Uganda's APAC District: Contraceptive Logistics System Assessment and Action Plan - Covering the Last Mile to Ensure Availability

Publication date: 2008

UGANDA’S APAC DISTRICT: CONTRACEPTIVE LOGISTICS SYSTEM ASSESSMENT AND ACTION PLAN COVERING THE LAST MILE TO ENSURE AVAILABILITY NOVEMBER 2008 This publication was produced for review by the U.S. Agency for International Development. It was prepared by the USAID | DELIVER PROJECT, Task Order 1. UGANDA’S APAC DISTRICT: CONTRACEPTIVE LOGISTICS SYSTEM ASSESSMENT AND ACTION PLAN COVERING THE LAST MILE TO ENSURE AVAILABILITY The authors' views expressed in this publication do not necessarily reflect the views of the U.S. Agency for International Development or the United States Government. 3 USAID | DELIVER PROJECT, Task Order 1 The USAID | DELIVER PROJECT, Task Order 1, is funded by the U.S. Agency for International Development under contract no. GPO-I-01-06-00007-00, beginning September 29, 2006. Task Order 1 is implemented by John Snow, Inc., in collaboration with PATH, Crown Agents Consultancy, Inc., Abt Associates, Fuel Logistics Group (Pty) Ltd., UPS Supply Chain Solutions, The Manoff Group, and 3i Infotech. The project improves essential health commodity supply chains by strengthening logistics management information systems, streamlining distribution systems, identifying financial resources for procurement and supply chain operation, and enhancing forecasting and procurement planning. The project also encourages policymakers and donors to support logistics as a critical factor in the overall success of their health care mandates. Recommended Citation USAID | DELIVER PROJECT, Task Order 1. 2008. Uganda’’s Apac District: Contraceptive Logistics System Assessment and Action Plan: Covering the Last Mile to Ensure Availability. Kampala, Uganda. USAID | DELIVER PROJECT, Task Order 1. Abstract A successful health care program delivers consistent, high-quality, cost-effective services. A carefully planned, well-functioning logistics system can ensure a dependable supply of health care products for the clients who need them. When a health facility is fully stocked with a wide range of contraceptive methods and essential drugs, clients gain confidence in that facility and they are more likely to return. Women without reliable access to reproductive health care and commodities face an increased risk of birth complications, unintended or mistimed pregnancies, unsafe abortions, infectious diseases, and even death. A reliable, responsive logistics system makes the difference between a client consistently receiving the product he or she needs——condoms, vaccines, and other drugs——or a client walking away empty-handed. This report presents the findings of an assessment of Apac district’’s contraceptive supply chain and a short and long-term action plan to improve the contraceptive logistics system to ensure product availability in Apac district. Cover photo: Apac district team work on the assessment at the Metropole Hotel in Kampala, Uganda, in October 2008. USAID | DELIVER PROJECT John Snow, Inc. Plot 65 Katalima Road Naguru Kampala, Uganda Phone: (256) 414-253-246 Fax: (256) 414-253-245 E-mail: askdeliver@jsi.com Internet: deliver.jsi.com CONTENTS Acronyms. v Acknowledgments . vii Executive Summary . ix Background.1 Context.3 Objectives.3 Methodology .3 Contraceptive Logistics System Assessment . 5 I. Organization and Staffing.5 II. Logistics Management Information System.5 III. Obtaining Supply and Procurement.6 IV. Inventory Control Procedures.7 V. Warehousing and Storage .7 VI. Transportation and Distribution.8 VII. Organizational Support for Logistics .8 VIII. Product Use.9 IX. Finance and Coordination.10 Action Plan .11 References.15 Appendices Appendix A: List of People Interviewed.17 Appendix B: Facilities Visited .19 Appendix C: LSAT and Action Plan Development Workshop Participation.21 Appendix D: Apac District Demographic Info .23 Figures Figure 1. Contraceptive Logistics System Scores in Apac District .x Tables Table 1. Key Logistics Element Scores for Contraceptive Management in Apac District . ix Table 2. Key Health Indicators .2 Table 3. District Trends for the 5 PEAP Indicators .2 Table 4. Action Plan Table.11 Table 5. Interviewee List.17 iii Table 6. List of Participants .21 Table 7. Apac District Demographic Features (2006-2007) .23 iv ACRONYMS ADLG Apac district local government ANC antenatal care CBDs community-based distributors DHO Distrct Health Office DHT District Health Team FEFO first-to-expire, first-out HC health center HIV human immunodeficiency virus HMIS health management information systems HSD health subdistrict IMR infant mortality rate IUD intrauterine device LMIS logistics management information systems LIAT Logistics Indicators Assessment Tool LSAT Logistics System Assessment Tool MMR maternal mortality ratio MR mortality rate MOH Ministry of Health NTLP National Tuberculosis and Leprosy Program OPD outpatient department PEAP Poverty Eradication Action Plan PHC primary health care RH reproductive health SDP service delivery point TFR total fertility rate TOR terms of reference UNEPI Uganda National Expanded Program on Immunization UNICEF United Nations Childrens’’ Fund USAID U.S. Agency for International Development v vi ACKNOWLEDGMENTS We offer particular thanks to the Apac District Health Office and the District Health Team, the heads of each facility visited and their respective team members, all the participants in the central workshop where action plans were developed, organizers, hosts, financers and the entire USAID | DELIVER PROJECT staff for their priceless contributions towards making this activity a success. vii viii EXECUTIVE SUMMARY The district of Apac partnered with the USAID | DELIVER PROJECT to assess the logistics system for managing contraceptives within its borders. Apac district is located in northern Uganda, bordered by the districts of Oyam towards the north, Lira in the northeast, Nakasongola in the south, and Masindi to the west. The district has a population of 447,217 which is approximately 49% male and 51% female. The district includes three counties, three constituencies/ health subdistricts (HSDs), fifteen subcounties, 81 Parishes, and 1093 villages. Assessment teams studied the district’’s contraceptive commodity management, carefully focusing on implementation of each element of the logistics cycle. This was accomplished through field facility visits and interviews, followed by joint discussions of findings among system participants. Based on these findings and discussions, teams participated in a workshop where a district action plan was developed to further strengthen the system. Table 1. Key Logistics Element Scores for Contraceptive Management in Apac District Logistic Element Evaluated Assessment score I. Organization and Staffing 32.6% II. Logistics Management Information System (LMIS) 35.2% III. Obtaining Supplies/Procurement 30.8% IV. Inventory Control Procedures 32.5% V. Warehousing and Storage 60.7% VI. Transport and Distribution 0% VII. Organizational Support for Logistics System 54.5% VIII. Product Use 87.5% IX. Finance/Donor Coordination/RHCS Planning 14.3% All public institutions offer family planning (FP) services to clients. Treatment guidelines have been developed and distributed to all units. Sixty community-based service providers were trained in three HSDs. Still, uptake remains low and additional sensitization is needed. Through the assessment, it was noted that most personnel who manage stores and supplies in the district lack formal training in logistics. Stores management was not their primary role in the facilities and skills were acquired hands-on. Salaries for only a few logistics staffers in the district are covered within the district budget. All other logistics activities (e.g. transportation, waste management, LMIS, storage) are not supported by budget lines. ix In the three months leading up to this assessment, all sites evaluated had received a supportive supervision visit, including attention to reproductive health (RH) aspects. However, logistics topics weren’’t covered sufficiently and further attention to logistics during supervision is needed. Although stock cards were in use in all facilities visited, most stock cards examined had not been updated. Forms such as HMIS 105 and 018 were on hand at facilities for reporting and ordering purposes; however; in many cases, LMIS forms weren’’t being completed at lower levels. According to the order forms and delivery notes seen, facilities that ordered supplies had received their full order. The HSD prepared default orders for facilities that did not order, but a defined formula had not been set for determining order quantities. Minimum and maximum stock levels were set by the central level, but these were not being followed at the lower facilities. The HSD is the main player in delivering supplies to the facilities. In some instances, however, facilities have had to travel to collect their supplies. Lower-level facilities lack transport means, making it difficult to collect their supplies as required. Once at facilities, commodities are stored in generally acceptable conditions, with facilities meeting 12 out of the 17 proper storage parameters on average. The most common storage concern was the lack of fire safety equipment and pallets. Reproductive health utilization and corresponding logistics management in Apac district generally remains poor. Using assessment findings, the district created an action plan for improving the system. Actualizing this plan, coupled with continuous monitoring, can result in significantly- improved contraceptive availability for the people of Apac district. Figure 1. Contraceptive Logistics System Scores in Apac District 33% 35% 31% 33% 61% 0% 55% 88% 14% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% IX . Finance/ D onor C oordination/ RH C S Planning VIII. Product U se VII. O rganizational Support for Logistics System VI. Transport and D istribution V. W arehousing and Storage IV. Inventory C ontrol Procedures III. O btaining Supplies/ Procurem ent II. Logistics M anagem ent Inform ation System (LM IS) I. O rganization and Staffing x BACKGROUND Apac district is located in northern part of Uganda, between longitudes 320 East and 340 East and latitudes 20North and 30 North. It is bordered by Oyam in the North, Lira in the North East, Nakasongola in the South, and Masindi in the West. The district is comprised of 3 counties, 3 constituencies/ HSD, 15 Sub counties (inclusive of Apac town council), 81 parishes, and 1093 villages. Apac district has a population of 447,217,1 approximately 49% male and 51% female. The district’’s primary socioeconomic activity is subsistence farming. Other activities include fishing, small scale trading, rearing animals, and poultry keeping. Yields are typically poor due to lack of modern farming technology, yet over 95% of the local economy depends on agriculture, resulting in low household income. The district includes 37 health facilities, including Apac hospital. The hospital is in a sorry state of disrepair; in July 2005, its renovation/rehabilitation was estimated at 4 billion Uganda shillings by engineers from MOH headquarters. Only 36 (45%) out of 83 parishes have health facilities. Inomo, Akalo and Bala Sub-counties have one health unit each while Ayer subcounty has no HC III. Physical access is limited to 37% of the population within 5 km radius of a health facility. In terms of infrastructure, it should be noted that only 8 kilometers of road are constructed of tarmac, with remaining roads made of murrum which is poorly maintained. The national electricity grid supply is in place in Apac town council and Aduku town board; however, most areas of the district remain without national grid service. Water is not piped into the district except in a few limited areas in Apac town. Most health facilities are in remote areas without such utilities. Safe water coverage is estimated at 52%, with latrine coverage is at only 57% coverage. On the other hand, three mobile telephone systems are in place, including MTN, Mango and Celtel. Many participants support health sector activities in Apac district. These include PHC, whose grant supports the district in delivering the national minimum health care package at all levels throughout the community based on approved annual work plan. NTLP supports the district health department with leprosy and tuberculosis drugs. UNICEF supports the district in immunization, nutrition, hygiene education in home-based care and HIV/AIDS. ADLG pays staff salaries and logistical support in maintaining vehicles. UNEPI works on routine immunization and IDSR, while NUMAT supports malaria, HIV/AIDS, and tuberculosis control and prevention. 1 2002 census projection 1 Table 2. Key Health Indicators2 Indicators Apac District National IMR 114/1000 83/1000 live birth UNDER 5MR 191/100 MMR 505/100,000 435/1000 Growth rate 3.5 Life expectancy Male Female Average (Total) 47.7 yrs 53 yrs 50.3 yrs - - 52 yrs TFR 7.07 6.9 Contraceptive prevalence rate 9% 30% Table 3. District Trends for the 5 PEAP Indicators3 Indicator 2002/03 2003/04 2004/05 2005/06 2006/07 Percentage of deliveries taking place in health facilities` 8.8% 18% 27% 25% Proportion of approved posts filled by trained health workers 34% 65% x Utilization of the outpatient department is steadily increasing, possibly due to improved availability of essential medicines and health supplies as a result of the pull system using primary health care and credit line funds x A leap in facility-based deliveries to 27% in 2005/06 (from 18% in 2004/05) is attributed to provision of ITNs to mothers who attend ANC and those delivering at health facilities. Secondly, health workers were recruited and trained on various reproductive health skills that may have improved on mother-health worker relationship stimulating utilization of RH services during the year. 2 UDHS Source: HMIS 2 3 CONTEXT A successful health care program delivers consistent, high-quality, cost-effective services. A carefully planned, well-functioning logistics system can ensure a dependable supply of health care products for the clients who need them. When a health facility is fully stocked with a wide range of contraceptive methods and essential drugs, clients gain confidence in that facility and they are more likely to return. For example, if women were given reliable access to the full range of contraceptives, it is possible to prevent one of every four deaths related to pregnancy in the developing world. Women without reliable access to reproductive health care and commodities face an increased risk of birth complications, unintended or mistimed pregnancies, unsafe abortions, infectious diseases, and even death. A reliable, responsive logistics system makes the difference between a client consistently receiving the product he or she needs——condoms, vaccines, and other drugs——or a client walking away empty-handed. The success of your health care program depends on the strength of your system. Stock level challenges, ranging from stockouts to overstocks, have inspired further attention to address contraceptive availability irregularities in the district. Field visits were conducted using a mini LIAT and then followed by an LSAT which yielded inputs for the development of an action plan to ensure contraceptive commodity security in Apac district. In fact, the overall objective of the exercise was aimed at ensuring commodity security in Apac district. OBJECTIVES x Provide comprehensive view of all aspects of the contraceptives logistics system x ҏDiagnose and identify logistics and contraceptive security issues and opportunities x ҏRaise collective awareness and ownership of system performance and goals for improvement x ҏBe used by country personnel as a monitoring tool for continuous learning and performance improvement x ҏProvide input to inform workplanning METHODOLOGY A group composed of central and district level participants conducted a logistics system evaluation of the district using the LIAT and LSAT tools. Six facilities were visited, including the district health office. After field visits were complete, a team of six district personnel were invited to join the visiting team for a three-day meeting to complete the assessment exercise. The meeting came to consensus over the SWOT analysis, drew a summary table, and identified opportunities of improvement. Next, the group collaborated to create an action plan to guide the district in ensuring commodity availability. 3 4 CONTRACEPTIVE LOGISTICS SYSTEM ASSESSMENT I. ORGANIZATION AND STAFFING District logistics activities are managed by two fully-paid staffers, including the supplies officer at the hospital and the district stores person. Other personnel up to HC III (records assistants) were expected to participate as well, however, the human resource budget line proved inadequate. They had a communication system in place which helped pass on information especially about reporting and receiving of supplies at the district. Due to the limited staff, the logistics activities were assigned to other people but not as primary role STRENGTHS WEAKNESSES ƒ Basic logistics team overseeing the system in the district ƒ Full-time personnel managing stores at the district and hospital ƒ Coordinating logistics activities (e.g. departmental meetings, radio calls) ƒ Lack of defined TOR for the unit managing logistics in the district ƒ Restrictive staffing structure ƒ Inadequate capacity to manage logistics at facility level ƒ No documented clear guidelines for inventory management, storage, distribution and obtaining of supplies needed RECOMMENDATIONS ƒ Train personnel managing stores ƒ Develop standard guidelines for ordering, storage and inventory management procedures ƒ Increase target support supervision on logistics ƒ Review the staffing norms to advocate for stores assistants to be recruited at HC IIIs ƒ Formalize the terms of reference for the logistics management unit at the district II. LOGISTICS MANAGEMENT INFORMATION SYSTEM The section focuses on LMIS form use, reporting and ordering, reported lead time and accuracy of data. During the visit, it was discovered that the facilities had most LMIS tools such as HMIS 105, 018 and 55(stock cards). The stock cards were being used; however, the biggest challenge faced was updating them. The report and order forms were not being sent. The facilities visited showed no use of the data they were collecting and the district generally lacked feedback mechanisms. 5 STRENGTHS WEAKNESSES ƒ Trainable staff available to manage the LMIS ƒ Lack of automated LMIS ƒ No feedback mechanisms ƒ No data validation on data collected ƒ Order form for contraceptives tagged to credit line order form for essential medicine RECOMMENDATIONS ƒ Train staff in LMIS ƒ Institute a mechanism to ensure feed back to the lower units ƒ Provide Automated LMIS to all units managing logistics information in the district ƒ Develop criteria for data validation at the district and lower levels III. OBTAINING SUPPLY AND PROCUREMENT As set out in the national system design, facilities send orders to the central level, where product resupplies are predetermined by the national coordination program. However, most facilities visited were not sending these to the center. As a result, default orders are made by HSDs and submitted on behalf of facilities under them. For products procured under the PHC funds, the district has a procurement plan and pre-qualified supplier list; however, they lack a quality assurance scheme. STRENGTHS ƒ Facility managers responsible for obtaining needs ƒ Procurement plan in place for district ƒ District has procurement guidelines which limits procurements to pre-qualified suppliers and products on the essential medicines list WEAKNESSES ƒ No quality assurance mechanisms ƒ Procurement plan doesn’’t consider most essential data items and lead times ƒ No monitoring of the procurement pipeline status RECOMMENDATIONS ƒ Develop and enforce quality assurance mechanisms to ensure standards ƒ Training in proper quantification methods that consider all data items in the process ƒ Put in place indicators, parameters and mechanisms that monitor procurement pipeline performance 6 IV. INVENTORY CONTROL PROCEDURES The national program has set min and max levels for all points at which the products are handled (2 & 5 for SDPs) and the system of receiving supplies is bottom-up. Facilities determine what they need and the center supplies them with only the amounts requested. Facilities are also required to ensure that products with a short shelf life are used first, hence the FEFO system. During the visit to the district, it was established that stockouts were a frequent occurrence, yet there were no established procedures of placing emergency orders. STRENGTHS WEAKNESSES ƒ The district uses the pull system. ƒ FEFO policy is in place ƒ Damaged and expired products are separated from usable stock ƒ Frequent supply stockouts in the district ƒ No established procedures for making emergency orders ƒ No guidelines ensuring min and max stock levels ƒ No system for tracking losses and adjustments RECOMMENDATIONS ƒ Set and distribute to all levels the guidelines for ensuring min and max levels of stock ƒ Sensitize stores in charges on the procedures of making emergency orders in case of stockouts or under-stocking ƒ Review inventory control tools/ systems to capture/ track losses and adjustments V. WAREHOUSING AND STORAGE To determine proper storage conditions, a set of 17 parameters were considered, including separation of expired products, good condition of products (e.g. not damaged), etc. The facilities visited scored 12 out of 17 parameters on average, showing acceptable storage conditions. Fire safety equipment proved to be the most widespread concern. With the exception of the district hospital, none of the facilities had fire safety equipment. A second problem faced by most facilities was lack of pallets and shelves, reducing storage space significantly. STRENGTHS WEAKNESSES ƒ Physical inventory is done at all levels ƒ Guidelines for disposal of sharps and biohazardous materials exist ƒ Space exist for handling the needed current stock quantities ƒ Visual quality assurance conducted at all levels ƒ Storage capacity inadequate at service delivery points with product level expansion ƒ No written guidelines for expired product disposal ƒ No guidelines for product storage and handling ƒ No procedure for recording complaints for product quality ƒ No fire safety equipment available 7 RECOMMENDATIONS ƒ Improve storage conditions and expand the capacity at service delivery points ƒ Establish guidelines for disposal of expired/damaged products. ƒ Establish guidelines for handling and storage of products ƒ Put in place an effective procedure for recording and submitting complaints about product quality ƒ Improvise fire safety equipment at all units where they are not available VI. TRANSPORTATION AND DISTRIBUTION The HSD was the major player in delivering the supplies to the SDPs. And average lead time was 90 days. In some instances, facilities had to collect their own supplies though it was not a common scenario. The district had tried to integrate distribution into all other district activities and this was mainly because they had no specific budget line for distribution and transportation. The problem this caused was that they could not develop a distribution schedule due to the irregularities of transports availability STRENGTHS WEAKNESSES ƒ Integrated system of transport use ƒ No specific transport for the program ƒ No delivery schedules for distribution of products ƒ No specific budget line for transportation costs RECOMMENDATIONS ƒ Provide a budget line to cater for a specific transport system and its related running costs. ƒ Develop a delivery schedule and time line of how the products will be distributed to the facilities VII. ORGANIZATIONAL SUPPORT FOR LOGISTICS Most facilities had radio calls and at least the health facility in charges had mobile telephones, thereby easing the communication process. A support supervision plan is in place and, according to facility records, all facilities visited had received a support supervision visit in the three months prior to the visit. These visits included aspects of reproductive health and logistics, although this was on a small scale. Despite the supervision plans, during the LSAT, it was noted that some are not conducted largely due to lack of funds. 8 STRENGTHS WEAKNESSES ƒ Communication at least quarterly ƒ Monthly support supervision visits ƒ Supervisory roles stipulated in job descriptions ƒ Written schedules for supervision ƒ Irregular support supervision due to limitations of funds, transport ƒ Limited technical staff to conduct logistics support supervision RECOMMENDATIONS ƒ Train more people to be involved in supervision especially of logistics aspects in the district ƒ Create funds for technical logistics supervision programs in the district VIII. PRODUCT USE Product use proved to be the district’’s strongest aspect of the logistics cycle. Guidelines had been distributed to all SDPs and commodities were distributed to facilities that had personnel trained to offer the service. In instances where HC IIs received products they were not supposed to get (e.g. IUDs), the district family planning focal person withdrew them. Donor partners had trained CBDs in family planning sensitization as a means of improving uptake. However, the practice of comparing prescriptions to standard treatment guidelines was not being done STRENGTHS WEAKNESSES ƒ BCC to encourage product uptake ƒ Have treatment guidelines and they are distributed to all units ƒ All public institutions offering FP to clients ƒ Trained 60 community based service providers in three HSDs ƒ No procedure to monitor standards and following of treatment guidelines ƒ Culture and religious aspects still affecting uptake of family planning methods ƒ No assessment of implications of contraceptive method mix in the district RECOMMENDATIONS ƒ Set up procedures and mechanisms to monitor adherence to the national standard treatment guidelines ƒ Increase level of community sensitization of family planning needs and benefits ƒ Need to update the district contraceptive prevalence rate, adherence and complications where applicable 9 IX. FINANCE AND COORDINATION Finance and coordination was rated as the weakest link in the district’’s contraceptives logistics management. Only three logistics staffers were included within the district human resource budget. No budget line was available specifically for medicines distribution or support supervision. Staff appraisal was lacking and there were no funds for staff development through training. Each depended on the central level to provide basic LMIS tools such as stock cards. STRENGTHS WEAKNESSES ƒ Salaries for logistics staff is included in the ƒ No specified budget for transport budget ƒ No staff logistics development funds ƒ No funds allocated for LMIS RECOMMENDATIONS ƒ Specify or create a budget line for transport especially for distribution of supplies ƒ Develop a plan for staff logistics development ƒ Create a budget line for LMIS especially reporting and order tracking 10 ACTION PLAN Table 4. Action Plan Table Logistics components Objectives Activities Indicators Objectively verifiable Timeline Responsible Assumptions/ remarks Organizational context and staffing: Conduct Needs assessment and Train personnel managing stores Number of personnel trained at least 80% of personnel managing supplies Start by January 31st 2009 Reproductive health focal person Funds available in time Increase target supervisory visits on Start date is a District supplies To work with the hospital support supervision logistics per facility at month after officer supplies officer on logistics least one every two months training Obtain and distribute Availability of the During the District Health Guidelines should be standard guidelines guidelines at all training Officer availed to the district prior for ordering, storage health facilities to the training and inventory managing the management supplies procedures Set up and Availability of written To be set up by District Health TOR should include: Formalize the terms of reference for the logistics down TOR for the logistics management unit end of November 2008 Officer Follow up reporting rates and accuracy of reports. management unit at the district Unit in place and functional Ensure orders are placed in time. Supervision and staff development 11 Any other task aimed at improving logistics management LMIS: Institute a mechanism to ensure feed back to the lower units Filed copies of feedback reports Start October 2008 Bio Statistician To work with family planning focal person and District supplies officer Develop criteria for data validation at the district and lower levels Number of facilities whose data is validated. 80% of all facilities reporting End 30TH November 2008 Reproductive health focal person Work with the district logistics management unit All levels to validate Provide automated 30th September District Health To be piloted at HSD and LMIS to all units 2009 Office selected HC IIIs managing logistics information in the district Obtaining supply/Procurement: Obtain and put in use quality assurance mechanisms to ensure standards Availability of quality assurance tools, Number of QA procedures conducted. At least one bi-annually for all facilities Obtain tools by December 2008 District Assistant Drug Inspector Dependent on availability of quality assurance tool at the Center Put in place Monitor rate of stock Start after set District supplies Collaborate with indicators, outs, Number of up of logistics officer Reproductive health focal parameters and facilities placing management person mechanisms that timely orders and unit monitor performance adherence to of procurement distribution schedule pipeline 12 Warehousing and Improve storage Availability of Guidelines for District health Funds to be availed to storage: conditions and guidelines at all storage are officer prepare the pallets and expand the capacity health facilities available before shelves at service delivery points and obtain guidelines for handling and storage of products Availability of pallets and shelves at lower health facilities training. At least 80% of facilities to have pallets and shelves by Sept 2009 Transportation and distribution: Provide a budget line to cater for the logistics (distribution and supervision) transport system and its related running costs Availability of earmarked funds for distribution of supplies and logistics targeted support supervision To start after the training of personnel. Chief Administrative Officer To work with District Health Officer Develop a delivery Products should not To start after District Supplies To work with the logistics schedule, timeline of spend more than 7 training of staff Officer management unit how the products will days before in logistics be distributed to the distribution management facilities Product use: Set up procedures and mechanisms to monitor adherence to the national standard treatment guidelines Number of prescriptions meeting standard treatment guidelines at each facility (at least 80%) To start after training of personnel District Health officer Works with family planning focal person Update the district Quarterly reports on First report District Health Works with family planning contraceptive prevalence rate, produced by Officer focal person and family prevalence rate, adherence and January 2009 planning service providers adherence and complications of complications where contraceptives applicable 13 Increase level of community sensitization of family planning needs and benefits Monthly percentage increase of family planning uptake Start November 2008 Family planning focal person Works with community based distributors, health educators and other service providers Financing/RHCS Planning: Develop a plan for staff logistics development Develop operational work plan October 2008 District Health Officer To work with Logistics management unit 14 REFERENCES Apac district, District Integrated Health Sector Annual Workplan. 2007 15 16 APPENDIX A- LIST OF PEOPLE INTERVIEWED Table 5. Interviewee list N Name Qualification/Title Facility/Institution Contacts 1 Dr Emer DHO Apac District 0772406695 2 Dr Acanga Principal Medical Officer Apac Hospital 0772390197 3 Sr P Erac District FP- Focal Person Apac District 4 Oluma Denis Senior Supplies Officer Apac District Stores 0772595295 5 Okello Louis Senior Supplies Officer Apac Hospital/Maruzi HSD Stores 0782399432 6 Opio James Senior Clinical Officer Akokoro HC III 0753312067 7 Tino Beatrice Enrolled Midwife Chegere HC II 0782905646 8 Akwanga Jackson Enrolled Nurse Olelpek HC II 0752426390 9 Olet Godfrey Records Assistant Akokoro HC III 0753583653 10 Auma Grace Nursing Assistant Chegere HC II 0777107750 17 18 APPENDIX B - FACILITIES VISITED x Apac District Stores x Apac Hospital/HSD Stores x Akokoro HC III x The DHO`s Office, Apac District x Chegere HC II x Olelpek HC II 19 20 APPENDIX C - LSAT AND ACTION PLAN DEVELOPMENT WORKSHOP PARTICIPATION Table 6. List of Participants N Name Qualification/Title Facility/Institution Contacts 1 Dr. Acanga Principal Medical Officer Apac Hospital 0772390197 2 Sabiiti Mbabazi Atenyi District Health Inspector Apac District 3 Oluma Denis Senior Supplies Officer Apac District Stores 0772595295 4 Opio James Senior Clinical Officer Akokoro HC III 0753312067 5 Apio Betty Nancy Registered Midwife (For FP focal person) Apac Hospital 0772360154 6 Tino Beatrice Enrolled Midwife Chegere HC II 7 Ogwal H Jackson Pharmacist/Short Term Consultant DELIVER/USAID PROJECT 0772692802 8 Mumbe Lawrence DELIVER/USAID PROJECT 21 22 APPENDIX D – APAC DISTRICT DEMOGRAPHIC INFO Table 7. Apac District Demographic Features (2006-2007) HSD S/county Total Pop Males Female Infants 6 mo- 5 yrs 0-5 yrs 1-5 yrs Women 15-45 yrs Preg women Exp. Births Health Units Level Owner ship Kole Aboke 35,813 17,548 18,265 1,683 6,446 7,342 5,658 6,375 1,862 1,791 Aboke Opeta HC IV HC II Gov't Akalo 22,320 10,320 11,383 1,049 4,018 4,576 3,527 3,973 1,161 1,116 Akalo HC III Alito 53,849 26,386 27,463 2,531 9,693 11,039 8,508 9,585 2,800 2,692 Apala Barowo Alito HC III HC III Gov't Ayer 27,809 13,626 14,183 1,307 5,006 5,701 4,394 4,950 1,446 1,390 Bung Ayer Okole HC II HC III HC II Bala 33,065 16,202 16,863 1,554 5,952 6,778 5,224 5,886 1,719 1,653 Bala HC II Gov't Total 172,886 84,699 88,157 8,124 31,114 35,435 27,311 30,768 8,988 8,643 Kwania Abongomola 28,575 14,002 14,573 1,343 5,114 5,858 4,515 5,086 1,486 1,429 Ab'mola HC III Gov't Aduku 29,497 14,454 15,043 1,386 5,309 6,047 4,661 5,250 1,534 1,475 Aduku Aduku HC IV HC II Gov't NGO Chawente 22,680 11,113 11,567 1,066 4,082 4,649 3,583 4,037 1,174 1,134 Alido Apwori I HC III HC II Gov't 23 Inomo 23,651 11,589 12,062 1,112 4,251 4,848 3,737 4,210 1,230 1,183 Inomo HC II Gov't Nambieso 28,704 14,065 14,639 1,349 5,167 5,884 4,535 5,109 1,493 1,435 N'bieso Owiny HC III HC II Gov't Total 133,107 65,222 67,885 6,256 23,959 27,287 21,031 23,693 6,922 6,655 Maruzi Akokoro 25,626 12,557 13,069 1,204 4,613 5,253 4,049 4,561 1,333 1,281 Atar Olelpek HC II Gov't Apac 37,040 18,150 18,890 1,741 6,667 7,593 5,852 6,593 1,926 1,852 Apac Hosp. Hosp. Gov't Apac T.C 11,004 5,392 5,612 507 1,981 2,256 1,739 1,959 572 550 Ako-koro Apoi Kungu HC III HC II HC II Gov't Chegere 27,403 13,427 13,976 1,288 4,933 5,618 4,330 4,878 1,425 1370 Teboke Kidilani Chegere HC IV HC II Gov't Ibuje 26,589 13,029 13,560 1,250 4,786 5,451 4,201 4,733 1,383 1,329 Ibuje Alenga Aganga Alado HC III HC III HC II HC II 3 Gov't NGO Total: 127,662 62,554 65,108 6,000 22,979 26,171 20,171 22,724 6,638 6,383 Kole Kole 172,856 84,699 88,157 8,124 31,114 35,435 27,311 30,768 8,988 8,643 Kwania Kwania 133,107 65,222 67,885 6,256 23,959 27,287 21,031 23,693 6,922 6,655 Maruzi Maruzi 127,662 62,554 65,108 6,000 22,979 26,171 20,171 22,724 6,638 6,383 Source: Population office Apac 24 For more information, please visit deliver.jsi.com. USAID | DELIVER PROJECT John Snow, Inc. Plot 65 Katalima Road Naguru Kampala, Uganda Phone: (256) 414-253-246 Fax: (256) 414-253-245 Email: askdeliver@jsi.com Internet: deliver.jsi.com

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