda Health Facilities Survey 2002. The frame used in the selection for this sample includes health facilities (government and non- 1 One objective of this survey was to provide baseline estimates for AIM (AIDS/HIV Integrated Model Dis- trict Program), a USAID-funded project which focuses on HIV/AIDS interventions in certain districts in the country. Therefore, the sampling strategy included over-sampling of these districts. Analysis of the AIM districts is not pro- vided in this report. 8 | Survey Objectives and Methods government) located in the 45 districts in Uganda listed in the 2000 Uganda MoH Inventory of Health Institutions. However, Uganda has undergone redistricting since 2000, and an updated Inventory of Health Institutions was not available at the time of the survey. For institutions selected into the sample that were in newly created districts, replacements were selected of the same ownership and level in the originally selected district. Each district was classified as an AIM or a non-AIM district: 10 districts were classified as AIM districts and the rest as non-AIM districts. Each facility was classified by type of facil- ity (district hospital, HC IV, HC III, HC II, and district warehouse) and by ownership (government and non-government). Six of the 10 AIM districts and six of the 35 non-AIM districts were selected for the sample of fa- cilities. The selection of six districts, in each of these two groups, was done with probability proportional to size (size considered as the number of facilities in the district). After facility stratification was imple- mented, a target of 20 selected facilities was ob- tained in each district. Actually, the number of facilities in two districts (Pader and Ntugamo) was almost or equal to this number of 20 facili- ties. The selection of the target of facilities in each district was done systematically. It should be pointed out that there is only one district warehouse in each district; therefore, it was de- cided that every district warehouse should be in- cluded in the facilities sample. The final sample is described in Table 2.1. A total of 238 facilities were selected. It should be noted that Kampala district was not selected into the sample. This was by chance and the result of random sampling. It is known that many unique health care delivery fa- cilities exist in Kampala district. The services of those facilities are not included in the estimates of this report. Nonetheless, the sample is considered un- biased and representative of the country. It is certain that some of the estimates would have been higher if Kampala had been included in the sample. These differences should be considered with the 95 percent confidence intervals that can be calculated based on the standard error presented in Appendix A. Table 2.1 Sample of facilities Final facility sample size, by ownership, program area, and facility type, Uganda Health Facilities Survey 2002 Ownership/program area/facility type Number of facilities Ownership Government 190 Non-government 48 Program area AIM 118 Non-AIM 120 Government Non-government Facility type District warehouse 12 NA District hospital 8 NA HC IV 21 9 HC III 97 27 HC II 52 12 NA = Not applicable 2.3.2 Weights and minimum sample sizes for stable estimates The design of the survey provides for over-sampling of some facilities, which allows for different weights to be attached to various facilities. All estimates in this report are accordingly weighted. Numbers of fa- cilities are unweighted to allow the reader to appreciate the numbers of observations on which estimates are calculated. While the results of the Uganda Health Facilities Survey 2002 have been judged to be robust, some caution in the use of the data is warranted rated to estimates based on a small number of facilities. This report provides estimates based on denominators of no less than ten facilities. An asterisk is used in cells of tables when the estimates are based on denominators less than ten. This rule is relaxed for hospital es- timates. Because of the few numbers of hospitals in the country, estimates are provided with denomina- tors as small as five facilities. Survey Objectives and Methods | 9 2.4 Data collection teams Because of the sample size required to ensure a nationally representative number of health facilities, twelve teams of 2 to 3 data collectors were assembled to carry out the data collection during the two-week period of fieldwork. The teams consisted of a mix of senior and mid-level MoH staff, plus independent consultants hired specifically to carry out this survey. Upon reaching the District Health Office, each team was also assigned a MoH district representative for the duration of the data collection to facilitate the vis- its to facilities within each district and to serve as an additional team member for data collection. At the start of the facility visit, the team met with the person in charge of the health facility or other knowledgeable person in order to understand the organization of the service delivery system for the HIV/AIDS, STI, opportunistic infections and tuberculosis services, as well as laboratory and pharmacy activities. This included designating whom to interview, where the services are being provided, where the laboratory is located, and where medications and supplies are stored and managed. 2.5 Survey instrument The survey instrument is a structured questionnaire divided into two parts. Part I, Facility Infrastructure and Services Offered, collected data on HIV/AIDS and related services, sharps management and infection control, and laboratory capacity. Part II of the instrument, Commodity Management, collected data on health commodity logistics system performance and commodity availability at health facilities. The instrument included sections on the following areas: 1. Availability of key HIV/AIDS prevention, care and support services, including volun- tary counseling and testing (VCT), prevention of mother-to-child transmission (PMTCT), youth-friendly programs, programs targeted for orphans and vulnerable children, social support and post-test services for HIV-positive patients and their fami- lies, home-based care, management of opportunistic infections (OIs) in HIV/AIDS pa- tients, STIs, and diagnosis and treatment of tuberculosis (TB); 2. Sharps management and infection control; 3. Laboratory diagnostics, including the capacity to conduct HIV, TB, and syphilis test- ing; 4. Pharmacy and health commodity management; 5. Availability of essential medicines and supplies. Part II of the instrument on commodity management is derived from a standardized assessment tool developed by the DELIVER project called the Logistics Indicators Assessment Tool (LIAT). The LIAT is a primarily quantitative assessment tool that can be used to collect data to calculate key logistics indica- tors for program monitoring and for evaluating program impact. Part II included questions about key lo- gistics operations such as managing and reporting logistics data, logistics management information sys- tems, inventory control, ordering supplies, distribution, transportation, and training and supervision in logistics. The list of health commodities studied for this survey includes several indicator commodities from seven categories of products: HIV test kits, contraceptives, drugs for treating opportunistic infections, malarial drugs, STI drugs, anti-retroviral drugs, TB medications, and several consumable supplies (see Appendix D). The list represents the range of commodities required to offer the HIV/AIDS services that were studied during this survey and are also representative of the wide range of health commodities man- aged through the MoH logistics systems. 10 | Survey Objectives and Methods Survey Objectives and Methods | 11 An additional short interview questionnaire was added to solicit information from individual pro- viders of HIV/AIDS support services about which services they personally offer and whether they had received any training or supervision in the HIV/AIDS service areas being studied. 2.6 Tabulation and key outcome indicators The tabulation of this report focuses on two strata or categories of facilities: ownership and facility type. Ownership is either government or non-government, according to the definitions described in Section 2.3.1, in which the sampling frame is described. Facility type refers to the level of facility: district ware- house, district hospital, health center IV, health center III, and health center II. The key outcome indicators for commodities management used for this survey are calculated using data from this section of the survey instrument. These indicators include: • Stockout rates: The percentage of the facilities visited that experienced a stockout of one of the selected commodities during a six-month period between December 1, 2001 and May 31, 2002; • Stock status: The average level of stock at facilities based on the physical count of stock and average monthly consumption at each facility. This indicator is reported as the average number of months of stock on hand; • Expired products: The sum of expired commodities that were on the shelf or in the storeroom of each facility on the day of the visit; • Data quality on stock cards: The percentage of facilities that use stock cards as well as the accuracy of the data kept on those stock cards compared to a physical inventory; • Storage conditions: The percentage of the facilities that met a set of minimum accept- able storage conditions. Unlike the commodity component of this survey, the service component did not have indicators de- veloped specifically for the survey. The reports draw on a number of targets and objectives that the Minis- try of Health has developed. Those objectives and targets serve as service indicators and are listed in Sec- tion 1.4. Chapter 3 Health Commodity Management and Logistics System Performance As decentralization unfolds in Uganda, policy-level changes are influencing how health commodities are managed and consequently the structure of the entire logistics system. There is recognition within the Ministry of Health (MoH) that priority must be given to addressing health commodity availability. In re- sponse, the MoH is increasing budgets for essential drugs and reproductive health products and reviewing the procurement of drugs and the role of the central medical warehouse. As a part of this shift, the logis- tics system for health commodities is moving from a “push” system to a “pull” system (see Section 3.6 for details). Overall commodity availability and logistics system performance are described below. 3.1 Commodity availability The five-year Health Sector Strategic Plan (HSSP) designed by the MoH outlines the following goals for 2000/01–2004/05: • Improve access of the population to the Uganda National Minimum Health Care Pack- age (UNMHCP), paying special attention to increasing effective access for the poor, the difficult to reach and the otherwise disadvantaged; • Improve the quality of delivery of the package; and • Reduce inequalities between various segments of the population in accessing quality services (MoH, 2000). Without the appropriate health commodities, health facilities and health care providers cannot offer the population a full range of comprehensive services and products to meet these goals. Ensuring health commodity availability to meet the needs of the clients that it serves is the ultimate goal of a logistics sys- tem—to make certain that clients receive the right goods, in the right quantities, in the right condition, delivered to the right place, at the right time, for the right cost. For this survey, a list of 32 indicator health commodities were selected to represent the 67 com- modities on the Uganda Essential Drugs and Health Supplies List (draft May 2002) that prioritizes the vital and essential health commodities required to fulfill the Uganda National Minimum Health Care Package. The MoH identified these specific categories and the commodities selected for this survey to represent the range of health commodities required for offering the HIV/AIDS support services described in Section 4.1 of this report. The list of commodities studied in this survey can be found in Appendix D; they are listed by brand name, generic name, and unit of count (e.g., cycle, tablets, vials). For consistency in data collection, substitutes of other units of count or brands of the same commodity were not consid- ered. These indicator commodities were selected from among seven categories: HIV test kits, contracep- tives, drugs to treat opportunistic infections (OI), malarial drugs, drugs to treat sexually transmitted infec- tions (STI), anti-retroviral drugs (ARV), and tuberculosis (TB) drugs. To establish the performance level of the logistics system in Uganda, the survey team interviewed the staff identified at each facility as the person responsible for commodity management and reviewed logistics reports and storage areas. To correspond with the survey of HIV/AIDS support services in Sec- tion 4.1, the health facility staff were asked if they are supposed to manage each of the commodities on the list, that is, whether a facility at their level is supposed to offer the services that require each commod- ity. According to the MoH’s document on health services, all HC IIIs, HC IVs, and district hospitals Health Commodity Management and Logistics System Performance | 13 should have all of the contraceptives, malaria drugs, and STI drugs selected for this survey in stock and available to clients. The DOTS tuberculosis treatment program, which is currently operational in ap- proximately 20 to 30 districts, requires the availability of TB blister packs. HC IIs will not necessarily maintain stock of the entire list of commodities studied. The survey results indicate that some HC IIIs, IVs, and hospitals reported that they do not manage each of the products that they are supposed to man- age, often because of extended stockouts of certain commodities. For the analysis presented here, a stock- out occurs when a facility has no supply of a particular brand even though there may be other supplies of other brands for the same method of treatment. The actual reported results for each commodity category are described in detail below. However, in order to calculate a few of the indicators presented later in this chapter, all facilities that are, in fact, supposed to manage each commodity according to the MoH were included in the denominator for calculations. 3.1.1 Commodity management The essential drug list (EDL) has been revised, and drug price lists are now available from the National Drug Authority (NDA), National Medical Stores (NMS), and Joint Medical Stores (JMS). In October 2001, the MoH developed the National Drug Policy (NDP). The policy aims to “contribute to the attain- ment of a good standard of health by the population of Uganda through ensuring the availability, accessi- bility and affordability at all times of essential drugs of appropriate quality, safety, and efficacy, and by promoting their rational use” (MOH, 2000). With the new “pull” system, health facilities will be able to select the commodities they require and can afford from NMS after receiving approval from the health sub-district and district officials. The MoH has defined a minimum requirement for commodities that must be available at each level of the system based on the type of care different levels are expected to provide. The selection of commodities will be simplified with the introduction of a pre-printed order form. In the area of financing for the health commodities, the Government of Uganda (GoU) remains very donor dependent. Even with large donor inputs, the MoH is still finding it difficult to secure the health commodities needed to fulfill the minimum health care package. The cost of the minimum health care package, as defined by the MoH, is US$2.40 per person. In 2002, the available funds (government and donor) came to US$1.10 per person. The extent of donor funding for each type of commodity is further discussed in this section. 3.1.1.1 HIV test kits There is a major expansion plan in the area of HIV testing through the Global AIDS Fund, UNICEF, and the Model AIDS Program (MAP). Additionally, Uganda has recently received approval for US$51.6 mil- lion in the area of HIV/AIDS from the Global Fund for AIDS, TB, and Malaria (GFATM). Approxi- mately 40 percent of this will be devoted to drug purchases. There are still policy questions to be decided regarding what HIV test kits to use, but plans are well under way in the areas of training and designing distribution systems. Official guidelines and protocols for HIV testing were not yet developed at the time of this survey. Section 4.1.2 on laboratory services presents more information on how the test kits studied are currently being used. The targets set for 2004/05 in the HSSP include the following: • Attaining a 25 percent reduction in HIV seroprevalence; • Increasing and sustaining male condom use from 50 percent to 75 percent in rural ar- eas, and sustaining the rate in urban areas at or above the current rate of 80 percent; • Providing voluntary counseling and testing (VCT) services for HIV at all health units of HC III level and above; 14 | Health Commodity Management and Logistics System Performance • Reducing mother-to-child HIV transmission from 25–27 percent to 15 percent; • Providing counseling and psychosocial support to individuals and families affected by HIV (MOH, 2000). Table 3.1 shows the percentage of the government and non-government facilities visited that re- ported managing each of the HIV test kits studied. Table 3.1 Management of HIV test kits Percentage of facilities that reported managing various HIV test kits, by ownership, Uganda Health Facilities Survey 2002 Ownership Capillus Bionor Determine Serocard Hema-strip Multispot Number of facilities Government 4.0 3.7 2.9 3.8 0.1 1.1 183 Non-government 21.0 0.9 8.2 14.9 0.4 3.1 55 During this survey, Capillus and Serocard were found to be the most commonly managed HIV test kits in the non-government facilities, while Capillus, Bionor, Determine, and Serocard were the most commonly managed kits at the government facilities. 3.1.1.2 Contraceptives and condoms The results of the 2000–2001 Uganda Demographic and Health Survey indicate an increase in the contra- ceptive prevalence rate from 15 percent in 1995 to 23 percent in 2000 (Uganda Bureau of Statistics and ORC Macro, 2001). During this period, there has been a corresponding increase in unmet need for family planning among married women from 29 percent to 35 percent. Donors (USAID, UNFPA and DFID) provided all the contraceptives distributed in Uganda until the late 1990s. In 2001, the MoH made its first purchase of contraceptives (400,000 units of Depo-Provera). Since 2000, some donors have withdrawn direct support of contraceptive products in favor of Sector-Wide Approach (SWAp) funding, which the MoH is expected to use for contraceptive supply purchases. MoH budgets have been submitted for the use of SWAp funds, but final levels are not yet certain. USAID and UNFPA continue to provide modest fund- ing levels for contraceptives. Social marketing organizations have also played a substantial role in distributing contraceptives. Both Commercial Marketing Strategies (CMS) (with funding from USAID) and Marie Stopes Interna- tional (with funding from the German development bank Kreditanstalt für Wiederaufbau) have distributed contraceptives in Uganda. Commodities that are supplied directly to commercial marketing programs are included in the calculations for nationwide requirements. In theory, contraceptive needs should be in full supply (i.e., there should be sufficient quantities of contraceptives in country so that no client request will go unmet). However, contraceptive security is dependent not only on donor funding and commodities but also on an operational forecasting and procurement mechanism and effective commodity management. The HIV/AIDS program of the MoH primarily manages condoms. Following a national stockout of condoms in 1999, there was a large purchase of condoms with World Bank funds in 2000. These con- doms arrived in 2001 and distribution to the districts was completed in July 2002. Additional condoms have been ordered by the MoH and the MAP project, funded by the World Bank, and are due to arrive in early 2003. Additional purchases of 30 million condoms per year will be made by the social marketing programs run by the CMS project and by Marie Stopes International. Given the current condom projec- tions, and delays in delivery of donated condoms, there is concern about condom availability after 2003. Health Commodity Management and Logistics System Performance | 15 In 2000–2001, there was a shortage of contraceptives, especially Depo-Provera. The Annual Health Sector Performance Report 2000–01 (AHSPR) states that management of logistics and supplies improved during the year but also identified a need to streamline logistics management for family planning and re- productive health (MoH, 2001). This program has been identified as a new priority area for year 2 of the HSSP. Out of the 238 facilities visited during this survey (government and non-government), 66 percent of facilities reported that they manage Microgynon oral pills, 90 percent manage condoms, and 82 percent manage Depo-Provera. These three methods make up the majority of the method mix in Uganda. While almost all government facilities reported managing these three contraceptive methods, the non-government facilities visited were managing them at much lower rates (Table 3.2). The low rates for Microgynon may be due to the fact that Lo-Femenal, a combined oral contraceptive pill identical to Mi- crogynon, was also found in many facilities, and many service providers use the two brands inter- changeably. In addition, some of the non-government facilities visited were faith-based and were there- fore less likely to stock contraceptives. Table 3.2 Management of contraceptives and condoms Percentage of facilities that reported managing Microgynon oral pills, condoms, and Depo-Provera, by ownership, Uganda Health Facilities Survey 2002 Ownership Microgynon Condoms Depo- Provera Number of facilities Government 72.7 98.0 87.9 183 Non-government 41.4 61.5 63.4 55 3.1.1.3 Drugs to treat opportunistic infections Opportunistic infection (OI) drugs encompass a broad range of commodity types and many of the drugs are used to treat multiple types of infections. In practice, OI drugs are given both as treatment and as pro- phylaxis for people living with HIV/AIDS. There is a large overlap in use between STI and OI drugs. For this survey, fluconazole, co-trimoxazole and acyclovir were identified as indicators for OI drug manage- ment. Of the 238 facilities visited during this survey (government and non-government), 9 percent re- ported that they manage fluconazole, 95 percent manage co-trimoxazole, and 6 percent manage acyclovir. Table 3.3 shows the percentage of government and non-government facilities visited that manage each of these commodities. Co-trimoxazole is the most common drug, while fluconazole and acyclovir are managed by a much smaller proportion of the facilities visited. Table 3.3 Management of drugs to treat opportunistic infections Percentage of facilities that reported managing fluconazole, co-trimoxazole, and acyclovir, by ownership, Uganda Health Facilities Survey 2002 Ownership Fluconazole Co-trimoxazole Acyclovir Number of facilities Government 6.9 94.2 1.7 183 Non-government 17.8 96.9 18.8 55 16 | Health Commodity Management and Logistics System Performance 3.1.1.4 Malarial drugs Malaria drug needs represent 50 percent of health center visits in Uganda (DISH Distribution of Stock and Drug Use Survey, May 2002). Resistance to present chloroquine treatments is increasing and the treatment protocol is changing in Uganda. These changes have made recent quantification exercises diffi- cult. Chloroquine-based treatment drugs are included in the essential drug kits; however, sulfadoxine- pyrimethamine (SP)-based drugs, recommended internationally as the next line of treatment, are not. SP- based drugs will be distributed with the kits in July 2002. According to the AHSPR, treatment failure was approximately 30 percent for chloroquine and 10 percent for SP. The National Anti-Malaria Drug Policy now suggests that the first line of treatment in- clude a combination of chloroquine and SP. As this new policy is implemented, DFID and Ireland AID will pay for a one-year supply of chloroquine and SP. NMS currently offers SP drugs for sale, but these have not consistently been available in public sector health centers. USAID supports the private sector sale of anti-malaria drugs and is providing a malarial expert to work with the MoH. The GoU has re- quested US$45.1 million from the GFATM to support their work to fight malaria and TB. The targets for 2004/05 set in the HSSP for malaria include the following: • Increasing from 30 percent to 60 percent the proportion of the population that receive effective treatment for malaria within 24 hours of the onset of symptoms; • Raising to 60 percent the proportion of pregnant women who receive protection against malaria through intermittent presumptive treatment with SP; • Reducing malaria case fatality at the hospital level from 5 percent to 3 percent (MoH, 2000). Of the 238 facilities visited during this survey (government and non-government), 98 percent reported that they manage chloroquine, and 94 percent reported that they manage sul- fadoxine-pyrimethamine (Table 3.4). Table 3.4 Management of malarial drugs Percentage of facilities that reported managing chloroquine and sulfadoxine-pyrimethamine, by ownership, Uganda Health Facili- ties Survey 2002 Ownership Chloroquine Sulfadoxine- pyrimethamine Number of facilities Government 98.3 94.9 183 Non-government 96.9 91.1 55 At the time of the survey, almost all of the health facilities visited reported that they manage both of these drugs. 3.1.1.5 Drugs to treat sexually transmitted infections Previously, sexually transmitted infection (STI) drugs were provided in STI kits using World Bank fund- ing, but these funds were entirely spent by 2000. The last shipment of STI supplies funded through the World Bank STI project was received two years ago. STI drugs are available through the private sector pharmacies and retail outlets, and some health care providers choose to procure them independently in order to have them available to clients. Alternatively, providers send clients to the private sector to pro- cure the drugs after diagnosis. One of the HSSP’s first-year targets was to procure and distribute STI drugs. At the time of the 2000/01 Performance Report, STI drugs had not been procured because the available funds had been real- located to purchase essential drug kits. The HSSP set a goal for the “effective management of STIs and OIs provided in all health units” by 2004/05. For this survey, ciprofloxacin, benzathine penicillin, doxycycline, and metronidazole were selected as indicators for STI management. Of the 238 facilities visited during this survey (government and non- Health Commodity Management and Logistics System Performance | 17 government), 63 percent reported that they manage ciprofloxacin, 86 percent manage benzathine penicil- lin, 67 percent manage doxycycline, and 95 percent manage metronidazole (see Table 3.5). Table 3.5 Management of STI drugs Percentage of facilities that reported managing ciprofloxacin, benzathine penicillin, doxycycline, and metronidazole, by ownership, Uganda Health Facilities Survey 2002 Ownership Ciprofloxacin Benzathine penicillin Doxycycline Metronidazole Number of facilities Government 61.2 84.1 64.5 96.1 183 Non-government 70.0 92.5 73.2 91.5 55 At the time of the survey, almost all facilities visited reported that they managed STI drugs. How- ever, as noted in the Introduction and below in Section 3.1.2, stockouts and stock availability, even though STI drugs are supposed to be managed by the facility, they are not necessarily widely available at the health centers throughout Uganda. 3.1.1.6 Anti-retroviral drugs The AHSPR indicates that HIV seroprevalence at sentinel sites and STI treatment clinics continue to de- cline. In addition, the report states that the GoU has negotiated a reduction in the prices for anti-retroviral drugs in order to increase access to these drugs. According to the AHSPR, the community is pressuring the government to ensure that anti-retroviral drugs (ARV) are both available and affordable. In response, the MoH has formed a committee to design a strategy to oversee the expansion of outlets for these drugs. In addition to being costly, launching a program for offering ARV treatment requires significant capacity in laboratory diagnosis of HIV and monitoring adverse reactions, plus counseling services. These issues will need to be addressed before an ARV treatment program can be widely implemented. At the time of the survey, only one of the non-government facilities visited had an ARV in stock (nevirapine). There are facilities in the country known to provide ARVs; by chance none were selected in the sample. 3.1.1.7 Tuberculosis drugs Tuberculosis (TB) drugs are managed through the MoH TB Program. Drugs to treat TB are donated by the Stop TB Program and German Leprosy Relief. Currently, the TB program operates as a vertical sys- tem and delivers drugs directly to their regional coordinators. Regional coordinators distribute the TB drugs to local distributors. This vertical system is effective but inefficient in terms of leveraging MoH resources used for distributing other health commodities. The MoH is looking at ways to integrate deliv- eries with other medical supplies. According to the AHSPR, TB case notification has been increasing at 8 percent per year since 1994. The AHSPR also states that the increase in TB could be primarily attributed to the effect of the HIV/AIDS epidemic and to an improvement in the capacity of the health services to detect cases of TB. Half of the new cases are said to be related to HIV infection. Given this linkage, management of these two diseases will need significant coordination. For adequate control of TB, the treatment drugs should be maintained in full supply to meet all the needs of the population. Currently, TB drugs are packed in bulk bottles and blister packs. The blister packs are used by facilities that provide DOTS treatment for TB. DOTS is currently being implemented in about 20 to 30 districts, only a few of which were sampled for this survey. Management and availability of the blister packs is irregular because they have spread through the health care system, even to districts that have not yet officially launched the program. According to the HSSP, DOTS will be expanded to all 18 | Health Commodity Management and Logistics System Performance 56 districts with a goal of 80 percent case identification by 2004/05. This will be done at a controlled pace given the time needed to train providers and “observers” (MoH, 2000). Forecasting for TB drugs requirements is based on the number of reported cases. For each new re- ported case, a six-month supply of drugs is reserved and sent to the district that will manage the treatment. The quantities of needed blister packs will increase with the spread of the DOTS program and in light of the 8 percent annual increase in case notification mentioned above. The current supply is anticipated to last until early 2003. The next cycle of drugs will be paid for by the MAP project, and they are expected to continue to procure TB drugs for the next few years. As mentioned above, the GoU has requested US$45.1 million from the GFATM to support both TB and malaria programs. Due to inconsistencies in the data collection for TB drugs, the availability of first treatment blister packs was taken as an indicator for TB drug availability and closely mirrors the percentages found of ethambutol, isoniazid and rifampin. Table 3.6 shows the percentage of facilities visited that reported man- aging the first treatment blister packs. Of the 238 facilities visited during this survey, only 35 percent reported that they manage TB blister packs. Table 3.6 Management of TB drugs Percentage of facilities that reported managing tuberculosis drugs, by ownership, Uganda Health Facilities Survey 2002 Ownership TB blister pack Number of facilities Government 39.3 183 Non-government 21.4 55 As seen in Table 3.6, on the day of the visit, government facilities were managing first treatment blister packs at a slightly higher rate than non- government facilities. 3.1.1.8 Essential drug kits Following Uganda’s civil war, the Danish aid organization DANIDA began supplying essential drugs in pre-packaged, fixed-quantity kits in 1987. For the last 15 years, most essential drug supplies for lower level government clinics have been supplied through these kits. Originally, these were funded entirely by DANIDA, and are now funded 50 percent from DANIDA and 50 percent from MoH funds. The kits are currently “pushed” to the health centers by way of the district warehouses. The National Medical Stores (NMS), which charges ten percent of the commodity value to cover the handling and distribution costs, distributes the kits. The number of kits a facility receives is based on the population it serves. Each kit was designed to cover 800 cases/patients and each distribution was intended to meet a health facility’s commodity needs for three months. In reality, facilities run out of many of the products before receiving resupply. The purchase of additional essential drugs from the NMS is possible. These supplemental or- ders depend heavily on available funds. Furthermore, because drugs are in short supply, it is suspected that many clients are referred to private pharmacies to purchase their commodities. As stated above, the estimated cost for the basic health care package is US$2.40 per person. Current drug supplies from the MoH and donors are currently estimated at only US$1.10 per person. As a result, essential drugs are in short supply and will continue to be rationed in the future. The kits are being phased out as the public sector transitions to a pull ordering system for health commodities. The last shipments of essential drug kits were scheduled to go to the health facilities in September/October of 2002. As of Janu- ary 2003, facilities will place orders with NMS based on funds allocated to each facility. Each facility will use a pre-printed order form and default orders will be available until training is completed at the local level. The GoU recently increased its current funding available for essential drugs at the HC II and HC III level by 34 percent. This is encouraging, but will not cover all the resources needed for commodity secu- rity at the facility level. Availability of essential drug kits was assessed in a smaller sample of facilities (21). The contents of these kits are listed in Appendix D (Health Commodities Surveyed). Of this small sample, 75 percent Health Commodity Management and Logistics System Performance | 19 of the facilities visited had received essential drug kits in the last three months (HC IV, III and II). This is relevant to the results of this survey because the survey was carried out in the middle of a nationwide dis- tribution of the kits. This fact may result in slightly inflated drug availability rates because of the number of the facilities visited that had just received a shipment of drugs in the month prior to the survey. This should be taken into consideration when readers review the drug availability and stock status results from this survey and when comparing these results to any future drug availability surveys. 3.1.2 Stockouts and stock availability Logistics managers strive to ensure a consistent and reliable supply of the products that they require to serve their clients. Health commodity security is achieved when every client is able to chose, obtain and use quality health products whenever she or he needs them. A key indicator to measure whether a logis- tics system has achieved this goal is stockout rates or, the opposite, stock availability rates. When facili- ties experience stockouts, they are unable to serve clients with a comprehensive range of health commodi- ties or services. Because stock availability is the ultimate measure of logistics system performance, this indicator also gives an idea of the overall effectiveness and efficiency of the entire system, from forecast- ing and procurement to distribution, storage, and inventory management. At each facility visited for this survey, facility staff were interviewed and stock records reviewed to collect information on stock availability on the day of the visit and for the six-month period prior to the survey from December 1, 2001 to May 31, 2002. A six-month period is reviewed in order to capture a more accurate picture of stock availability at each facility and to allow for seasonal trends in consumption (e.g., malarial drug use increases during the rainy season) and availability (e.g., periodic shipments of supplies). Figure 3.1 shows the results of this review of stock records for a sample of the commodities stud- ied. The graph shows the percentage of facilities that experienced at least one stockout of each commod- ity during this six-month period for all facilities combined (all levels, all districts), shown separately for government and non-government facilities. UHFS 2002 Mi cro gy no n Co nd om De po -P rov era Co -tri mo xa zo le Ch lor oq uin e Be nz ath ine pe nic illin TB bl ist er pa ck 0 20 40 60 80 100 Pe rc en ta ge o f f ac ilit ie s Government Non-Government Figure 3.1 Stockouts over the six-month period December 1, 2001–May 31, 2002 In the last six months, a larger percentage of facilities had a stockout of Microgynon than the other contraceptives studied. Only around 20 percent of all facilities experienced a stockout of condoms or Depo-Provera during this period. Over 50 percent of government facilities experienced a stockout of co-trimoxazole, 29 percent of chloroquine, 46 percent of benzathine penicillin, and 50 percent of the TB blister pack. For Microgynon, condoms, and TB blister packs, the non-government facilities had a higher frequency of stockouts than government facilities. For the essential drugs distributed through the kits (co-trimoxazole, chloroquine, and benzathine penicillin), government facilities were much more likely to experience a stockout than non- government facilities. In theory, both the contraceptives and TB drugs are kept in full supply to meet the needs of all clients; all hospitals, HC IVs, and HC IIIs should have co-trimoxazole, chloroquine and ben- 20 | Health Commodity Management and Logistics System Performance zathine penicillin in stock. As we can see from this graph, this is not happening in practice. Each stockout that takes place represents clients who will not receive the treatment that they were seeking at the health care facility. In the HSSP, the MoH includes this same indicator—percentage of facilities without any stockouts for essential drugs (for the MoH, these drugs are chloroquine tablets, co-trimoxazole tablets, measles vac- cines, and ORS sachets, with SP and Depo-Provera also monitored)—in a given time period. This should be collected through the health unit monthly report and will be monitored monthly and quarterly, with a goal of 90 percent of facilities without a stockout during a given time period by 2005. Figure 3.1 shows that there is much work to be done in reducing the occurrence of stockouts. For a different look, stock availability on the day of the visit reflects whether the facility could offer a service and the related commodity to the next client (or clients) who visit a health facility. This indicator simply provides a snapshot in time and does not represent continuous availability over time. For example, the facility may have just used its last available injection, tablet, or test kit of a given commodity on the client who was seen before the data collection team arrived at the facility. Alternatively, the facility might ration commodities and offer them to only the most critical clients, in order to avoid a total stockout. Or the facility may have just received a shipment of commodities the week before the survey team’s visit and therefore the facility appears to have an adequate supply of commodities. All of these scenarios are possi- ble, and the data on stock availability at the time of the survey visit must be interpreted cautiously. In fact, as previously mentioned, the survey team discovered that a nationwide distribution of essential drug kits was underway at the time of the survey. To assess this indicator, the survey teams looked at stock records and did a physical inventory to assess stock availability on the day of the visit at each facility. Table 3.7 shows the results of this review for a sample of the commodities studied, broken down by government and non-government. Table 3.7 Stock availability on day of survey Percentage of facilities in which each commodity was available on the day of the survey among those managing the commodities, by ownership and facility type, Uganda Health Facilities Survey 2002 Ownership/ facility type Microgynon Male condom Co-trimoxazole Chloro- quine Sulfadoxine/ pyrimethamine Cipro- floxacin Benzathine penicillin TB blister pack Government District hospital 80.9 100.0 83.9 100.0 96.1 49.4 68.5 80.7 HC IV 91.1 100.0 72.5 94.1 76.4 24.9 58.0 92.3 HC III 76.4 87.1 70.2 87.7 72.4 41.6 56.2 89.6 HC II 17.1 31.1 54.7 66.0 30.8 5.9 16.5 * Total 65.9 77.3 64.6 81.6 64.3 33.5 46.5 89.6 Non-government HC III 89.0 98.3 96.9 100.0 78.9 84.6 85.8 * Total 84.6 91.5 90.5 93.3 69.2 77.2 79.4 91.2 Note: Facilities without stock records are excluded. An asterisk indicates that a figure is based on too few cases to present and has been suppressed. The availability of Microgynon, co-trimoxazole, ciprofloxacin, and benzathine penicillin was sub- stantially lower at the government facilities than at non-government facilities. Overall, commodity avail- ability rates were found to be better at the non-government facilities on the day of the visit. Health Commodity Management and Logistics System Performance | 21 3.1.3 Stockout duration, December 1, 2001–May 31, 2002 As mentioned above, the survey looked at stockouts of the commodities studied both on the day of the survey team’s visit and during the six-month period prior to the survey. However, this data does not yet give a measure of the severity of the stockout problem during this period or a means for differentiating between commodities stocked out for a short period of time versus those stocked out for long periods of time. An assessment of the average duration of those stockouts that occurred during that period provides us with a more in-depth look at how long the stockouts lasted and the probability that a client who sought health care during this time period would not have received the commodity or commodities needed. Stockout duration data at non-government facilities was insufficient for reporting results. Facilities without stock records are excluded from the calculation since duration data was not available. Conse- quently, the results are limited and are not nationally representative, although the average duration of stockouts for all government facilities provides an interesting picture. Microgynon was out of stock for an average of 75 percent of this six-month period, while condoms and Depo-Provera were stocked out for an average of approximately 45 percent of this period. Chloroquine and SP fared much better at an average of 22 percent and 34 percent of the time, respectively, while ciprofloxacin and benzathine penicillin fared much worse at an average of 77 percent and 60 percent of this time period, respectively. Co-trimoxazole was out of stock for an average of 31 percent of this period. It is clear that the stockouts that were re- corded in facilities with stock records available were significant in impact because they were stocked out for considerable lengths of time. 3.1.4 Record keeping in relation to stockouts When assessing the number and duration of stockouts during the survey, the survey teams also recorded whether the stock managers were keeping stock cards for the commodities managed and whether those stock cards were up to date on the day of the visit. This provides an indicator of the quality of record keeping and how well stock managers are actively monitoring and managing their inventory to avoid stockouts and stock imbalances that may result in expirations. In the public sector, the majority of facili- ties experiencing a stockout of contraceptives between December 1, 2001 and May 31, 2002 did not have an updated stock card on the day of the survey. Although the rates for other products are lower, it is clear from the survey results that many facilities that experience stockouts are not keeping their stock cards up to date. Information management will be discussed further in Section 3.3, Health Management Informa- tion System. 3.1.5 Reasons for stockouts As seen above, widespread stockouts pose a chronic threat to the availability of services and quality of care. In order to better understand the causes of stockouts within the Ugandan public health commodity logistics system, the survey also attempted to qualify the reasons why the stockouts discussed above oc- curred. The survey instrument offered a choice of seven options to the respondents for the reason why the stockout occurred: 1. Higher level facility did not send enough products 2. Higher level facility did not send products in time 3. Increase in consumption 4. Did not request the correct amount 5. Did not request products at the correct time 6. Insufficient resources (financial, human or transportation, specify) 7. Other reasons 22 | Health Commodity Management and Logistics System Performance For Bionor HIV test kits, all responding facilities reported that the higher level did not send prod- ucts in time and that insufficient funds were the main reasons cited for stockouts during this time period. The most commonly cited reason for stockouts for Microgynon and condoms was that the higher level did not send the products in time. For Microgynon, condoms, and Depo-Provera some facilities reported that the reason for stockouts was insufficient resources (financial, human, or transportation). For co- trimoxazole, chloroquine and SP, ciprofloxicin, benzathine penicillin, metronidazole, and doxycycline, again, the main reason given was that the higher level did not send the products in time. Most of these drugs are included in the essential drug kits that are shipped from the higher levels at regular intervals. For TB blister packs, reasons included that the higher level did not send the products in time or did not send enough products. Overall, the most common reason cited was that the higher level facility did not send products in time, most likely because of stockouts or low stock availability at higher-level facilities, as seen in this chapter. 3.2 Inventory management 3.2.1 Stock status An assessment of the stock status of the commodities studied is an important complement to the stockout and stock availability rates presented above. Stock status offers an estimate of how long the commodities in stock will last to serve clients at the facility. Health facility staff can ration commodities in order to avoid a stockout; however, by rationing, or selectively offering commodities according to certain condi- tions, all client needs will not be met and the logistics system has not met its goal. Reviewing stock status provides a more profound picture of how commodities are being managed through the logistics system and also reflects upon the efficiency of the forecasting, procurement, distribution, storage, and inventory control processes. All of these components of the logistics system must be functioning effectively and efficiently in order to ensure that stock managers can maintain adequate stock levels. This indicator does not, however, highlight which component of the logistics system is not functioning properly, resulting in stock imbalances. To ascertain whether stock levels of health commodities are adequate, an indicator on the average number of months of stock on hand is calculated. This indicator provides this data for a particular point in time (i.e., the day of the survey team’s visit) and can identify situations where commodities are over- stocked, which could lead to commodity expiration and wastage, and situations where commodities are stocked at low levels which could result in rationing of commodities or stockouts. To calculate this indi- cator, data collectors carried out a physical inventory of the commodities studied and reviewed the stock ledger or stock cards to gather historical data on the quantities consumed by clients or issued from one level of the system to another during the six-month period prior to the survey. The average monthly con- sumption or issues rates were calculated and then compared to the physical inventory to establish the number of months of stock available to be dispensed to clients or issued to other facilities on the day of the visit. Record keeping is obviously an important key to inventory management and this will be dis- cussed in the next section. The draft guidelines for drug management (draft May 2002) indicate that all health commodities will be managed according to the same inventory control procedures. The Health Management Informa- tion System (HMIS) has distributed written instructions regarding how to assess the adequacy of current stock levels. For all levels of the system, the minimum amount of stock that managers should keep in stock, and which indicates when to place an order, is two months’ consumption. The maximum amount of stock, or the level that facilities’ stock on hand should reach when an order is placed but should not ex- ceed, is five months’ consumption. These inventory control procedures have not yet been officially im- plemented. Health Commodity Management and Logistics System Performance | 23 Figure 3.2 shows the average number of months of stock on hand at each level for government fa- cilities. It is clear that, on the day of the visit, two of the contraceptives studied, Microgynon and condoms, are significantly overstocked, with one year or more worth of stock at all of the service delivery points (SDPs). For condoms, these high stock levels are likely due to the fact that a one-year supply of condoms was distributed to facilities between March and July, so they were just arriving during this survey. For most of the remaining commodities, the stock levels are low at the higher levels of the system and higher at the lower levels of the system, which is where they need to be to serve clients. Most of these commodities are stocked according to the proposed inventory control levels, with the exception of co-trimoxazole, which is understocked at all levels, and TB blister packs, which are overstocked at the HC III level. It is important to reiterate that a wave of distribution of the essential drug kits began immediately prior to the survey and was ongoing during the survey. This distribution may affect the results in some of the districts visited that had already received their shipments and therefore had adequate stock of these commodities by the time of the survey. On the other hand, those districts that had not yet received their scheduled shipment of the kits were running very low on supplies in anticipation of their shipments. UHFS 2002 Mi cro gy no n Co nd om s De po -P rov era Co -tri mo xa zo le Ch lor oq uin e Be nz ath ine pe nic illin TB bl ist er pa ck 0 2 4 6 8 10 12 M on th s District Warehouse District Hospital HC IV HC III HC II Figure 3.2 Stock on hand (government facilities) Note: Facilities without stock records are excluded. 3.2.2 Expired products Not only does effective inventory management reduce the chance of experiencing stockouts or stock im- balances, it also helps prevent losses through expiration. Using first-to-expire, first-out (FEFO) inventory management, where the stock that will expire first is placed in the front of the shelf to be used first, com- modity managers can better monitor expiration dates to ensure that products are used before they expire. This can also help to ensure that expired products are not distributed to clients but rather are removed from inventory and disposed of properly. Managers may also transfer excess supplies that they recognize will not be used at their facility before expiring to other facilities who may be able to use them faster. Be- cause expired products can no longer be offered to clients, they can contribute to the threat of stockouts or stock imbalances if they are not properly managed, separated from usable stock in a timely manner, and replaced with usable stock. Furthermore, most health care systems in developing countries operate with limited funding; health commodities are precious and rarely in full supply. Therefore, losses of otherwise usable commodities due to expiration should be avoided at all cost. As with other indicators noted above, reviewing the quantities of expired stock provides another measure of overall logistics system perform- ance, though it will not highlight the causes or the components responsible for any deficiencies in per- formance. Some amount of commodity loss to expiration is expected in any logistics system, but large quantities should be investigated. Because of a lack of available historical data on expired products, the survey teams counted the to- tal amount of expired commodities that were either on the shelf with usable commodities or anywhere inside the storeroom on the day of the visit. No rates can be calculated from this data, but there were sev- eral cases of high amounts of expired commodities worth noting. In many cases, the expired products rep- resented specific cases; for example, there was a total of 1,223,888 expired cycles of Microgynon. The 24 | Health Commodity Management and Logistics System Performance large majority (1,219,362 cycles) were found at a non-governmental HC IV in Luwero district and a smaller amount in a government HC III in Nebbi district. A total of 82,257 expired condoms were found in different districts, at different levels, mostly in the public sector (63,313). Further, 18,943 expired con- doms were found at the HC III level at NGO facilities visited in Rukungiri district, and 805 expired Bi- onor HIV test kits were found. Government facilities in Lira district accounted for the majority of these expired drugs (663). For STI drugs, a total of 2,450 expired vials of benzathine penicillin were found at government and non-government facilities at various districts and levels of the system. 3.3 Health Management Information System Valid and timely information can greatly improve stock managers’ ability to identify, forecast, and pro- cure sufficient quantities to meet the needs of the facilities in the supply chain and ultimately the needs of the clients at service delivery points. By making decisions based on the current stock status and projected needs based on past consumption trends, stock imbalances can be avoided. The essential data items needed for such decisions include stock on hand, the rate of consumption for each product, and losses and adjustments. This data can be routinely collected through a logistics management information system (LMIS) which is the engine of a logistics system. In Uganda, this information is collected through the Health Management Information System (HMIS). The HMIS was recently redesigned by the MoH to include forms that will enable all levels of the system to track commodity availability. The new forms include stock cards, records of issuing, requisition and issue vouchers, and a form for revising the average monthly consumption. Information from individ- ual facilities is entered and consolidated at the district level and sent to the MoH office in Kampala. The AHSPR reports an improvement in the timeliness and completeness of HMIS reporting in the last year. It is the intention of the MoH to use the HMIS system to track commodity availability at the health sub- district level and eventually at the facility level. However, the monthly report does not contain informa- tion regarding the stock status, only if the facility is stocked out. The system is automated at the central level with plans to automate at the district level. UHFS 2002 District warehouse District hospital HC IV HC III HC II 0 20 40 60 80 100 Pe rc en ta ge o f f ac ilit ie s Government Non-government Figure 3.3 Reported use of stock cards for commodity managementThe instructions for the HMIS forms require that any commodity which is kept for more than one week are to be tracked using a stock card. The stock card includes information on where the commodities were issued to or from, the quantity issued, and the balance on hand. Of the 238 ware- houses and service delivery points visited during the survey, 79 percent reported that they have the stock cards and are using them. Figure 3.3 com- pares the difference in the reported use of stock cards for commodity management between government and non-government facilities. At the district hospital and HC IV level, all of the facilities visited reported using stock cards to manage their inventory. However, at the HC III and HC II levels, fewer facilities reported using stock cards, and government facilities reported using stock cards more often than the non-government facilities visited. Health Commodity Management and Logistics System Performance | 25 In reality, among all facilities, 45 percent were found to be using stock cards for at least one of the con- traceptives studied; 75 percent were found to be using stock cards for at least one of the essential drugs for treating OIs, malaria, and STIs; and 28 percent were using stock cards for at least one of the TB medications studied. Figure 3.4 shows the differ- ence between government and non- government facilities by commodity category. Government facilities main- tain stock cards at a higher rate than non-government facilities, and the results show that stock card use is more common at the higher levels of the system. Facilities are much more likely to maintain stock cards for one of the essential drugs than for contraceptives or TB medications. UHFS 2002 Contraceptives OI/malaria/STI drugs TB drugs 0 20 40 60 80 100 Pe rc en ta ge o f f ac i lit ie s Government Non-government Figure 3.4 Actual use of stock cards by commodity category Accurate data on the current stock status is vital for effective decisionmaking at every level of the system. The survey collected information regarding the accuracy of logistics data at the facility level. For each commodity studied, the quantity of stock on hand was recorded by reviewing the stock cards and by taking a physical stock count. A comparison of the overall average percent discrepancy between the stock card and the physical count for all facilities surveyed revealed that there was a median discrepancy of 84 percent for contraceptives, a 40 percent median discrepancy for OI/malaria/STI drugs, and a 92 percent median discrepancy for TB drugs. There are no consistent patterns in the discrepancies found between the different levels of the system; however, it is clear from the summary data presented in Table 3.8 that the general quality of the data recorded on stock cards in the facilities surveyed is poor, particularly for TB drugs and contraceptives. Table 3.8 Data quality: median percent discrepancy Median percent discrepancy between the quantity of stock available for distribution as recorded on the stock records ver- sus the count from a physical inventory of those facilities that manage contraceptives, essential drugs used to treat OIs, malaria, and STIs, and TB drugs studied and that have stock records available, by ownership, Uganda Health Facilities Survey 2002 Ownership Contra- ceptives Number of facilities stock- ing contra- ceptives OI/malaria/ STI drugs Number of facili- ties stocking OI/malaria/ STI drugs TB drugs Number of facilities stocking TB drugs Government 84.0 81 40.8 129 91.3 35 Non-government 83.0 10 24.9 35 536.0 6 Note: Facilities without stock records are excluded. 3.4 Training in logistics and human resources Health workers in Uganda begin their training for their assignments in pre-service nursing, pharmacy, medical, and other public health schools. This usually includes a module on management, including re- cord keeping, financial management, facility management, and supplies management. Staff responsible for managing health commodities need to be trained in how to maintain stock cards, how to calculate or- der quantities and place orders, and how to fill out records and reports. These activities, when done accu- 26 | Health Commodity Management and Logistics System Performance rately, help to ensure proper stock management and to give an accurate picture of consumption rates and stock on hand at each facility. Without well-trained staff, facilities run the risk of poor record keeping and inaccurate ordering, which in turn can lead to stockouts, overstock, and expired products. In-service training can be carried out periodically to update staff on new developments, revised procedures, or new technologies. In 1999–2000, the Ugandan MoH carried out a nationwide training on planning and management for 100 heads of health sub-districts. The MoH also trained health workers in 12 districts on the recently revised HMIS in early 2002. This training included how to fill out the HMIS reporting forms and procedures for reporting health information. When conducting the commodity management portion of the survey, the survey team interviewed either the staff in charge of managing the commodities or, if not available, the person acting as the in- charge on the day of the visit. In order to gather information on whether the staff interviewed about com- modity management on the day of the facility visit had received any training in logistics management, the instrument included questions on when and what specific training they received. Respondents were also asked how they learned to complete the logistics forms used at this facility, either during a logistics train- ing, during on-the-job training, self-learned on the job, or other forms of training. However, these indica- tors do not provide insight into the quality of the training provided nor the trained staff’s ability to apply the material taught nor whether performance has improved as a result of the training. Overall, 32 percent of all facilities had at least one person available on the day of the visit that had received training in logistics management (e.g., ordering, receiving supplies, and inventory management) (see Table 3.9). Table 3.9 Availability of staff trained in logistics Percentage of facilities with at least one staff member trained in logistics available on the day of the survey, by facility type and ownership, Uganda Health Facilities Survey 2002 Facility type Government Number of government facilities Non- government Number of non- government facilities District warehouse 79.6 12 NA NA District hospital 55.4 8 NA NA HC IV 23.5 16 22.2 9 HC III 30.8 86 20.1 31 HC II 26.5 61 50.0 15 NA = Not applicable There was no clear distinction between the percentage of government versus non-government fa- cilities that had at least one person available on the day of the visit who had received training in logistics for HC IVs. However, for HC IIs, twice as many of the non-government facilities had a trained staff per- son on the day of the visit. For all types of facilities except the district warehouses and half of the district hospitals, most facilities did not have trained staff in charge of commodity management. Health Commodity Management and Logistics System Performance | 27 Of all the stock managers inter- viewed, 37 percent reported that they learned how to complete the forms used at the facility during a logistics training, while 46 percent reported learning during on-the-job training, 33 percent reported self-learning on the job, and 12 percent reported that they learned elsewhere. Figures 3.5.1 and 3.5.2 show the differences between government and non-government fa- cilities by facility type. Of the government facilities, a greater proportion of district hospital and warehouse staff received formal training in logistics. However, HC IV and HC III staff were most likely to have learned through on-the-job train- ing, and HC II staff were more likely to have learned how to complete the logistics forms through on-the-job training or self-learning. UHFS 2002 District warehouse District hospital HC IV HC III HC II 0 20 40 60 80 100 Pe rc en ta ge o f f ac ilit ie s During a logistics training On the job training On the job (self-learning) Other Figure 3.5.1 Training in completing logistics forms (government facilities) Note: Respondents could choose more than one answer. UHFS 2002 HC IV HC III HC II 0 20 40 60 80 100 Pe rc en ta ge o f f ac i lit ie s During a logistics training On the job training On the job (self-learning) Other Figure 3.5.2 Training in completing logistics forms (non-government facilities) Note: Respondents could choose more than one answer. A common concern expressed by some of the facility staff interviewed was that there were limited opportunities for in-service training for maintaining skill levels. Other respondents expressed that some skills were weak because frequent supply shortages meant that they were not often applying the skills learned. 3.5 Supervision in logistics Supervision of the logistics system and the staff who manage it is necessary to ensure that the system is running properly, to anticipate the need for adjustments to the system, and to improve staff performance and quality of care. Effective supervision can help avoid problems or resolve them quickly. Supervision visits can also be an opportunity for monitoring and evaluating HMIS and on-the-job training of staff. In Uganda, supervisory systems for the public sector health care system are in place and routine schedules exist. The MoH’s “Indicators for Monitoring Health Indices” includes an indicator for the aver- age number of supervision visits conducted during a quarter, which should be reported on the Health Unit Quarterly Report. According to the national guidelines, every health facility should receive a monthly supervisory visit from district and/or health sub-district staff. The survey results give an estimated measure of the frequency of supervisory visits and the types of logistics issues addressed during supervision. Each respondent for the commodity management section of the survey was asked when he or she received their most recent supervisory visit. They were also asked what was done during the visit, including the following activities: supplies checked, stock cards checked, expired stock removed, HMIS reports checked, on-the-job training/coaching, or other activities. 28 | Health Commodity Management and Logistics System Performance Overall, 85 percent of the gov- ernment facilities had had a supervi- sory visit in the past three months and 58 percent had received a supervisory visit within the past month. Figures 3.6.1 and 3.6.2 show the timing of the most recent supervisory visit for gov- ernment and non-government facilities by level. Although supervision is report- edly taking place at the majority of facilities, supervision is less frequent at the higher levels of the system, in- cluding the district warehouses, while the majority of HC IIs and HC IIIs in both the government and non- government sectors had received a supervisory visit in the month prior to the survey. UHFS 2002 District warehouse District hospital HC IV HC III HC II 0 20 40 60 80 100 Pe rc en ta ge o f f ac i lit ie s Within the past month Within the past 3 months Within the past 6 months Never Other Figure 3.6.1 Most recent supervisory visit (government facilities) UHFS 2002 HC IV HC III HC II 0 20 40 60 80 100 Pe rc en ta ge o f f ac ilit ie s Within the past month Within the past 3 months Within the past 6 months Never Other Figure 3.6.2 Most recent supervisory visit (non-government facilities) Of the logistics-related activities carried out during supervision, two are highlighted in Figures 3.7.1 and 3.7.2: whether supplies were checked and whether stock records were checked. For both gov- ernment and non-government facilities, both supplies and stock cards were checked during the majority of recent supervisory visits at government facilities and at non-government HC IVs and HC IIs. 3.6 Forecasting, ordering, and procurement Forecasting or quantification involves the estimation of the quantities of health commodities a program or a specific facility will dispense to other levels of the logistics system or to clients for a specific period of time in the future. In order to generate a well-informed and accurate forecast, commodity managers need good data on consumption trends by clients or on issues from one level to another. These data can be col- lected through the logistics or health management information system, but the data must be complete, Health Commodity Management and UHFS 2002 HC IV HC III HC II 0 20 40 60 80 100 Pe rc en ta ge o f f ac ilit ie s Supplies checked Stock cards checked Figure 3.7.2 Supervision of logistics practices (non-government facilities) UHFS 2002 District warehouse District hospital HC IV HC III HC II 0 20 40 60 80 100 Pe rc en ta ge o f f ac ilit ie s Supplies checked Stock cards checked Figure 3.7.1 Supervision of logistics practices (government facilities) Logistics System Performance | 29 timely and accurate, within an appropriate margin of error, to inform decisions on future use. This is criti- cal to ensure that sufficient quantities will be procured and distributed to storage and service delivery points to meet clients needs. Because forecasting involves an estimation of need, some margin of error is to be expected, particularly when forecasting for long periods of time. Once a solid forecast or projection of future needs is completed and budget levels established at the level where orders are made, the commodity manager can place an order for the forecasted amount of products and procure those commodities according to established procurement policies. Lower levels of the logistics system are not usually responsible for procuring commodities but rather usually place orders to the higher level. These functions—forecasting, ordering, and procurement—are necessary to determine the resupply quantities each facility will need and to ensure that those quantities arrive at the proper time and at the right cost to ensure continuous availability throughout the system. They are key components of the logistics cycle and critical for ensuring that the logistics system can meet its objective of making commodities available to the service providers who will dispense them to clients. Under the new decentralized system in Uganda, health facilities will complete their orders every two months and send them to the health sub-district (HSD). The HSD will authorize orders from the fa- cilities in their area. After receiving approval from the district, the HSD will order commodities from the National Medical Stores (NMS). NMS, an autonomous government corporation, was established in 1993 to procure, store, and distribute medicines and other health commodities to the public and private health sectors in Uganda. NMS is responsible for carrying out the international procurements of health com- modities for the country and also receives and manages donated commodities (e.g., contraceptives, vac- cines, TB medications) at the central level. If commodities are unavailable at NMS, the HSD will receive a letter indicating unavailability, and they are then authorized to purchase the commodities from another source. There is a parallel service offered by the Joint Medical Stores (JMS) that primarily serves NGOs and other private sector health facilities. The public sector does not routinely utilize the JMS as a supplier unless the NMS does not have commodities available. For public sector facilities, the up-front financial requirements and lack of delivery service at the JMS make purchases from JMS problematic. The NMS maintains a credit line or funds available for each facility in the country. This fund is drawn upon as fa- cilities place orders throughout the fiscal year. The credit lines are tracked by the NMS and notification of the remaining balance is sent with each filled order. The items ordered are packed by NMS according to the district requests and will be distributed to the district every two months. The transition to this new system is still underway, and the efficiency and effectiveness of the design will need to be assessed in the very near future. In the meantime, regional pharmacists will be tracking the flow of commodities monthly and will be conducting quarterly visits. Funding for essential drugs is now being provided directly from the MoH to districts and in some cases to health sub-districts for the purchase of drugs and other supplies, shifting logistics decision-making to this lower level. However, the absence of logistics training in how to make these decisions creates a real risk that commodities will not be properly planned for or purchased in the correct amounts. In logistics systems, there are two types of ordering systems, “push” and “pull,” distinguished by whom and how order quantities are determined. Uganda has been operating as a push system in which the staff who issue the supplies determine the quantities to be issued to each facility, in Uganda’s case through a pre-packaged essential drug kit system with commodities in fixed quantities. However, the MoH is currently transitioning to a pull distribution system in which the staff at the district and health sub-district levels who receive the supplies determine the quantities to order. The fixed quantity drug kits will be gradually phased out, and staff will have to determine order quantities for individual commodities for their facilities based on consumption trends and the availability of funds. Beginning in late 2002, the NMS plans to begin delivering commodities to each district every two months, and orders should be placed every two months using the HMIS pre-printed order forms. 30 | Health Commodity Management and Logistics System Performance Overall, 41 percent of facilities reported that they determine their re- supply quantities at least some of the time. In the current push system, 68 percent reported that the higher level facility determines their resupply quantities. Facilities could choose more than one answer for this ques- tion because there is not always a clear distinction of responsibility for calculating resupply quantities. For example, the essential drug kits are most often pushed in fixed quantities to each facility; however, each facility can also order supplemental com- modities to complement the kits to fulfill their needs. Figure 3.8 shows that while all of the district hospitals determine their own needs and HC IVs are a mix of push and pull ordering, the lower levels and the dis- trict warehouses rely mostly on the higher level to determine their order quantities in the public sector. UHFS 2002 District warehouse District hospital HC IV HC III HC II 0 20 40 60 80 100 Pe rc en ta ge o f f ac ilit ie s Pull Push Figure 3.8 Push vs. pull ordering practices (government facilities) The survey also looked at how often facilities placed orders in the last year. Twenty-five percent of the gov- ernment facilities and 26 percent of the non-government facilities placed be- tween 4 and 6 orders in the past year. In other words, a quarter of the facili- ties already place orders at intervals similar to what the new pull system will require. These facilities, in some capacity, are assessing their commod- ity needs to place orders. Of the gov- ernment facilities, Figure 3.9 shows that the majority of district hospitals, warehouses, and HC IVs are placing orders between 1 and 6 times a year. As mentioned above, by the end of 2002, all facilities should begin plac- ing commodity orders to the next highest level of the logistics system every two months. The MoH and NMS are committed to meeting this demand for government facilities. UHFS 2002 District warehouse District hospital HC IV HC III HC II 0 20 40 60 80 100 Pe rc en ta ge o f f ac ilit ie s None 1-3 times a year 4-6 times a year More than 6 times a year Figure 3.9 Frequency of orders placed in past year (government facilities) 3.7 Distribution and transportation Distribution and transportation are very important links in the supply chain for managing health com- modities. Timely distribution of the correct quantities of health commodities is critical for ensuring a con- tinuous supply. In resource-constrained environments, efficient use of transportation and/or transportation resources is key to minimizing wasted deliveries or trips to pick up or deliver commodities. Distribution of health commodities in Uganda is also being redesigned to reflect the decentralization of decisionmak- ing, ordering, and commodity delivery responsibilities. Health Commodity Management and Logistics System Performance | 31 Currently, the NMS receives orders from and delivers products to each of the 56 districts. The dis- tricts are then responsible for delivering the appropriate commodities to the health sub-districts. Each fa- cility then collects their commodities from the health sub-district (HSD). The MoH and NMS are explor- ing options for distributing commodities directly to the HSD level. In November 2002, a distribution cost study will be carried out to explore the possibilities of having NMS deliver directly to the health sub- districts. This would involve NMS delivering to 214 HSD sites as opposed to the 56 districts to which they currently deliver commodities. From the HSDs (HC IV level), the majority of health centers are within a reasonable distance to pick up their commodities. According to the survey results, 71 percent of facilities reported that they collect commodities from a higher level of the logistics system. The other 29 percent have the commodities delivered by other means: the district, health sub-district, supplier, or another mechanism. Table 3.10 presents these results by government and non-government facilities and by level of the system. Respondents could again choose more than one answer, since distribution often involves a mix of mechanisms in Uganda. Table 3.10 Distribution Percentage of facilities reporting various means by which they receive commodities, by facil- ity type and ownership, Uganda Health Facilities Survey 2002 Facility type Facility collects District-level facility delivers Sub-district- level facility delivers Supplier delivers Other GOVERNMENT FACILITIES District hospital 80.9 17.8 0.0 59.4 20.0 HC IV 71.9 48.6 18.1 0.0 0.0 HC III 71.3 37.6 35.8 0.0 0.8 HC II 60.3 33.3 30.2 0.0 0.4 District warehouse 33.3 0.0 0.0 50.0 33.3 NON-GOVERNMENT FACILITIES HC IV 67.3 5.4 0.0 32.9 16.3 HC III 100.0 6.7 3.1 0.0 0.0 HC II 79.1 10.2 0.0 19.6 18.2 For all levels of the system, the majority of both government and non-government facilities re- ported that they collect their commodities themselves from the source of supply. Most warehouses, on the other hand, have their supplies delivered from the higher level or directly from the supplier. The survey further explored what modes of transportation are used to transport commodities to fa- cilities. Poor infrastructure and road conditions and shortages in funding for fuel or other means of trans- portation often make distribution difficult. The modes of transportation most commonly used by govern- ment facilities are facility-managed vehicle (48%) or public transportation (48%) (Figure 3.10). The most common mode of transportation used in non-government facilities is public transport (70%), with a much smaller percentage using a facility-managed vehicle (27%). In the public sector, public transport is more frequently used at the lower levels, while a facility-managed vehicle is more commonly used at the higher levels. 32 | Health Commodity Management and Logistics System Performance UHFS 2002 Public transportation Facility-managed vehicle Private, hired vehicle Bicycle Other 0 20 40 60 80 100 Pe rc en ta ge o f f ac ilit ie s District warehouse District hospital HC IV HC III HC II Figure 3.10 Most frequently used mode of transport UHFS 2002 District warehouse District hospital HC IV HC III HC II 0 20 40 60 80 100 Pe rc en ta ge o f f ac ilit ie s < 50% of conditions met 50-75% of conditions met > 75% of conditions met Figure 3.11.1 Compliance to minimum storage criteria (government facilities) 3.8 Storage conditions Figure 3.11.2 All health commodities require specific procedures and conditions for safe storage that protect their integ- rity and effectiveness, maximize their shelf life, and make them readily available for distribution. When all levels of the system follow the same standards of storage, clients can be assured that they will receive a high-quality product. Because commodities are stored and transported from one level of the system to another, all levels of storage areas within the logistics system must comply with a set of minimum stan- dards to protect the commodities until they are distributed to a client at a service delivery point. 60 80 100 o f f ac ilit ie s At each facility, the survey teams visually inspected each storage area for each of the commodities studied. If commodities on the list were stored in different areas, then a separate checklist was completed for each area. The survey instrument includes a checklist of 13 standard storage conditions for all storage areas to ensure quality storage of all commodities, plus an additional 5 storage conditions for larger stor- age areas that require the stacking of multiple boxes (see the complete list in the survey instrument in Ap- pendix F). Some of these conditions are qualitative in nature and require a certain level of judgement on the part of the survey team; however, they are designed to be as objective as possible. HC IV HC III HC II 0 20 40 Pe rc en t < 50% of conditions met 50-75% of conditions met > 75% of conditions met UHFS 2002 ag e Compliance to minimum storage criteria (non-government facilities) Figures 3.11.1 and 3.11.2 present a summary of the level of compliance with the 13 minimum con- ditions for proper storage of health commodities in government and non-government facilities. It is clear that the non-government facilities comply with these conditions more often than the government facilities, although most of the government facilities also met the majority of the storage conditions studied. Overall, only about one-half of all government facilities met 75 percent or more of the conditions. The individual storage conditions can also be analyzed to extract problem areas in need of improve- ment or reinforcement. Figure 3.12 shows the percentage of facilities that met each of the 13 minimum conditions for storage areas, broken down by government and non-government facilities. Health Commodity Management and Logistics System Performance | 33 La be ls/ ex pir y da tes vi sib le Ac ce ss ibl e f or FE FO Ca rto ns , p rod uc ts in go od co nd itio n Da ma ge d & ex pir ed pr od uc ts se pa rat ed & rem ov ed Pr ote cte d f rom dir ec t s un lig ht Pr ote cte d f rom wa ter & hu mi dit y Fre e f rom in se cts & r od en ts Se cu red w ith lo ck & ke y Sto red at ap pro pri ate tem pe rat ure Ha za rdo us w as te pro pe rly di sp os ed of Ro of in go od co nd itio n Sto rer oo m in go od co nd itio n Su ffic ien t s pa ce 0 20 40 60 80 100 Pe rc en ta ge o f f ac ilit ie s Government Non-government Figure 3.12 Compliance with individual storage conditions UHFS 2002 All of the minimum storage criteria were met by at least half of the facilities visited. However, in the survey team’s judgement, about half of government facilities were not maintaining their storage space in good condition (Condition 12),1 that is, clean, all trash removed, sturdy shelves in place, and boxes or- ganized. Similarly, approximately half of the government facilities and close to half of the non- government facilities did not have sufficient space for the existing commodities (Condition 13)1 or space for reasonable expansion (i.e., for receipt of expected commodity shipments in the near future). This is difficult to judge, however, because health commodities are not currently maintained in full supply and it is difficult to know whether storage space would be sufficient if commodities were in full supply. 1 See storage conditions table, Question 429 (Part II Commodities Management), Survey Instrument (Appen- dix F). 34 | Health Commodity Management and Logistics System Performance Chapter 4 Service Provision While it is feasible to offer outpatient health services under a variety of conditions, there are infrastruc- ture, resource, and health system components that are important for enabling a facility to provide and maintain good quality health services, as well as to increase appropriate utilization by the population be- ing served. The health services that are assessed by this survey include services for HIV/AIDS, opportun- istic infections, sexually transmitted infections, and tuberculosis diagnosis and treatment. The Uganda Health Facilities Survey 2002 (UHFS) assesses the following basic infrastructure and resources related to service availability: 1) Availability of a range of services, with a frequency that meets basic needs; 2) Availability of qualified staff; 3) Infrastructure that provides basic client amenities; and 4) Infrastructure to support 24-hour emergency services and higher technical diagnostic and treatment interventions. Management and administrative systems are also important, to maintain and support quality health service delivery, to ensure that the health system is meeting the needs of the community, and to increase the probability that services will be appropriately utilized. The UHFS assesses the following basic sys- tems and strategies related to maintaining and supporting quality health service delivery and appropriate utilization, including 1) Management, supervision, and staff development activities; 2) Systems and practices for infection control; 3) Logistics systems to ensure quality and quantity of medicines and diagnostic commodi- ties; 4) Laboratory facilities; and 5) Availability of services, program components, and other aspects of services. 4.1 HIV/AIDS Support Services The UHFS investigated programs related to HIV/AIDS services in areas including voluntary counseling and testing (VCT), prevention of mother-to-child transmission (PMTCT), “youth-friendly” programs, ac- tivities for orphans and vulnerable children (OVCs), home-based care, management of opportunistic in- fections (OIs) and sexually transmitted infections (STIs), and diagnosis and treatment of tuberculosis (TB). The survey asked if each of these services was offered in the facility. Definitions for these services were provided in the training manuals and were available to the interviewer as probes. For example, VCT service was defined as requiring all three of the following: 1) laboratory test for HIV on request; 2) staff responsible for counseling for all clients on prevention of HIV/AIDS; and 3) staff responsible for counsel- ing positive clients. It is clear from the comparison of the responses to the question about availability of VCT service that the question may not have been well understood. Many of the facilities that reported having VCT services did not actually have laboratory testing for HIV on request. Because some of these definitions may have been a bit loose or may not have been completely understood, we present the avail- ability of services in this section as the perception of the facility that such a service was offered. Details of Service Provision | 37 the instructions to the interviewers, definitions of services, and the probes used are available in the man- ual for the survey instrument (Appendix F). Comparisons of this perception of provision of service with the minimum criteria that is used to judge the services in Chapter 5 are useful to evaluate the meaning of these responses. The survey investigated the components of each type of service, including outreach, partnerships, availability of guidelines, and exis- tence of a register to record program information. Figure 4.1 shows the proportion of health care facilities in the country that reported providing certain HIV/AIDS services in gov- ernment and non-government facili- ties. More detailed data can be found in Appendix G. OI and STI services are much more readily available than the other services studied in all facilities visited. It is clear that a larger percentage of the non-government facilities visited offer VCT, OI, STI, and TB diagnostic services, while a larger percentage of the government facilities visited offer PMTCT and TB treatment. UHFS 2002 VCT PMTCT OI STI TB Dx TB Rx 0 20 40 60 80 100 Pe rc en ta g e o f f ac ilit i e s Government Non-government Figure 4.1 Facilities providing HIV/AIDS services, government and non-government 4.1.1 Voluntary counseling and testing HIV VCT services encourage safe sex practices to ensure prevention and positive living for those already infected. Since the implementation of the VCT strategy, considerable progress in the health care delivery system has been made, and over 400,000 individuals have been tested for HIV countrywide since large- scale counseling and testing were initiated. Although HIV/AIDS counseling and testing facilities have been expanded considerably, there are still a number of constraints. These include: 1) inadequate HIV testing and counseling services, particu- larly in rural areas; 2) limited VCT counselors; and 3) low quality of testing facilities (e.g., staff, laborato- ries, and consumables) available at some sites. Based on this analysis, key recommendations have been identified in the Health Sector Strategic Plan (HSSP), including 1) expansion of HIV testing and counseling facilities to all districts; 2) develop- ment and provision of VCT guidelines to NGOs undertaking VCT and all districts; 3) training of VCT counselors and technical staff; 4) establishment of additional HIV VCT sites in other districts and sub- districts; and 5) carrying out VCT outreach activities (MoH, 2000). The UHFS investigates many of these issues by asking questions about program components, out- reach, partnerships, availability of guidelines, and existence of a register to record program information. Highlights of the findings are presented in this section. More detailed data can be found in Appendix G. Voluntary counseling and testing for HIV is reported available in 11 percent of the facilities in the country. VCT is more commonly offered in non-government compared to government facilities (21% and 7%, respectively). Differences among the various facility types and between government and non- government facilities are illustrated in Figure 4.2. 38 | Service Provision Of those facilities that report- edly offer VCT, the majority, 58 per- cent, are specialized services. All fa- cilities provide counseling upon request and post-test counseling, and nearly all (99%) offer testing. Most (78%) report that guidelines are avail- able in the clinic, and most (63%) have some type of visual aid to sup- port services. The mean number of clients in these facilities is 39 per month. 4.1.2 Prevention of mother-to- child transmission Given the heavy disease burden due to HIV/AIDS associated with pregnan- cies and recognizing the benefits of averting vertical transmission of HIV/AIDS, prevention of mother-to- child transmission has been a focus area for intervention in Uganda. Since 1992, a number of achieve- ments have been recorded in the prevention of HIV through PMTCT, including the launch of national policy guidelines for reduction of mother-to-child transmission. UHFS 2002 Government Non- government District hospital HC IV HC III HC II 0 20 40 60 80 100 Pe rc en ta ge o f f ac ilit ie s Figure 4.2 Facilities providing VCT, by ownership and facility type The constraints that have been identified in PMTCT within the Uganda health care delivery system include: 1) inadequate supervision and adherence to medical precautions of mothers who give birth at home; and 2) limited capacity of the health care system to offer counseling, testing, and follow-up of cli- ents, especially men, after delivery. Based on this analysis, the HSSP has made the following recommendations for developing the health care delivery system: 1) initiate a phased implementation of PMTCT in selected health units; 2) strengthen awareness and sensitization on PMTCT in order to facilitate informed decisionmaking and re- duce pregnancies among HIV-positive and discordant couples; and 3) promote utilization of disposable or sterile and other necessary maternal and child health, family planning, and safe motherhood equipment (MoH, 2000). The UHFS looks at many of these issues by asking questions about program components, outreach, partnerships, availability of guidelines, and existence of a register to record program information. High- lights of the findings are presented in this section. More detailed data can be found in Appendix G. Less than 6 percent of all facilities surveyed reported providing PMTCT services; HC IVs were mostly likely to provide the service, with 15 percent of HC IVs offering PMTCT. Of all facilities sur- veyed, 20 percent reported offering anti-retroviral therapy (ART). Figure 4.3 shows the proportion of facilities that offer PMTCT services by ownership and facility type. There are generally low levels of PMTCT services offered in the country. Service Provision | 39 UHFS 2002 Govern- ment Non- government District hospital HC IV HC III HC II 0 20 40 60 80 100 Pe rc en ta ge o f f ac ilit ie s Figure 4.3 Availability of PMTCT, by ownership and facility type 4.1.3 Services to improve the quality of life for the HIV-positive client Provision of care for the HIV-positive client remains an important challenge for the health care delivery system of Uganda. Current estimates indicate that 1.9 million people may be infected with HIV, and 400,000–500,000 are living with full-blown AIDS. These people and their families need psychosocial support, health care, and sources of income. Based on this analysis, key recommendations have been identified in the HSSP, including: 1) pro- viding more support to local NGOs and community-based organizations (CBOs) providing AIDS care and treatment; 2) strengthening palliative care for people living with HIV/AIDS (PLHAs); 3) strengthen- ing modern and herbal treatment for opportunistic infections; and 4) sensitization and education of com- munity members on health care delivery, counseling, hygiene, nutrition and other relevant issues for PLHAs (MoH, 2000). The UHFS studied many of these issues by asking questions about program components, outreach, partnerships, availability of guidelines, and existence of a register to record program information. High- lights of the findings are presented in the next two sections on management and treatment of opportunistic infections and home-based care. More detailed data can be found in Appendix G. 4.1.4 Management and treatment of opportunistic infections HIV infection predisposes the infected person to a number of diseases, including pneumonia, cryptococ- cal meningitis, Kaposi’s sarcoma, cryptosporidial diarrhea, candidiasis of the esophagus, and herpes infections. Tuberculosis is also considered an opportunistic infection (OI). Because of its importance in the Ugandan context, tuberculosis diagnosis and treatment is dealt with in a subsequent section. Management (prevention, diagnosis, and treatment) of OIs in HIV/AIDS patients is reportedly of- fered in 63 percent of health care facilities in the country. The service is offered at different levels in dif- ferent facility types and in government versus non-government facilities (Figure 4.4). 40 | Service Provision In facilities that offer manage- ment of OIs, most provide these ser- vices integrated with other services (97%). However, more than 25 per- cent of district hospitals offer special- ized services for OI management. Most facilities that offer OI services provide counseling (88%) and pre- scribe drugs (99%). However, only one-third of these facilities provide laboratory diagnosis, and only 7 per- cent offer x-ray services. Guidelines are available in 60 percent of facilities that offer OI management. Most (over 90%) have a register to record pro- gram information. UHFS 2002 Govern- ment Non- government District hospital HC IV HC III HC II 0 20 40 60 80 100 Pe rc en ta ge o f f ac ilit ie s Figure 4.4 Availability of OI management services, by ownership and facility type 4.1.5 Social, economic, and psy- chological support It was recognized early in Uganda that the HIV/AIDS epidemic would result in serious social and eco- nomic consequences due to a changed pattern of public expenditures and private savings. The morbidity and mortality rates of the workforce would increase, leading to a serious loss of manpower. NGOs and CBOs have been the lead agencies in the provision of social support to PLHAs. Government ministries, through their AIDS control programs (ACPs), have also extended social support to the respective em- ployees and their dependents. Contributions of government, NGOs, and community in the following areas have helped mitigate some of the socio-economic impact of the epidemic: 1) development and support of income-generating projects (IGPs) as one way to minimize the adverse socio-economic effects on PLHAs; 2) provision of social support to PLHAs by NGOs/CBOs, religious groups and community; 3) training community-based counselors to enable community members to handle HIV/AIDS issues; and 4) setting up peer post-test clubs. Based on this analysis, the HSSP has made the following recommendations for development of the health care delivery system: 1) provision of financial and material support (shelter, food, school fees) to AIDS orphans, child-headed households, and guardians/foster families; 2) promotion of economic and material assistance to PLHA families; and 3) promotion of protection of legal, ethical and social rights of PLHAs (MoH, 2000). The UHFS addresses many of these issues by asking questions about program components, out- reach, partnerships, availability of guidelines, and existence of a register to record program information. Highlights of the findings are presented in the next three sections on targeted activities for orphans and vulnerable children, youth-friendly programs, and social support/post test services targeted to HIV- positive clients and their families. More detailed data can be found in Appendix G. 4.1.5.1 Targeted activities for orphans and vulnerable children Targeted activities for orphans and vulnerable children (OVCs) can include programs and outreach ser- vices funded by the facility that address social issues, economic support, or psychosocial counseling for Service Provision | 41 OVCs and/or their caretakers. These services were reported to be available in 5 percent of facilities in Uganda. One-fourth of HC IVs had OVC services. Among those facilities that reported having OVC services, most offer these services integrated with general services (62%). More than 95 percent of these facilities offer counseling, 49 percent offer support, and 53 percent organize groups. Guidelines for OVC services were available in 13 percent of the facili- ties. 4.1.5.2 Youth-friendly programs “Youth-friendly” programs address adolescent audiences, focusing on youth participation, utilization of services, or outreach services funded by the facility. These services may relate to preventative education for HIV, VCT, diagnosis and treatment of STIs, family planning and safe motherhood services. Youth- friendly services were reported available in 12 percent of facilities in the country. One-fourth of HC IVs and 39 percent of hospitals have youth-friendly programs. Among those facilities that reported having youth-friendly programs, most offer them integrated with general services (89%), and 85 percent have outreach programs. Ninety-five percent of these facili- ties offer STI diagnosis and treatment, and VCT is offered in 36 percent of those programs. Table 4.1 de- scribes the level of the various program components in youth-friendly services by ownership and facility type. Guidelines for youth-friendly services were available in 34 percent of the facilities. Table 4.1 Youth-friendly services Among facilities with youth-friendly services, percentage of facilities offering various specific ser- vices, by ownership and facility type, Uganda Health Facilities Survey 2002 Ownership/ facility type Group meetings Information campaigns VCT STI Dx and Tx Family planning Safe motherhood Ownership Government 63.1 86.2 35.0 93.4 93.6 85.9 Non-government 52.9 44.8 37.8 100.0 91.8 91.8 Facility type District hospital 100.0 100.0 100.0 100.0 100.0 100.0 HC IV 52.4 77.5 30.8 93.9 85.4 85.4 HC III 62.6 66.8 32.4 96.3 96.3 96.3 HC II 46.7 77.2 15.6 91.9 92.5 69.5 Total 60.6 75.9 35.7 95.0 93.1 87.4 4.1.5.3 Home-based care The demand for palliative care services by patients with HIV/AIDS is expected to increase further as more people are infected. The annual population per hospital bed has risen to 800. Likewise, health per- sonnel are now attending to many more patients as a result of the HIV/AIDS epidemic. As of 1997, pa- tients with HIV/AIDS-related illness occupied more than 55 percent of hospital beds. Furthermore, health workers also experience psychosocial stress due to fear of being infected, while some may exhibit stigma. This implies that a proportion of PLHAs are turned away. Home-based care is reportedly offered by 12 percent of the facilities in the country. Of those facili- ties that offer home-based care, 69 percent offer services that are integrated into general services, and 31 percent have specialized services. Over 87 percent of the facilities offer outreach services. Over 90 per- cent of the facilities that offer home-based care offer services in home, train caretakers, and do commu- 42 | Service Provision nity education and advocacy, while only 14 percent offer material support. Guidelines for providing home-based care are available in less than 30 percent of facilities. 4.1.5.4 Social support/post-test services targeted to HIV-positive clients and family The AIDS epidemic has also adversely affected the economic sector. Unlike other illnesses, it selectively affects adults in their prime productive years. Sickness and death due to HIV/AIDS affects places of work through absenteeism and loss of skilled or trained employees. At the household level, treatment cost of AIDS financed from household savings reduces the capital available for investment in agriculture, educa- tion, and other areas. Furthermore, the time spent by relatives on care for AIDS patients is deducted from the time spent on production and income-generating activities. This tends to worsen poverty and increases inequality. Social support/post-test services targeted to HIV-positive people and their families were reportedly available in 8 percent of facilities in the country. Half of hospitals and one-quarter of HC IVs had social support and post-test services. Services were available at approximately equal levels in government and non-government facilities (7%). Among those facilities that have social support and post-test services, 48 percent offered them as integrated with general services, and 89 percent have outreach programs. All of the facilities offering so- cial support and post-test services provided counseling, 21 percent provided support, and 66 percent had social programs. Guidelines for social support and post-test services were available in 44 percent of the facilities. 4.1.6 Sexually transmitted infections The close association between the presence of an STI and HIV infection has made STI prevention and treatment an important component of HIV/AIDS prevention. Progress in the area of STI care includes 1) development and distribution of guidelines on syndromic management of STIs; 2) training service pro- viders in diagnosis and syndromic management of STIs; and 3) integrating STI services with primary health care, maternal and child health, and family planning services. In spite of the progress realized, there are still a number of constraints in implementing the strategy of preventing HIV transmission through the prevention and treatment of STIs. These include 1) limited number of trained personnel in STI syndromic management; 2) low partner notification of STI infection (about 5–15 percent of STI patients ever notify their partners about their STI status [MoH, 1999]); and 3) inadequate treatment of STIs resulting in resistance to drugs. Based on the assessment of the HSSP, recommendations include: 1) strengthen syndromic man- agement of STIs through comprehensive screening and treatment and special studies to keep track of STI transmission and prevalence in core groups; and 2) integrate STI prevention and treatment into other health services (MoH, 2000). The UHFS looks at many of these issues by asking questions about program components, outreach, partnerships, availability of guidelines, and existence of a register to record program information. High- lights of the findings are presented in this section. More detailed data can be found in Appendix G. STI services are reportedly provided by 72 percent of facilities in the country. Figure 4.5 shows the level of STI services by facility type and ownership. STI services are available in 67 percent of govern- ment facilities and 86 percent of non-government facilities. Most STI services are integrated into general services (98 percent). Service Provision | 43 UHFS 2002 Govern- ment Non- government District hospital HC IV HC III HC II 0 20 40 60 80 100 Pe rc en ta ge o f f ac ilit ie s Figure 4.5 Availability of STI services, by ownership and facility type 4.1.7 Diagnosis and treatment of tuberculosis Tuberculosis (TB) has been identified as one of the common HIV-associated infections. A study con- ducted among a pediatric cohort revealed that 18 percent of HIV-infected infants developed TB compared with 1.4 percent of those not infected with HIV, and the successful response to treatment was 31 percent and 83 percent respectively. Because the cost of TB treatment spreads over a long period of time, the capacity of hospitals and dispensaries is often over-stretched. The management of other infections commonly associated with HIV/AIDS also generally involves long periods of stay in hospitals and is expensive. Consequently, there is a general shift of emphasis from hospital-based care to home-based care as a means of reducing the pressure on hospitals and health units and providing similar services to PLHAs and community members wherever they may be. It is also recognized that integrating primary health care, AIDS care, and counsel- ing into home-based care would enhance the quality of care for PLHAs while reducing the cost of care. The expansion of the DOTS tuberculosis treatment system to all health facilities is a goal of the current HSSP. UHFS 2002 Govern- ment Non- government District hospital HC IV HC III HC II 0 20 40 60 80 100 Pe rc en ta ge o f f ac ilit ie s Diagnosis Treatment Figure 4.6 Availability of tuberculosis diagnosis and treatment, by ownership and facility typeThe UHFS addresses many of these issues by asking questions about program components, outreach, part- nerships, availability of guidelines, and existence of a register to record program information. More detailed data can be found in Appendix G. Figure 4.6 presents the propor- tions of all facilities in the country that reported providing tuberculosis diag- nosis and treatment by ownership and facility type. Tuberculosis diagnosis and treatment are available in 23 per- cent and 31 percent, respectively, of health care facilities in the country. 44 | Service Provision Hospitals are most likely to offer these services. Over 90 percent of tuberculosis diagnosis services are integrated into general services across own- ership and facility type. Tuberculosis treatment services are also highly integrated (over 85% of all facili- ties offering treatment). 4.2 Facility infrastructure and resources 4.2.1 Provider training and supervision The UHFS interviewed providers of HIV/AIDS-related services in each facility regarding their basic training and experience, as well as recent (in the past three years) in-service training and experience with being personally supervised. Data collectors were instructed to interview all staff who were providing the services being assessed on the day of the survey. Anticipating that time might not be sufficient for this in large facilities, a minimum of 4 different staff interviews was required, with the selection ensuring that providers for all four of the following service areas would be interviewed: 1) HIV/AIDS counseling and testing services, including VCT and PMTCT; 2) Management of OIs; 3) Management of STIs; and 4) Tuberculosis diagnosis and treatment. Where staff members provided more than one service, an attempt was made to identify other pro- viders to ensure that interviewed providers covered as many of the specific services assessed in this sur- vey as possible. It can be assumed that in most cases these criteria result in a sample where findings are positively biased, as staff whose attendance is irregular, or who are less active in providing services, are less likely to have been present. The next three sections draw on the “Provider Interview” component of the instrument. 4.2.1.1 Training and experience A total of 366 providers of HIV/AIDS-related services were interviewed. Of those interviewed, the major- ity were women (women 62%, men 38%). Professional midwife was the most common level of education among providers (23%), followed by medical assistants (22%), and professional nurse (20%). Only 2 per- cent of the interviewed providers were doctors. 4.2.1.2 In-service training In order to maintain levels of knowledge and technical competence achieved during basic training, it is essential that health workers be provided continuous exposure to current and new information, both to refresh knowledge and to update practices as new policies and protocols are introduced. This is most of- ten achieved through in-service education. In addition, supportive supervision is important to ensure that standards and protocols are followed at the facility level and to promote an “organizational culture” where it is expected that these standards and protocols will be implemented. Figure 4.7 shows the proportion of all interviewed health care providers who reported receiving in- service training in the preceding three years for any HIV/AIDS-related topics. Prevention and support counseling were the most frequently reported in-service training received by providers (32% each). In- service training for DOTS was reported by 11 percent of providers (data not shown), although, as noted in Chapter 3, DOTS had not yet been implemented in all districts at the time of the survey. Service Provision | 45 Table 4.2 shows the proportion of health care providers interviewed who reported receiving any in-service training in the past three years by ownership and facility type. Providers working in hospitals are most likely to have received any in-service training in the past three years, with over 80 percent of hospital providers receiving training. Table 4.2 In-service training of staff Percentage of interviewed providers who reported having received any in-service training in the 3 years preceding the survey, by ownership and facility type, Uganda Health Facilities Survey 2002 Facility type Government Non-government District hospital 84.0 NA HC IV 62.5 66.2 HC III 43.9 44.3 HC II 41.8 43.8 NA = Not applicable UHFS 2002 STI VCT PMTCT OI ART Counseling, support Other 0 20 40 60 80 100 Pe rc en ta ge o f p ro vi de rs Figure 4.7 In-service training in HIV/AIDS-related topics in the past three years 4.2.1.3 Supervision Supervision of individual staff members helps to promote adherence to standards and to identify problems that contribute to poor quality services. The UHFS documents whether staff members report they have been personally supervised by someone from outside the facility during the past six months and, if so, how many times during the past six months they were supervised. Table 4.3 shows the proportion of interviewed providers who reported being personally supervised by someone external to the facility within the past six months and the average number of times they were supervised, by ownership and facility type. Health care providers in Uganda reported being supervised an average of 3.4 times during the prior six months by external supervisors, with 86 percent of those inter- Table 4.3 Outside supervision of providers Percentage of interviewed providers who reported having received any outside supervision in the past 6 months, and aver- age number of times providers were supervised, by ownership and facility type, Uganda Health Facilities Survey 2002 Percentage receiving outside supervision Average number of times supervised Facility type Government Non-government Government Non-government District hospital 58.6 NA 3.1 NA HC IV 88.1 64.9 4.0 2.1 HC III 89.2 82.4 3.7 2.5 HC II 96.6 79.5 3.6 2.6 NA = Not applicable 46 | Service Provision viewed providers having been supervised at least once. Staff at government facilities were much more likely to receive supervision and at a higher fre- quency than non-government facilities. Among government facilities, an increasingly greater percentage of facilities at the lower levels received outside supervision. 4.2.2 Laboratory capacity and facilities As stated in the MoH Annual Health Sector Performance Report (AHSPR), TB rates have steadily in- creased 8 percent each year since 1994. This is mainly due to the increasing number of people living with HIV/AIDS. The reported HIV prevalence rate in Uganda as of 2002 is 6 percent. People with STIs are at greater risk of contracting HIV. Comprehensive and well-functioning laboratory services are imperative for the prevention, diagno- sis and control of HIV/AIDS, and related communicable diseases such as TB and STIs. Laboratory tests are essential for early diagnosis of TB and for implementing and monitoring the effectiveness of treat- ment programs (such as DOTS). They are also essential for diagnosing HIV/AIDS (for VCT and PMTCT), and for monitoring effectiveness of treatments, including anti-retroviral therapy. In addition, laboratory diagnostic testing provides accurate diagnoses of STIs and OIs so appropriate treatment can be provided. 4.2.2.1 Indicators for laboratory diagnostics In order to assess laboratory capacity for diagnosis of HIV, TB, and STIs, the survey identified basic cri- teria that must be available at each laboratory on the day of the visit. To conduct an HIV, TB, or syphilis test, laboratories require: a)

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