Uganda Health Facilities Survey 2002

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; Internet: 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; Internet: 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 Pre- vention (CDC). The Programme was devised in consultation with the Ministry of Health, the Uganda AIDS Commission, international agencies, non-governmental organizations (NGOs), community-based organi- zations (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 | iii 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 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 HIV test kits .14 Contraceptives and condoms .15 Drugs to treat opportunistic infections .16 Malarial drugs .17 iv | Contents Drugs to treat sexually transmitted infections .17 Anti-retroviral drugs .18 Tuberculosis drugs .18 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 4.1.5 Social, economic, and psychological support .41 Targeted activities for orphans and vulnerable children.41 Youth-friendly programs.42 Home-based care .42 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 Training and experience .45 In-service training .45 Supervision.46 4.2.2 Laboratory capacity and facilities .47 Indicators for laboratory diagnostics .47 HIV diagnosis.48 TB diagnosis .49 Syphilis laboratory diagnosis.50 4.2.3 Infection control .51 Contents | v Capacity to disinfect equipment.51 Infection prevention in the service delivery area.52 Laboratory infection control.54 Management and disposal of hazardous health care waste .55 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 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 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. xxviii | Summary of Findings 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.

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