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Dr0 Ambrosoli Memorial Hospital - Kalongo P.O. Box 47 - Kalongo Agago District

Endorsement of Report This Annual Analytical Report for Dr Ambrosoli Memorial Hospital – Kalongo covering the period 1st July 2015- 30th June 2016 (Financial Year 2015-2016) has been prepared by the Management of Dr Ambrosoli Memorial Hospital. I endorse that it represents Management’s views on the position of the hospital in the reported period.

Dr Filippo Ciantia

________________________________ Chief Executive Officer Dr Ambrosoli Memorial Hospital Date: ___________________________

ANNUAL ANALYTICAL REPORT

This is to acknowledge that I have received this Annual Analytical Report for Dr Ambrosoli Memorial Hospital – Kalongo covering the period of the Financial Year 2015-2016, I have read it and endorse its authenticity and representativeness of the position of the hospital in the year under report.

FY 2015 - 2016

H. G. Archbishop John Baptist Odama

Chief Executive Officer _________________________________ Chairperson of the Board of Governors December Date: ____________________________

2016

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Endorsement of Report This annual analytical report for Dr. Ambrosoli Memorial Hospital covering the period of Financial Year 2015-2016 has been prepared by the management of Dr. Ambrosoli Memorial Hospital. I endorse that it represents management’s views on the position of the hospital in the period under report.

Name: Dr. Filippo Ciantia

Signature ________________________________ Chief Executive Officer Dr. Ambrosoli Memorial Hospital

Date ______________________

This is to acknowledge that I have received this faithfulness to the mission report for Dr. Ambrosoli Memorial Hospital- Kalongo covering the period July 1st 2015 to June 30th2016. I have read it and endorse its authenticity and representativeness of the position of the hospital in the year under report. Name: His Grace John Baptist Odama

Signature ________________________________ Chairperson of the Board of Governors

Date ______________________

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Foreword "When a flower opens the butterfly arrives, but at the same time, when the butterfly arrives the flower opens." The butterfly is a mysterious insect, because during its journey …., it reproduces itself and multiplies; and at the same time, the butterfly, by the process called pollination, enables the flowers it encounters along its way to bear fruit. Thus the butterfly not only feeds on the flower's nectar, but it helps the flower to accomplish its purpose by transforming itself into a fruit. When the baby chick is hatching, it pecks at the shell from the inside in order to break it, while at the same time the mother hen is trying to break the shell from the outside. These two actions that take place in the same moment allow the chick to be born. I heard this Japanese proverb and these two examples, in 1999, from a Japanese monk, Prof. Shodo Habukawa, whose followers visited Uganda in the mid-90s, when I was working in Kampala. There is a meaning in everything that happens. There is no action that is not linked with another event and therefore to the whole of reality: there is a harmony at the heart of the world. Even the friendship between many donors and the community of Kalongo and the people of Uganda has a meaning, provides a message. This hospital was founded in 1957 and developed thanks to the humble service of Fr. Dr. Giuseppe Ambrosoli, a surgeon who lived a total dedication to the suffering people of this land. He is buried in the cemetery of Kalongo, as he died in Lira in March 1987 as a displaced person, when he got sick, but, due to the guerrilla affecting the region, he could not receive the proper medical care. The great doctor, Ajuaka Madit, as the Acholi people still call him, died without the assistance of a doctor. The imposing mountain Oret, providing a unique landscape to this place, is also carrying another message. In Acholi language Oret means “mountain of the wind”. It is true indeed: here we have winds and rains in abundance. But the mountain is also called Jalabub. It is an Arabic name, meaning again “mountain of the wind”. Here, exactly in this place the Arab traders were coming to collect tusks, other goods and human beings. The hospital was erected here by the Comboni Missionaries as a sign of liberation from disease and poverty, where there was slavery and oppression. Dr. Ambrosoli Memorial Hospital is a private not for profit general hospital serving Agago and neighboring districts, offering quality care and training services and ensuring access to the poor and vulnerable people. This vision is translated into a clear mission, entrusted to the current management and staff by the founders and the diocese of Gulu.

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“Based on the imitation of Christ and His deeds, the hospital promotes life to the full and heals, providing services to treat and prevent diseases, with a preferential option for the poor and less privileged. Being the person at the centre of all our activities, we provide services, including training in midwifery, respecting the human dignity, according to the principles of justice, universality and equality, through professionalism, dedication and transparency. The principles of subsidiarity and solidarity are applied in all relationships and processes. Since each human life is sacred, the personnel works for the healing of the people with total respect for life.” Our motto is “Serve with love and humility”. This report is narrating, through data, figures, graphs and comments, the intense work of a year done by the staff of the hospital in providing care to thousands of people looking for a healing place for their body and their sufferings. We could not perform all what has been done without the help of the Government and the Local Authorities and the generosity of many people and Organisations, above all the Dr. Ambrosoli Foundation, the Comboni Missionaries, UCMB/CDC and others. This generosity is carrying a message of solidarity and collaboration amongst peoples. All this goodness and the message of Dr. Ambrosoli Memorial hospital display fruits of peace and solidarity, hatching a better world. And we need, today; we need indeed, such a cultural revolution of love and development. This Annual Analytical Report covers the period between July 2015 and June 2016 and portrays the performance of Dr. Ambrosoli Memorial Hospital. The Hospital runs a wide range of activities, including curative, preventive and rehabilitative services, training, administrative, logistics and technical support services. Data presented are directly derived from the hospital’s activities and financial data. Unless specified, data can be retrieved from the HMIS database. The data of previous years have been reviewed sourcing info from the HMIS: this explains differences with previous Annual Reports

Filippo Ciantia Chief Executive Officer

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Table of Contents Foreword .....................................................................................................................................II List of Abbreviations/Acronyms ................................................................................................. VI Acknowledgements................................................................................................................... VII Important Indicators and Definitions ........................................................................................ VIII Executive Summary......................................................................................................................X

CHAPTER ONE: INTRODUCTION ........................................................................................ 1 The Hospital and its Environment........................................................................................................... 1 Demographic data for the hospital catchment area............................................................................... 4

CHAPTER TWO: HEALTH POLICY AND DISTRICT HEALTH SERVICES ..................................... 7 Health policy ........................................................................................................................................... 7 Role of the hospital as headquarters of the HSD.................................................................................. 13

CHAPTER THREE: GOVERNANCE ...................................................................................... 14 The Board of Governors ........................................................................................................................ 14 Management......................................................................................................................................... 15 Statutory commitments compliance .................................................................................................... 15 Internal regulatory documents ............................................................................................................. 16

CHAPTER FOUR: HUMAN RESOURCES ............................................................................. 17 Staff Establishment ............................................................................................................................... 17 Human resources development and career progression ..................................................................... 19

CHAPTER FIVE: FINANCES ............................................................................................... 21 Income .................................................................................................................................................. 21 Expenditure ........................................................................................................................................... 22

CHAPTER SIX: SERVICES .................................................................................................. 28 Out Patient Department (OPD) ............................................................................................................. 29 HIV / AIDS Clinic .................................................................................................................................... 35 Inpatients Department ......................................................................................................................... 45 Medical Ward........................................................................................................................................ 51 Surgical Ward ........................................................................................................................................ 54 Operating Theatre................................................................................................................................. 56 Paediatric Ward .................................................................................................................................... 58 Maternity Ward .................................................................................................................................... 62 Diagnostic Services................................................................................................................................ 68 Pharmacy Activities ............................................................................................................................... 71

CHAPTER SEVEN: SUPPORT SERVICES .............................................................................. 75 Pastoral care ......................................................................................................................................... 75 Technical services ................................................................................................................................. 75

CHAPTER EIGHT: QUALITY OF CARE AND PATIENTS’ SAFETY ............................................ 79 Quality indicators .................................................................................................................................. 79 Patient satisfaction survey .................................................................................................................... 81 Drugs prescription and dispensing survey ............................................................................................ 81 Standard Unit of Output and Faithfulness to the Mission .................................................................... 81

CHAPTER NINE: ST. MARY'S MIDWIFERY TRAINING SCHOOL ........................................... 84 Human resources management and development .............................................................................. 84 School Finances ..................................................................................................................................... 87 Faithfulness to the Mission ................................................................................................................... 89 Student’s satisfaction survey ................................................................................................................ 92

CHAPTER TEN: CONCLUSIONS ......................................................................................... 93 ANNEXES ........................................................................................................................ 96

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List of Abbreviations/Acronyms ACT AIDS ALoS ART BCG BoG BOR CEO DPT FSB FY CHD CO C/S HC FY HIV HMIS HMT HRM HSD HSSP IDP ITN LLU MO MoES MoH NSSF NTLP NUHEALTH OPD PCH PHCCG PMTCT PNFP SNO SUO TT UCMB UEC UNMEB HG

Aids Care & Treatment Acquired Immuno-Deficiency Syndrome Average Length of Stay Anti-Retroviral Therapy Bacillus of Calmette-Guérin Board of Governors Bed Occupancy Rate Chief Executive Officer Diphtheria-Pertussis-Tetanus Fresh Still Birth Financial Year Child Health Day Clinical Officer Caesarean Section Health Centre Financial Year Human Immunodeficiency Virus Health Management Information System Hospital Management Team Human Resources Manager Health Sub-District Health Sector Strategic Plan Internally Displaced People Insecticide Treated Nets Lower Level Unit Medical Officer Ministry of Education and Sports Ministry of Health National Social Security Fund National Tuberculosis Leprosy Programme Northern Uganda Health Programme Out-Patient Department Primary Health Care Primary Health Care Conditional Grants Prevention Mother To Child Transmission of HIV Private Not For Profit Senior Nursing Officer Standard Unit of Output Tetanus Toxoid Uganda Catholic Medical Bureau Uganda Episcopal Conference Uganda Nurses Midwives Educational Board His Grace

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Acknowledgements The management with great honour appreciates all staff of Dr Ambrosoli Memorial Hospital for their continuous collective efforts rendered to the patients. You contributed to make our hospital to be ranked by the Ministry of Health the third best performer amongst 132 general hospitals in the country. We also thank all those who, in different capacities and ways, have supported the hospital during the Financial Year 2015-2016 and contributed to its sustainability. Notable among them, but not limited to, are the Government of Uganda, Dr Ambrosoli Foundation, Comboni Missionaries, IDS, UEC/UCMB/CDC, the Japan and the Uganda Red Cross Societies, the NU-Health Programme, Wamba Athena Onlus,IDEA Onlus, and the Italian Cooperation. We have a special debt of gratefulness to UCMB for the continuous and valuable technical support and guidance. We would also like to thank H.G. Archbishop John Baptist Odama and all the members of the Board of Governors for the leadership and encouraging supervision given to the hospital. Last but not least, we extend our utmost appreciation to all the employees of the hospital and of the School who, at all levels and with different qualifications and responsibilities, have been the makers of all achievement that are presented in this report. This acknowledgement is certainly due, but wants to be also an encouragement to maintain and possibly enhance the same spirit in the future. This Report was written mainly by Mr. Geoffrey Watum, M&E Officer, Ms. Gloria Paolucci, CEO Assistant and Dr. Filippo Ciantia, Chief Executive Officer. Without the contributions of the Hospital Management Committee they could not have completed it.

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Important Indicators and Definitions 1. Inpatient Day / Nursing Day / Bed days= days spent by patients admitted to the health facility wards. 2. Average Length of stay (ALoS) = Sum of days spent by all patients/ Number of patients = Average length of days each in-patient spends during each admission. The actual individual days vary. 3. Bed Occupancy Rate expressed as % = used bed days/available bed days = Sum of days spent by all patients/ (365 x No. of beds) =ALOS x Number of patients / (365 x Number of Beds) 4. Throughput =Average number of patients utilising one bed in a year =Number of patients/ Number of beds 5. Turn over interval =Number of days between patients = (365 x number of beds) - Occupied bed days/number of patients 6. FSB (Fresh Still Birth): This is a baby born with the skin not pealing / not macerated. The foetal death is thought to have occurred within the 24 hours before delivery. 7. Post C/S Infection Rate: = (Numberof mothers with C/S wounds infected / Total number of mother who had C/S operations in the hospital) x 100. = The rate of caesarean section wounds getting infected. It is an indicator of the quality of post-operative wound care as well as pre-operative preparations. 8. Recovery Rate: = % of patients admitted who are discharged while classified as “Recovered” on the discharge form or register. = (Number of patients discharged as “Recovered” / Total patients who passed through the hospital) x 100

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9. Maternal Mortality Rate (for the hospital): = Rate of mothers admitted for delivery who die due to causes related to the delivery = (Total deaths of mothers related to delivery / Total number of live birth) x 100 10. SUO = Standard Unit of Output. All outputs are expressed into a given equivalent so that there is a standard for measurement of the hospital output. It combines Outpatients, Inpatients, Immunisations, Deliveries, Antenatal Clinic etc. that have different weights in terms of cost to produce each of the individual categories. They are then expressed into one equivalent. As the formula is improved in future it may be possible to include Outpatients equivalence of other activities that may not clearly fall in any of the currently included output categories. 11. SUOop = SUO calculated with inpatients, immunizations, deliveries, antenatal attendance, and outpatients all expressed into their outpatient equivalents. In other words, it answers to the questions: what would be the equivalent in terms of managing one outpatient when you manage for instance one inpatient from admission to discharge? 12. TB case notification rate = total cases of TB notified compared with the expected number for the population in one year =Total cases of TB Notified / Total population x 0.003. 13. OPD Utilisation = Total OPD New attendances in the year / Total population of the area.

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Executive Summary This Annual Analytical Report presents activities output and interpretation for both Dr. Ambrosoli Memorial Hospital Kalongo and Kalongo Midwifery Training School. Dr. Ambrosoli Memorial Hospital was founded in 1957 and St. Mary's Midwifery Training School in 1959 by Fr. Dr. Giuseppe Ambrosoli of the Comboni Missionaries.Until now, Kalongo Hospital, being a PNFP, is the only General Hospital in Agago district. It provides both preventive and curative services. Kalongo Town Council currently has a total estimated population of 11,077.Major key performance indicators are herein summarized as below. The hospital’s current bed capacity is 271; OPD total attendances increased by 13.2% (from 25,526 to 28,883); hospital’s admissions increased by 74% (from 12,799 to 22,274); Malaria remains the number one cause of Morbidity and Mortality in the hospital and the HSD representing 39.7% of all diagnoses in the HSD OPD. The increase in admissions was almost entirely due to the Malaria epidemic. Deliveries increased by 6.7% (from 3,247 to 3,465); Caesarian Section rate decreased from 11.3% to 9.2%; Maternal Deaths increased from 3 to 4, ANC total attendance decreased by 2.8% (from 5,909 to 5,743); Post-natal attendances reduced by 26.8% (from 847 to 620). The LLUs are increasing their services, but the hospital is performing 35.7% of the deliveries assisted by a qualified staff (3,463 out of 9179 deliveries). Moreover in Agago district 86.8% of deliveries are assisted by health workers: the highest level in the country. Recovery rate on discharge improved from 97.8% to 98.1%; SUOop greatly increased by 62% (from 237,527 to 384,902).These results allowed the hospital to rank third in the League Table amongst general hospitals (“Annual Health Sector Performance Report 2015-16” by MoH). HIV prevalence in PMTC was 2.7% and in HCT 7%. St. Mary’s Midwifery Training School, since foundation, has qualified a total of 1,312 competent staff and currently has a shortage of 5 qualified training staffs. The BoG comprises 14 members and the HMT comprises 6 members; a total of 5 staffs are currently being facilitated for further studies. Income decreased by 4.5% in the hospital, increased by 2.38% in the school and increased by 0.36% in the HSD; Expenditure exceeded Income for the first time in five years by UGX 479,871,430/=. Patients’ satisfaction declined from 79.3% to 75.2% and Quality of Drug prescription declined from 82% to 77%.

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CHAPTER ONE: INTRODUCTION The Hospital and its environment Dr. Ambrosoli Memorial Hospital was founded in 1957 and St. Mary's Midwifery Training School in 1959 by Fr. Dr. Giuseppe Ambrosoli of the Comboni Missionaries. Dr. Ambrosoli Memorial Hospital is a Private Not For Profit Health provider, member of the network of Catholic health facilities under the coordination of the UCMB. The legal and registered owner of the hospital is the Catholic Diocese of Gulu. Dr. Ambrosoli Memorial Hospital is a general rural hospital with 271 bed capacity distributed through 5 wards: Medical, Surgical, TB, Maternity and Paediatrics. In the FY 2015-2016 it provided services to 28,883 outpatients and 22,274 inpatients. Out of the 9,719 deliveries in Agago District, 35.7% (3,465) were in the hospital with a total of 315 caesarean sections. A comprehensive HIV/AIDS programme is also run with 2,952 patients involved. Moreover, Dr. Ambrosoli Memorial Hospital is the laboratory hub and head of the Agago Health SubDistrict. In this capacity, it supervises a total of 33 LLUs (25 HC2 and 8 HC3). The hospital is located in Kalongo Town Council (Oret Parish), within Agago County. Agago is the only county of the District which entails the entire District of Agago. It is bordered by 6 Districts: Pader to the West, Kitgum to the North, Kotido and Abim to the East, Otuke and Alebtong to the South. The majority of these neighbouring districts do not have functional hospitals and, therefore, Dr. Ambrosoli Memorial hospital serves also their population for all conditions requiring hospitalisation.

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Figure 1.1: Map of Uganda

Figure 1.2:Satellite Map showing Agago district boundaries

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The District is still lacking a good road network. There are no tarmac roads and most are in poor maintenance conditions, occasionally disrupting routine field activities (transfer of patients for emergency care, immunisation campaigns, supervision of LLUs, home visiting) and adding extra costs to all transport activities. Telephone and internet connections are available but erratic and not fully reliable. Availability of power supply, although not constant and regular, has been nevertheless improving in the last years, at least in the major urban centres. Therefore in the hospital electricity is provided 24 hours per day, mainly thanks to general electricity supply, with generators for backup.

Social and economic organization The level of literacy in the district population is still quite low and a large proportion of the inhabitants, especially women, do not speak or write English. Acholi is the main ethnic group. The spoken language is Acholi, with Lango being the other minority ethnic group in the southern areas of the district bordering Otuke and Aleptong districts. According to “National Population and Housing Census 2014”, 87.27% of Agago District's Population is living in rural areas and just 12.73% in urban areas with a population density of 65 people per km². The main economic activity of the population is agriculture, predominantly practised is subsistence farming. It absorbs about 85% of available labour force. The main crops grown in the region are millet, sorghum, maize, beans, groundnuts, simsim, cassava, and sweet potatoes, produced mainly for local consumption. Other crops include cotton, rice, soya beans and sunflower produced mainly as cash crops, but in limited quantities. Most homesteads in the area rear cattle, goats, sheep, poultry and pigs as additional source of income. There are no industries in the district and commercial activities are very limited. A large proportion of the population is living in a condition of poverty. According to “Poverty Status Report 2014” in Mid North Region, where Agago District is located, 35.2% of the population is poor (living with less than 1 $ per day) and another 41.4% is insecure non-poor. Any unexpected event (bad harvest, sickness or death of one member of the family, etc …) can change the status of insecure non-poor people to poor.

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While the monthly consumption per adult equivalent in Agago District is between 60,000 UGX and 80,000 UGX, in Kampala is more than 200,000 UGX. The poverty north-south gap in Uganda is still relevant. Agago district is one of the poorest areas of the country.

Demographic data for the hospital catchment area The population of Agago District for the FY 2015-2016 amounts to 230,908 people. In the catchment area (Kalongo Town Council) the population is 11,077. In Agago district there is only one Health Sub-District, covering the whole district. The hospital actually serves the population of the entire district. Table 1.1: Demographic Data of the Hospital, HSD and Agago district Population Group

Formulae

Catchment Area

HSD

District

A

11,077

230,908

230,908

(4.85/100) x A

537

11,199

11,199

3,465

9,719

9,719

(C/B) x100

645.3

86.8

86.8

(A)

Total Population

(B)

Total expected deliveries (4.85% of population)

(C)

Total Assisted Deliveries in Health Facilities

(D)

Total Assisted Deliveries as % of expected deliveries

(E)

Children <1 year (4.3%)

(4.3/100) x A

476

9,929

9,929

(F)

Children < 5 years (20.2%)

(20.2/100) x A

2,238

46,643

46,643

(G)

Women in Child-bearing age (20.2%)

(20.2/100) x A

2,238

46,643

46,643

(H)

Children under 15 years (46%)

(46/100) x A

5,095

106,218

106,218

(I)

Orphans (circa 10%)

(10/100) x A

1,107

23,091

23,091

(J)

Suspected T.B Cases in the Service Area

(A) x 0.003

33

693

693

To be noted that last year total population in the catchment area was 27,121. This number was including Kalongo Town Council and Parabongo Sub County. This year the catchment area is considering just Kalongo Town Council, because Parabongohas become an independent Sub County and it is reporting by its own.

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Community and health status Table 1.2: Top ten causes of morbidity in the HSD OPDs FY 2012-2013

Diagnoses

FY 2013-2014

FY 2014-2015

FY 2015-2016

Number

%

Number

%

Number

%

Number

%

Malaria

95,819

26.8

90,443

24.5

69,765

19.5

208,384

39.7

RTI

95,825

26.8

114,652

31.1

113,443

31.6

132,976

25.4

Diarrhea

17,990

5.0

19,189

5.2

23,287

6.5

23,084

4.4

Intestinal Worms

23,694

6.6

20,748

5.6

19,679

5.5

19,528

3.7

11,366

3.2

13,110

3.6

14,123

3.9

14,465

2.8

5,357

1.5

6,569

1.8

7,522

2.1

8,022

1.5

Skin Diseases

11,782

3.3

9,337

2.5

8,232

2.3

7,091

1.4

Eye conditions

9,650

2.7

10,265

2.8

7,488

2.1

5,987

1.1

Injuries

6,034

1.7

7,741

2.1

7,100

2.0

5,887

1.1

Pneumonia

3,407

1.0

4,552

1.2

4,817

1.3

5,332

1.0

Gastro-Intestinal Disorders Urinary Tract Infections (UTI)

Total

357,388

368,836

358,443

524,521

Table 1.3: Relative percentage of the top 10 causes of mortality during the last 4 FYs in the HSD Causes of Mortality

FY 2012-2013

FY 2013-2014

FY 2014-2015

FY 2015-2016

Number

%

Number

%

Number

%

Number

%

Malaria

43

21.6

34

14.1

23

11.0

60

21.4

Anaemia

12

6.0

13

5.4

15

7.2

17

6.1

Gastro-Intestinal Disorders

4

2.0

8

3.3

8

3.8

15

5.4

Pneumonia

31

15.6

31

12.9

24

11.5

15

5.4

Cardiovascular diseases

26

13.1

18

7.5

18

8.6

14

5.0

Injuries

9

4.5

8

3.3

15

7.2

13

4.6

Septicemia

4

2.0

18

7.5

7

3.3

12

4.3

Tuberculosis

13

6.5

8

3.3

6

2.9

10

3.6

Snake Bites

1

0.5

1

0.4

1

0.5

7

2.5

UTI

0

0.0

0

0.0

0

0.0

4

1.4

Total

199

241

209

280

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Morbidity and mortality Morbidity and mortality data are summarised in Tables 1.2 and 1.3 above, presenting in absolute number and percentage proportion the ten top causes. In relation to morbidity, in the FY 2015-2016 due to the persistent epidemic, Malaria is the major cause in HSD with 208,384 (39.7%), followed by Respiratory Tract Infections also considerably high at 25.4%. The other morbidity causes have a percentage lower than 4.4% (Diarrhoeal diseases). In the FY 2015-2016 21.4% of deaths recorded were attributable to Malaria, confirming the seriousness of the epidemic. Anaemia follows with 6.1% showing the impact of Malaria and poor nutrition. Moreover the lack of blood supply is one of the main challenges for the whole country and especially for remote areas: during the financial year we experienced several situations of lack of blood for needing patients. Cardiovascular diseases are the 5th cause of death registered in this FY: we are probably facing an epidemiological transition in the district that is not yet fully captured by the HMIS. Greater attention should be given to data collection to improve the quality (completeness and accuracy) of our recording system. Non-communicable diseases, including Diabetes and Chronic Hepatitis B, are most likely grossly under-reported and, therefore, the dimension of their role and impact may be largely underestimated.

Notifiable diseases and epidemics Weekly surveillance reporting was regularly maintained throughout the year to monitor the Malaria epidemic.

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CHAPTER TWO: HEALTH POLICY AND DISTRICT HEALTH SERVICES Health policy Dr. Ambrosoli Memorial Hospital is guided by the framework set in the National Health Policy (NHP) and the Health Sector Strategic Plan (HSSP), to provide the major components of the Uganda Minimum Health Care Package (UMHCP). It also adheres to the guidelines set by the Uganda Episcopal Conference through the UCMB.

District health services The District of Agago was established in July 2010, separating Agago County from Pader District. It comprises 13 sub-counties and 3 town councils (Kalongo, Patongo and Agago) that form the HSD of Agago. It acts as District Hospital and Head of Agago HSD. Table 2.1: Distribution of Health Service points by Sub-county Sub-Counties Kalongo Town Council Omiya Pacwa Paimol Lapono Adilang Patongo Patongo Town council Kotomor Omot Arum Lamiyo Lira Palwo Wol Parabongo Lukole Agago Total for HSD and District

Total Population

No of Hospitals

No of HC IV

No of HC III

No of HC II

Total Immunizations Static Stations

11,077 11,876 13,924 17,934 23,004

14,680 13,412 9,812 11,546 21,966 24,682 16,081 12,090 6,522

1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 1 1 1 0 1 0 0 1 0 1 1 0 1 0

0 2 1 4 3 0 0 1 2 0 2 3 2 3 2 0

1 2 2 5 4 0 1 1 2 1 2 4 3 3 3 0

230,908

1

0

8

25

34

22,302

The hospital participates in the planning process and disaster preparedness taskforce at the district level. As head of the HSD, it coordinates with the District Health Office to elaborate the HSD Annual Work plan and ensure its implementation.

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The functionality of LLUs has significantly improved in the last years, although it has not yet attained the ideal standard. Currently there are 8 HCIII and 25 HCII. They are all Government Units except one HCII (St. Janani in Lira Palwo Sub-County) belonging to the Church of Uganda. The limited available resources represent a major obstacle to successfully implement the required activities and gradually expand their scope to meet effectively the growing needs of the population.

Human resources The inadequate presence of qualified staff in most of the health facilities is a major constraint and affects the quality of provided services: only Patongo HC III has enough available staff compared to the norm. None of the other HC has the required number of staff in place. The total gap of staff is 76 units. However, if we do not consider Kalongo Hospital and Patongo HC III, the HSD lacks 140 staff in the peripheral units.

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Table 2.2: Population, health units and staffing in Agago District FY 2015-2016 by Sub-county Populations FY 2015-2016

Sub-Counties

Lira Palwo

21,966

Omot

13,412

Adilang

23,004

Lamiyo

11,546

Arum Kotomor

9,812 14,680

Omiya Pacwa

11,876

Lapono

17,934

Wol

24,682

Paimol

13,924

Parabongo

16,081

Lukole Sub-County & Town Council

18,612

Patongo Sub-County & Town Council Kalongo Town Council Total HSD

Health units (Level & ownership) Lira Palwo HC III Gov. Acuru HC II Gov. Obolokome HC II Gov. St Janani HC II CoU Omot HC II Gov. Geregere HC II Gov. Adilang HC III Gov. Ligiligi HC II Gov. Alop HC II Gov. Orina HC II Gov. Kwonkic HC II Gov. Lamiyo HC II Gov. Gov.GGGGoGov.Gov. Acholpii HC III Gov. Odokomit HC II Gov. Omiya Pacwa HC II Gov. Layita HC II Gov. Lira Kato HC III Gov. Lira Kaket HC II Gov. Ongalo HC II Gov. Amyel HC II Gov. Ogwangkamolo HC II Gov. Wol HC III Gov. Kuywee HC II Gov. Toroma HC II Gov. Paimol HC III Gov. Kokil HC II Gov. Pakor HC II Gov. Pacer HC II Gov. Kabala HC II Gov. Lapirin HC II Gov. Olung HC II Gov. Lukole HC III Gov.

Staffing levels Staffing No. Norm available 19 14 9 4 9 3 9 7 9 8 9 5 19 12 9 4 9 5 9 4 9 3 9 7 19 15 9 2 9 7 9 3 19 13 9 5 9 5 9 8 9 4 19 16 9 5 9 5 19 15 9 2 9 3 9 6 9 4 9 6 9 4 19 14

Staffing gap -5 -5 -6 -2 -1 -4 -7 -5 -4 -5 -6 -2 -4 -7 -2 -6 -6 -4 -4 -1 -5 -3 -4 -4 -4 -7 -6 -3 -5 -3 -5 -5

22,302

Patongo HC III Gov.

19

28

9

11,077

Kalongo Hospital NGO

190

245

55

227,486

32 Govt. and 2 NGO Units

567

491

-76

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Table 2.3: Structure of the Health Sub District team at the referral facility Human Resources (Cadre) Current Number Nursing Officer 1 Cold Chain Assistant 1 Professional Staff Theatre Assistant 1 Records Assistant 1 Office Typist 1 Office Assistant 1 Guard 1 Grand Total 7

Funding Funding for health services is quite inadequate compared to the needs. This inevitably affects the performance. However PHC Conditional Grant in the last financial year was fully realised for every quarter. The amount for this year has increased by 0.36% compared to FY 20142015, for a total of 12,401,032 UGX. Funds allocated for the function of the HSD is hardly sufficient to secure even the very minimum activities. Therefore supervision of the LLUs, distribution of drugs and vaccines, and effective implementation of the HMIS is challenged by the lack of financial as much as staff resources. Many essential and much needed activities could not be implemented and support supervision remains quite unsatisfactory.

Health infrastructure The major infrastructural issues faced in the FY are: a) insufficient or, in some cases, lack of staff accommodation, b) deficiency of proper electricity and water supplies for some units (despite the electricity lines passing near or through these units and water taps presence, the supply is not secured). Proper maintenance of supply lines is one of the main reasons for this situation. The HSD head office itself is very small and most of the equipment is stored in the hospital: HSD team members access computers and internet in Dr. Ambrosoli Memorial Hospital.

Essential medicines and supplies provision There has been a fairly good supply of essential medicines, but their management needs improvement, especially monitoring of the average monthly consumption in order to avoid drug stock outs.

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Equipment and other logistics The units are still not well-equipped as they lack the basics for effective service delivery. The available funds cannot provide the resources needed to bridge the gap.

Transport means The HSD lacks transport means for its activities (supervision, outreaches, HMIS monitoring, cold chain, TB Control Programme, referral of patients, etc.) and therefore rely on a limited number of motorcycles and vehicles provided by Dr. Ambrosoli Memorial Hospital. The government has never provided any vehicle for the HSD activities. The funds allocated are insufficient for the running costs and maintenance. Actually the vehicles provided by the hospital to support the HSD in the implementation of its activities are in need of major repairs and require a lot of funds. Moreover the lack of drivers and of proper management of the vehicles have often delayed or even caused cancellation of some of the organized programmes. This affects also the provision of a regular and meaningful supervision of the LLUs.

Prevention and health promotion services The hospital carries out a variety of prevention and health promotion activities. They include the HIV/AIDS projects, the immunisation programmes, health education and support supervision of the LLUs of the HSD.In terms of organisational set-up of a public health department, the hospital has provided personnel to carry out some activities, but dedicated personnel have not been appointed.

The HC II function of the hospital The assigned catchment area of the Hospital for the HC II functions covers the Town Council of Kalongo, with a total population for FY 2015-2016 of 11,077people. The overall performance of the Hospital, in relation to Immunisation, ANC, and Family Planning activities as proportion of the district coverage is summarised in the Tables 2.4.

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Table2.4: Hospitalcontribution to prevention &health promotion services of the HSD/District HSD/District

Hospital output as % of HSD/District

1,911 1,176 3 0 0

7,415 2,070 1,707 5,019 1,334

25.77% 56.91% 0.17% 0 0

0 0 0 0 0

5,983 3,062 2,525 3,455 2,471

0 0 0 0 0

132 116 77 42 0 1,294

1,216 722 530 882 446 5,854

10.85% 16.07% 14.53% 4.76% 0 22.07%

3,512 2,971 3,512 682 543 520 662 567 522 679 540 519 389

10,882 6,092 10,238 13,009 11,868 19,692 11,725 11,525 12,410 11,680 11,664 12,703 11,250

32.27% 48.77% 34.30% 5.24% 4.58% 2.64% 5.65% 4.92% 4.21% 5.81% 4.63% 4.09% 3.46%

Total Immunisation in Children

15,666

154,738

10.12%

Total Family Planning attendances Total ANC attendance Deworming Vitamin A Supplementation

216 5,743 4,016 2,330

118,165 201,148 150,469 80,062

0.18% 2.86% 2.67% 2.91%

Activity: TT to child bearing ages Pregnant women TT 1 TT 2 TT 3 TT 4 TT 5 Non Pregnant women TT 1 TT 2 TT 3 TT 4 TT 5 Immunization in school TT 1 TT 2 TT 3 TT 4 TT 5 Total TT 2 in all categories Immunization in Children BCG Protection at Birth for TT (PAB) Polio 0 Polio 1 Polio 2 Polio 3 PCV 1 PCV 2 PCV 3 DPT-HepB+Hib 1 DPT-HepB+Hib 2 DPT-HepB+Hib 3 Measles

Hospital

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For the immunisation programme the hospital has played a good role, accounting for 32.27% of BCG, 22.07% of all TT2, 2.64% of Polio 3, 4.09% of DPT3, 3.46% of Measles, and 4.21% of PCV3 doses administered in Agago HSD.

Role of the hospital as headquarters of the HSD Kalongo Hospital has the responsibility of heading Agago HSD. This responsibility implies the following main tasks: 

Coordination of the planning process for the yearly HSD work plan

Ensure proper utilisation of PHC Conditional Grant allocated to the HSD

Harmonization of all stakeholders actively involved in the HSD.

Coordination of main health programmes in support to the LLUs (EPI, TB control Programme, Essential Drug Programme, etc.).

Support supervision of LLUs.

The actual role of the Hospital as Agago HSD is very limited due to the lack of dedicated personnel, vehicles and funds.

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CHAPTER THREE: GOVERNANCE The Board of Governors The Board of Governors (BoG) is the supreme policy maker and controlling body of Dr. Ambrosoli Memorial Hospital and St. Mary's Midwifery Training School, while the Hospital Management Team is fully responsible for all operational aspects of the hospital and the school. The minimum number of BoG meetings to be held in a year is two, as enshrined in the hospital Statute. In the FY 2015-2016 the hospital held one ordinary and one extraordinary BoG meetings. The BoG received and discussed the hospital management report that highlighted key issues pertaining to the activities and challenges affecting the hospital and school. Furthermore the report also highlighted successes and work in progress. Due to organisational and financial constraints the hospital Stakeholdersâ&#x20AC;&#x2122; Meeting for external accountability planned in the FY 2015-2016 was not organized and deferred to the next FY. Table 3.1: Summary of BoG meetings held in the FY 2015-2016 BoG meetings

Reports presented / Key issues handled / Decision taken

Members present

20th Nov 2015

Ordinary Meeting: presentations on faithfulness to the mission, budget performance, hospital's activities report 1stquarter 2015-2016, 1st draft staff training and development policy guidelines.

11/15

2nd May 2016

Extraordinary Meeting: activity and budget performance report July 2015 to March 2016, appointment of new CEO and Technical Advisor for the Technical Department

08/15

The Statute enumerates 3 key thematic committees that have to be in place and functioning: Human Resources &Disciplinary Committee, Finance Committee and School Committee. The BoG can appoint additional committees if needed. Their role is to examine in advance reports and proposals from the Management and to present comments and suggestions to the BoG during the plenary meetings. Although it is requested that each committee meets at least twice a year, it has been observed that this practice has not been followed regularly.

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Table 3.2: Table showing functionality of the Board Committees Name of committee

Required No. of meetings per year

No. of meetings held

Percentage of required meetings held

Finance Committee

2

2

100%

School Committee

2

0

0%

Human Resources& Disciplinary Committee

2

0

0%

Management The Hospital Management Team headed by the Chief Executive Officer is the body responsible for decision making on all matters regarding the hospital and the school. The Hospital Management Team collectively shares the task of achieving the strategic objectives and the specific targets decided by the Board of Governors. It is granted operational autonomy within the scope of the hospital strategic plan, approved policies, manuals and procedures. The Hospital Management Team meets at least once every month. The core members of the Hospital Management Team are: 

The Chief Executive Officer

The Medical Director

The Administrator

The Senior Nursing Officer

The Principal Tutor of the School

Table 3.3: Frequency of HMT meetings FY 2015-2016 No of planned No. of Management Average No. of Management meeting held members present meeting 12

12

5

Reports / key issues handled Minutes of each meeting were prepared and circulated by the CEO

The Hospital Management Meetings formally held were 12, but less formal meetings have been held with higher frequency throughout the year.

Statutory commitments compliance The Hospital has been regularly complying with all statutory commitments set by Government, Ministry of Health and UCMB as displayed in details in Table 3.4.

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The Hospital satisfied the requirements established in the accreditation programme 20152016 for the hospitals of the Catholic health network. This accreditation entitles the hospital to the full range of services provided by UCMB for the period ending on the 31st December 2016. Table 3.4: Statutory commitments compliance No Requirement

1 2 3 4 5 7 1 2 3 5 6 7 8 9 10

Government / MOH Requirements PAYE NSSF Local service tax Annual operational licence Practicing licence for staff Monthly HMIS UCMB statutory requirement Analytical Report end of FY year External Audit end of FY year Charter (still valid) Contribution to UCMB for the year HMIS 107 PLUS financial report / quality indicators ending FY Report Status of staffing as of end of FY Manual of Employment (still valid) Manual Financial Management (still valid) Report on Undertakings & Actions of FY

Did you achieve? (Yes, Partly, No)

Comment

YES YES

Regularly observed Regularly observed

YES YES YES YES

Regularly observed Regularly observed Regularly observed Regularly observed

YES YES YES YES YES

Regularly observed Regularly observed Finalised revised version Regularly observed

YES YES YES YES

Regularly observed Revision Planned next FY Revision Planned next FY Regularly observed

Regularly observed

Internal regulatory documents Dr. Ambrosoli Memorial Hospital has in place manuals and guidelines (Employment manual and the Financial & Material resources manual). These documents need to be reviewed. However, there is need for improving the respect of norms and procedures set in these documents even in their current forms. Management intends to revise the aforementioned policy documents in the new FY 2016-2017.

Advocacy, lobby and negotiation The Hospital has not yet developed a formal advocacy agenda; however, it has maintained constant contacts with local leaders, international NGOs, and major donors as Dr. Ambrosoli Foundation and Comboni Missionaries according to the needs.

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CHAPTER FOUR: HUMAN RESOURCES Staff Establishment During the FY 2015-2016 there was a slight increment in the total number of employees, as clinical staff increased from 126 in the FY 2014-2015 to 148. According to the Ministry of Health1, 190 are the required staff for running a general100 bedded hospital: 165 clinical and 25 not clinical staff (Kalongo hospital as 271 beds!). Table 4.1: Total number of employees in the hospital in the last 5 FYs Category Qualified Clinical Unqualified Total Clinical Qualified Not Unqualified Clinical3 Total Non-Clinical Total Qualified Total Unqualified Grand Total 2

% of qualified clinical staff/total staff

FY 2011-12 FY 2012-13

FY 2013-14

FY 2014-15 FY 2015-16

100 19 119 13 81 95 113 100 213

88 28 116 32 72 104 120 100 220

97 26 123 41 48 89 138 74 212

108 18 126 86 27 113 194 45 239

130 18 148 38 59 97 168 77 245

46.9%

40.0%

45.8%

45%

53%

Staff turn-over4 The turn-over among enrolled cadres has been higher than in the previous FY, as shown in table 4.2. The hospital salary scale and benefit packages are still not competitive with the Government and other institutions in the area. This has contributed to the high attrition rate of employees. Other factors that may also have played a role are a) end of contract (almost all contracts are lasting only one year), b) personal interest for capacity building (staff leave as self-sponsored), c) remoteness of the hospital location (lack of amenities and quality social services), and d) personal issues (many staffâ&#x20AC;&#x2122;s families are not living in Kalongo).

1

The Health Management Information System, Health Unit and Community Procedure Manual (2014), Ministry of Health Resource Center, Uganda 2 Clinical Staff includes: Medical Doctors, Paramedics, Nurses, Midwifes, and Nursing Assistants. 3 Non Clinical Staff includes: Administration Officers, Procurement Officers, Accountants, Accountant Assistants, Record Assistants Clerks, Guards, Store Keepers, Cooks, Tailors, Porters and Nursing Aides. 4 Turn Over rate for each year is calculated as in the following example for FY 2015-2016: Total staff lost in FY 2015-2016/ď &#x203A; (Total staff available on June 30th 2015 + Total staff available on June 30th 2016)/2]

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Table 4.2: Turn-over trends of enrolled cadres5 in the last 3 FYs FY FY Cadres 2013-14 2014-15 Total staff 212 239 Enrolled cadres (all combined) 66 68 Turn-over for enrolled cadres 29.3% 19%

FY 2015-16 245 69 39.4%

Table 4.3 shows the general turn-over of the staff in FY 2015-2016: it was higher than during the previous FY, confirming the difficulties the hospital faces in retaining its staff. Management has been working during the year to develop and identify tools to handlethe main issues raised by personnel and increase the ownership of the hospital among the staff. In fact, a full revision of the salary scale, organization chart, job description, and appraisal process and performance evaluation of staff has been planned for the first semester of next FY. Table 4.3: Turn-over trends of Clinical Staff in the last 3 FYs FY Clinical Staff 2013-14 Total staff 212 Total arrivals of key health personnel 40 Total departures of key health personnel 25 Turn-over rate 20.9%

FY 2014-15 239 48 27 21.7%

FY 2015-16 245 48 37 27.0%

Engagement with Japanese Red Cross Society For the past six years, Dr. Ambrosoli Memorial Hospital has been supported by the Japanese Red Cross Society in partnership with the Uganda Red Cross. Health specialists from Japan have been regularly sent to the hospital during the six years and the projectjust ended in March 2016. During the current FY, a total of 4 Japanese Health Specialists were engaged in the hospital:1 Gynecologist, 1 Surgeon and 2 Nurses.

Management The working hours for all the staff are between 40 and 42 per week. Work schedule of shifts for subsequent month is communicated by the in charge before the end of the current month to the concerned personnel in the department and ward.

5

Enrolled Nurses, Enrolled Comprehensive Nurses and Enrolled Midwives.

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The hospital provides accommodation for a large proportion of its employees (140 staff and their families, 57% of the total staff) in the staff quarters located within its premises. This housing facilitation includes also availability of water and electricity for a nominal fee. Salaries have been regularly paid and any statutory obligations are regularly remitted (PAYE and NSSF) according to the current legislation. Staff elected their representative, who coordinates and facilitates, through the HR office, the communication of requests, grievances and suggestions of the staff to the hospital management. He also facilitates contacts of employees with the hospital authorities and conveys feedback, promoting teamwork and organizing routine meetings with employees.

Human resources development and career progression The training and development plan includes: a) provision of scholarship for further studies, b) participation in workshops and short courses, c) organisation of CME sessions within the hospital, and on the job training (specialists visiting the hospital and providing focused capacity building). A programme for weekly sessions of CME involves all departments of the hospital, encouraged to organise on rotation each session with different topics. A proper assessment of the impact of CME is yet to be conducted, but generally the CME sessions are focused on relevant issues for the hospital. A full plan of the candidates, opportunities and related costs for the next yearâ&#x20AC;&#x2122;s scholarship program promoted by the hospital will be discussed with the BoG and included in the Strategic Plan 2017-2022. Here below the list of staffbenefitting from Dr. Ambrosoli Memorial Hospitalâ&#x20AC;&#x2122;s scholarships. The hospital policy requires the staffs to sign an agreement binding them to work in the hospital for a specific number of years after the completion of their studies.

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Table 4.4: Hospital Staff who attended courses in FY 2015-2016

Name

Designation

Course

Sr. Ayakaka Hellen

Enrolled CN

Sr. Alobo Hellen

Clinical Instructor

Taabu Geoffrey

Clinical Officer

Moi Geoffrey

Senior Accounts Assistant

Okwir Denis

Accounts Assistant

Diploma in Nursing (St. Francis Hospital Nsambya) Bachelor in Medical Education (Mulago, Makerere University) Diploma in Anesthesia (Gulu University) BA Business Administration (Gulu University) BA Business Administration (Gulu University)

Date of start May 2016

Date of End Nov 2017

August 2015

July 2018

October 2015

July 2016

August 2015

July 2018

August 2015

July 2018

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CHAPTER FIVE: FINANCES Dr Ambrosoli Memorial Hospital and St. Mary's Midwifery Training School finances are managed distinctly. The two financial statements are also audited separately.

Income Table 5.1: Trend of Income by source over the last 5 years

Income over the last 5 Years Income Item

FY 2011-12

FY 2012-13

FY 2013-14

FY 2014-15

FY 2015-16

Variance 2014-15 vs. 2015-16

HOSPITAL User Fees

277,428,212

320,211,091

399,799,594

429,341,811

537,697,285

25.24%

PHC CG cash

455,045,373

494,261,142

494,379,756

506,731,434

496,440,741

-2.03%

73,525,612

29,690,056

13,240,715

17,549,163

Government donations in kind (Drug/Lab) Other donations in kind Donations in cash (including project funding) Others Financial sources (Deposit Interests & others) Technical Department Sub-Total Hospital SCHOOL Fees (private)

323,937,510

251,710,481 1,334.32%

852,245,261 1,019,614,218 1,073,509,815 1,171,239,924

1,218,257,145 1,561,261,600 2,261,661,058 1,976,532,864 1,352,092,200

9.10% -31.59%

100,706,070

56,767,272

119,265,960

82,600,220

76,684,887

-7.16%

54,331,333

51,596,750

64,191,141

56,945,511

70,879,020

24.47%

2,503,231,255 3,366,033,172 4,372,152,442 4,143,210,818 3,956,744,538

-4.50%

77,995,546

44,697,128

300,060,091

383,325,954

81,206,100

-78.82%

PHC CG School/PAF Delegate funds Donations and other income Sub-Total School HSD

49,083,184

58,935,060

56,468,241

55,634,813

53,939,020

-3.05%

303,496,320

341,583,977

120,496,956

153,923,602

471,872,451

206.56%

430,575,050

445,216,165

477,025,288

592,884,369

607,017,571

2.38%

Sub-Total HSD

90,772,200

98,669,600

98,668,800

12,356,576

12,401,032

0.36%

3,024,578,505 3,909,918,937 4,947,846,528 4,747,676,188 4,576,163,141

-3.61%

Grand-Total

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Expenditure Table 5.2: Trend of Expenditure over the last 5 FYs Expenditures over the Last 5 Years Expenditure Item HOSPITAL Human Resource cost Administration & Governance Costs Medical goods and supplies (included drugs)

FY 2011-12

FY 2012-13

FY 2013-14

FY 2014-15

Variation FY2015/16 and FY2014/15

FY 2015-16

1,207,759,814 1,272,027,988 1,481,676,063 1,454,269,387 1,571,469,625 71,362,652

165,565,943

137,309,190

86,721,317

95,753,358

592,602,710 1,231,903,798 1,629,096,034 1,436,533,515 1,937,705,529

8.06% 10.42%

34.89%

Non-medical goods / supplies

55,028,424

125,000,750

136,356,936

137,391,003

119,594,489

-12.95%

Property Costs

137,868,459

168,121,102

232,462,749

232,835,274

240,980,620

3.50%

PHC Transport & Plant Costs Capital Development

136,480,468

194,306,705

242,976,850

250,856,300

331,106,130

31.99%

195,149,382

178,580,518

157,759,179

147,434,856

140,006,217

-5.04%

0

0

112,542,651

42,812,692

0

Hospital Total Expenditure SCHOOL Employment

2,396,251,909 3,335,506,804 4,130,179,652 3,788,854,344 4,436,615,968

-100.00% 17.10%

170,609,669

180,326,141

204,087,584

216,704,264

200,984,878

-7.25%

Administration

48,646,463

78,195,938

78,545,960

77,132,419

87,858,321

13.91%

Students costs

145,231,270

133,043,554

112,017,152

139,925,472

148,001,835

5.77%

34,161,377

59,511,250

41,110,050

34,442,227

71,521,000

107.65%

28,405,798

17,737,723

7,061,219

12,821,329

59,910,050

367.27%

0

0

0

0

0

427,054,577

468,814,606

442,821,965

481,025,711

568,276,084

18.14%

90,772,200

98,669,600

98,668,800

12,456,576

12,401,032

-0.45%

2,914,078,686 3,902,991,010 4,671,670,416 4,241,686,664 5,017,293,084

18.29%

Transport & Travelling Property, Supplies, Services Capital Development School Total Expenditure

0

HSD HSD Total Expenditures Grand Total

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Figure 5.1: Revenue vs. Expenditure

Hospital Income vs Expenditure 5,000,000,000 4,500,000,000 4,000,000,000

3,500,000,000 3,000,000,000 2,500,000,000

Income

2,000,000,000

Expenditure

1,500,000,000 1,000,000,000 500,000,000

0

FY FY FY FY FY 2011-12 2012-13 2013-14 2014-15 2015-16

The income during the FY 2015/16 was lower than in the previous year (reduction by 4.5 %), as the hospital received a total sum of income worth UGX 3,956,744,538/=. Moreover for the first time in 5 years the expenditure exceeded the income. The Midwifery school on the other hand received a little increase in income of about 2.4 % from the previous financial year, made of a marked reduction of private fees and a sharp increase of donations. The hospital and the school are heavily dependent on donations. Support from major donors like NU-Health and others have come to an end. This has led to a significant reduction in cash donations of about 31.6 %. However, government donation in kind greatly increased. Government PHC Conditional Grants has been received promptly and consistently in full for all the quarters. However the amount of the grant is not increasing, making its impact on sustainability. Expenditure generally increased in both the Hospital (17.1%) and the Midwifery School (18.1%). Major increases in expenditure in the hospital arise from a) PHC (32 per cent) and b) Medical goods and supplies (35 per cent), whereas in the school, major increases come from a) Transport and travel (107.7 per cent) and b) Property, supplies and services (367.3 per cent).

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Income from user fees has grown from about UGX 429,341,811/= to UGX 537,697,285/= which represents about 25.2 % increase from the previous financial year. This increment is mainly due to the sharp growth in patientsâ&#x20AC;&#x2122; attendances, since fees have not been raised. Fees are still very low, representing 15-30% of the actual cost of services. The management is considering a prudent review and possible adjustment of feesâ&#x20AC;&#x2122; structure during next financial year. Table 5.3: Trend of average user fees by department in the last 5 FYs

Average Fees FY 2011-12 6,854

FY 2012-13 7,783

FY 2013-14 9,400

FY 2014-15 11,317

FY 2015-16 12,000

OPD Adult Female

6,854

7,783

9,400

11,317

12,000

OPD Children < 5yrs

1,583

1,885

3,300

3,499

4,500

OPD Children 5-13 yrs

1,583

3,750

4,800

6,507

7,000

IP Medical Male

23,611

20,860

18,868

25,149

26,000

IP Medical Female

22,511

20,860

18,868

24,276

26,000

IP Maternity

11,925

15,113

17,368

18,351

20,000

IP Paediatric < 5 yrs

4,212

4,821

6,343

8,300

8,500

IP Paediatric 5-13 yrs

4,212

4,821

6,343

8,300

8,500

25,350

25,832

27,689

19,306

25,000

OPD Adult Male

IP Surgical Ward

Figure 5.2: Average User Fee applied per SUO-OP

Average User Fees per SUO 1,443 1,549

FY 2012-13

FY 2013-14

1,808 1,397

FY 2014-15

FY 2015-16

The indicator Fee/SUOop decreased from 1,808 to 1,397. For the last four years the indicator has been increasing: actually in 2015-2016 on average people paid less for our services.

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The current cost recovery rate from fees collection has increased only by 0.6 % of allrecurrent expenditures. The recovery rate of 12.1 % is still very low, when the target is to attain 30% in the next 3 to 5 years.

Table 5.4: Trend of Cost Recovery from Fees in the last 5FYs FY FY FY 2011-12 2012-13 2013-14 Total User fees (a)

277,428,212

Total Recurrent Expenditure (b)6 Cost Recovery Rate = (a/b)x100

320,211,091

2,396,251,909 3,335,506,804 11.6 %

9.6 %

FY 2014-15

399,799,594

429,341,811

FY 2015-16 537,697,285

4,017,367,001 3,746,041,652 4,436,615,968 10.0 %

11.5%

12.1%

Figure 5.3: Cost Recovery Rate 11.6%

11.5% 9.6%

FY 2011-12

FY 2012-13

12.1%

10.0%

FY 2013-14

FY 2014-15

FY 2015-16

There is need to revise the user fees to meet the target, but this will be done cautiously to avoid marginalisation of the vulnerable groups. The Stakeholdersâ&#x20AC;&#x2122; meeting to be held during next FY will highlight the issues of sustainability of the hospital and the costs of services.

6

Total Recurrent Expenditure = Total Expenditure â&#x20AC;&#x201C; Capital Development

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Table 5.5: Trend of indicators of efficiency in utilisation of financial resources FY FY FY Indicator 2012-13 2013-14 2014-15 Cost per bed7 11,044,725 13,302,540 13,823,032 8

FY 2015-16 16,371,277

Cost per IP/day

52,282

52,338

56,428

51,055

Cost per SUOop

15,026

15,566

15,771

11,527

(NB: Total SUOop = Total OP + 15*IP + 5*Deliveries + 0.5*Total ANC + 0.2*Total Immunisation) Source: UCMB

The hospital economic efficiency has improved by 26.9%, as the cost of producing one SUO has decreased from UGX.15,771 to UGX.11,527as shown in Table 5.5 above. The cost of treating one inpatient per day has increased by 9.5%. However the cost per bed per year is constantly increasing over the previous 5 FYs and it has increased by 18.4% from the previous FY 2014/15. Figure 5.4: Cost per bed per year

Cost per bed 18,000,000

16,000,000 14,000,000 12,000,000

10,000,000 8,000,000

6,000,000 4,000,000 2,000,000

0

FY 2011-12

FY 2012-13

FY 2013-14

FY 2014-15

FY 2015-16

Table 5.6: Sustainability ratio trend without donors and PHC CG funding, in the last 5 FYs Without PHC CG

FY2011-12

FY2012-13

FY2013-14

FY2014-15

FY2015-16

Total Local 432,465,615 428,575,113 583,256,695 568,887,542 685,261,192 Revenues (a) Total Recurrent 2,396,251,909 3,335,506,804 4,017,637,001 3,746,841,652 4,436,615,968 Expenditures (b) Sustainability Ratio 18.1 % 12.8 % 14.5% 15.1 % 15.4% = (a/b)x100 (Local Revenues includes User Fees, Other Financial Sources and Technical Department)

7 8

Cost per bed = Total Recurrent Expenditure /Number of beds Cost per IP/day = Total Recurrent Expenditure/(Number of Admissions*days spent in the hospital)

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Figure 5.5: Sustainability without PHC CG 18.1% 14.5%

15.1%

FY 2013-14

FY 2014-15

15.4%

12.8%

FY 2011-12

FY 2012-13

FY 2015-16

Table 5.8: Sustainability ratio trend in absence of donor funding but with PHC CG - last 5 FYs FY 2011-12

FY 2012-13

FY 2013-14

FY 2014-15

FY 2015-16

Total in-country 961,036,600 952,526,311 1,090,877,166 1,075,618,976 1,181,701,933 funding (c) Total Recurrent 2,396,251,909 3,335,506,804 4,017,637,001 3,746,841,652 4,436,615,968 Expenditures (d) Sustainability Ratio 40.1 % 28.5 % 27.2 % 28.7 % 26.6% = (c/d)x100 (In-country funding includes User Fees, Other Financial Sources, Technical Department, PHC CG, Local Government contributions, IGAs, etc)

Donors play a major role and the sustainability ratio without their support is gradually decreasing over the years.

Figure 5.6: Sustainability without external Donors 40.1%

28.5%

FY 2011-12

FY 2012-13

27.2%

FY 2013-14

28.7%

FY 2014-15

26.6%

FY 2015-16

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CHAPTER SIX: SERVICES The hospital offers the following services:

Obstetrics & Gynecology Services

Pediatrics & Child Health

Antenatal, Delivery & Postnatal care

Young child clinic

Prevention of MTCT of HIV

Malnutrition Therapeutic feeding

Emergency Obstetric and Neonatal care

Neonatal intensive care

General and Specialized Obstetric and

Pediatric admissions and care

Gynecologic Surgery

Immunization and health promotion

General Surgical Services

Community Health

Trauma and Emergency care

Health promotion outreaches.

Surgical Clinic

Immunization

Minor Orthopedics services

Health education

Burns care

Primary Health Care

Anesthesia General surgical operations Health Training Midwifery training Internal Medical Care

Internship for Medical Doctors

HIV Care and Treatment

Opportunities also provided to other cadres

General and private Out-patient Clinic

like Clinical Officers, Pharmacy, Nurses,

Emergency medical care

Midwives and laboratory students for

Electro Cardiogram (ECG)

attachments during holidays; guidance is

Medical Admissions and care

usually provided by a senior staff in the area

TB Detection and treatment

of discipline.

Communicable and Non-Communicable Diseases care and prevention

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Out Patient Department Dr. Ambrosoli Memorial Hospital runs a general Out Patient Department (OPD) located at the main entrance of the hospital. The OPD operates six days a week from Monday to Saturday from 8.00 am to 9.00 pm excluding Sundays and Public Holidays, when OPD cases are managed from the wards. The hospital has expanded the working hours in OPD starting from this FY because the previous time frame from 8:00 am to 5:00 pm was too limited for the high number of patients.

Staffing composition OPD is run by 6 Clinical Officers, 6 Nurses, 3 Midwifes 3 Nursing Assistants and 1 Nursing Aid. The nursing staffs work in shifts, i.e. morning hours from 8:00 am to 3:00 pm, evening shift from 2:00 pm to 9:00 pm. The Clinical Officers are available in OPD from 9:00 am to 9:00 pm every working day. The Clinical Officers are still the main medical personnel who review patients in the OPD, but Medical Officers from the wards are running weekly clinics. In particular every Monday the Gynaecological Clinic, Tuesday the Sickle Cell Clinic, Wednesday the Surgical Clinic, Thursday the Hepatitis Clinic and Friday Medical Clinic. The OPD has not yet attained the optimal staffing level due to lack of personnel in areas such as Psychiatry, Ophthalmology and ENT. The hospital still faces difficulty in finding and attracting these cadres. For next financial year the hospital is planning to introduce the Diabetes, Cardiovascular, Mental Health and Screening of Cervical Cancer clinics. Table 6.1: The staff composition in OPD in the FY 2014-15 and FY 2015-16 FY 2014-15 4

FY 2015-16 6

Diploma in Nursing / Midwifery

1

2

Enrolled Midwife

Certificate in Midwifery

2

3

Enrolled Nurse

Certificate in Nursing

2

3

Enrolled Comprehensive Nurse

Certificate in Comprehensive Nursing

1

1

Nursing Assistant

Certificate in Nursing Assistance

3

3

Cashier

Trained on the job

3

0

Nursing Aide

Trained on the job

1

1

Cadre/ Discipline

Qualification

Clinical officers

Diploma in clinical Medicine

Double Trained Nurse/Midwife

The staffing level in OPD has increased from 17 in the FY 2014-2015 to 19 in the FY 20152016 thanks to the hiring of two additional Clinical Officers.

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The Clinical Officers in OPD run minor surgical procedure under local anaesthesia, but the safe male circumcision program has stopped due to lack of funds. The investigation from OPD is done in collaboration with other support service departments like X-ray, Ultrasound and Laboratory. OPD key indicators During the FY 2015-2016, the hospital registered an increase in OPD utilization with new OPD attendance increasing from 21,761 to 26,245 (increase of 20.6 %). The re-attendances decreased from 3,765 to 2,638 (decrease of 30%). The upward trend in OPD utilization in the hospital is consistent with the increase in Inpatients Department.

and with the increase of Malaria cases in the region. Table 6.2: Trend OPD attendance by gender & age in the last 5 FYs FY FY FY 2011-12 2012-13 2013-14

FY 2014-15

FY 2015-16

0-4 yrs New Attendance Over 5 yrs

2,321

3,067

3,156

2,642

3,372

7,385

8,737

11,997

10,690

12,294

0-4 yrs Reattendance Over 5 yrs

346

360

202

122

90

3,612

4,804

1,599

1,511

1,077

0-4 yrs New Attendance Over 5 yrs

2,495

3,603

3,469

3,188

3,794

4,568

5,898

6,413

5,311

6,785

0-4 yrs Reattendance Over 5 yrs

350

336

188

161

97

2,637

3,500

1,748

1.971

1,374

16,769

21,305

25,035

21,761

26,245

6,945

9,000

3,737

3,765

2,638

23,714

30,305

28,772

25,526

28,883

FEMALE

MALE

All New Attendances All Re-attendances All Attendances

The disaggregated data by gender of OPD attendances show that females represented 58.3% of all attendances. The dominance of new OPD attendance by female has been a continuous trend over the past years. There is no significant dominance of re-attendance by either gender.

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Figure 6.1: Trend of OPD attendances by frequency of visit

30,305

28,883

28,772 25,526

23,714

26,245

25,035

21,761

21,305 16,769

FY 2011-12 FY 2012-13 FY 2013-14 FY 2014-15 FY 2015-16 OPD New Attendance

OPD Total Attendance

Figure 6.2: Trend of OPD attendances by Age group 22,939

21,757

21,530 18,202

5,512

FY 2011-12

17,514

7,366

FY 2012-13

7,015

6,113

FY 2013-14

Under 5 Years

FY 2014-15

7,353

FY 2015-16

5 Years and above

During the FY 2015-2016 the OPD monthly attendances showed an average of 2,300 patients with some fluctuations: peaks recorded in the months of October 2015, January, February, and June2016 for the seasonal Malaria outbreaks.

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Figure 6.3: Trend of OPD total visits in the FY 2015-16 by months 3500 3000 2500 2000 1500 1000 500 0

Malaria was the most determinant of the increase in the number of outpatients in the hospital in FY 2015-2016 and the 16.4% of the total case load. RTIs decreased from 3,582 to 3,016, decreasing also the percentage of total diagnoses in OPD from 15% to 8.1%. On the contrary Gastro-Intestinal disorders have increased from 2,255 to 2,701 though the percentage of total diagnosis has decreased from 9.4% to 7.3%. Anaemia has increased dramatically: from 179 to 895 in line with the high number of Malaria cases. Injuries, Pneumonia and Skin Diseases slightly decreased in absolute numbers, but, due to the high number of Malaria cases, their percentage has decreased a lot. Acute Diarrhoea has dramatically decreased: from 1,018 in FY 2014-2015 to 643 cases in FY 20152016. Table 6.3: Top ten diagnoses in OPD in the last 2 FYs Causes of Morbidity 1 2 3 4 5 6 7 8 9 10

Malaria RTIs Gastro-intestinal disorders (noninfectious) Injuries UTIs (Urinary Tract Infections) Anaemia Skin Diseases Pneumonia Acute Diarrhoea Typhoid Fever Total top 10 diagnoses Total diagnoses for the year

FY 2014-15 No. of % on all cases diagnoses

FY 2015-16 No. of % on all cases diagnoses

1,077 3,582 2,255 1,938 990 179 869 810 1,018 346 13,064 23,910

6,095 3,016 2,701 1,414 1,164 895 806 750 643 566 18,050 37,126

4.5 % 15.0 % 9.4 % 8.1 % 4.1 % 0.7 % 3.6 % 3.4 % 4.3 % 1.4 % 54.6 %

Dr. Ambrosoli Memorial Hospital Kalongo Annual Analytical Report 2015-16

16.4 % 8.1 % 7.3 % 3.8 % 3.1 % 2.4 % 2.2 % 2.0 % 1.7 % 1.5 % 48.6 %

32


Figure 6.4: Top ten Diagnoses in OPD 7,000 6,000 5,000 4,000 3,000 2,000 1,000 0

FY 2014-15

FY 2015-16

The high number of patients and the inadequate number of staff too often unfortunately led to long waiting time for the patients (see further details in Chapter 8). Moreover, due to the heavy workload in the wards, Medical Officers seldom appear in the OPD except in emergency situations. This constrains the possibility to provide clinical guidance and support to the Clinical Officers. Another major limitation in OPD is the lack of equipment for clinical examination or, at times, their poor maintenance.

Ante Natal Clinic Ante Natal Clinic (ANC) is an outpatient clinic providing specialized services to pregnant women and their unborn children and to non-pregnant women of child bearing age. ANC is open and operational 5 days a week, from Monday to Friday, from 8.00 am to 5.00 pm. The clinic is closed on Saturdays, Sundays and all public holidays. ANC is autonomous from OPD and is hosted in the same building with eMTCT Care Point, Natural Family Planning and HCT clinics. These clinics provide a wide range of services to clients, yet the rooms available are clearly not sufficient for all these activities and, as a norm, are quite congested. With availability of funding, the entire area needs to be re-designed and

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improved to provide adequate working space and waiting shelter for the mothers and children attending the clinics.

ANC staffing composition The staffs working in the ANC include 8 Midwives, who are also responsible for the other programmes run in the structure. Considering the ever high numbers of ANC attendances in the hospital, the available midwives in ANC are certainly not enough to cover the current number of attendances, hence the need for future plans for further expansion of these services. Table 6.4: Antenatal and Postnatal indicators during the last 3 FYs ANTENATAL FY 2013-14 FY 2014-15 1,817 ANC 1st Visit 1,990 1,217 ANC 4th Visit 1,234 6,722 5,909 Total ANC visits new clients + Re-attendances 2 0 ANC Referrals to unit 0 0 ANC Referrals from unit POSTNATAL Post Natal Attendances 1,890 847 Number of HIV + mothers followed in PNC 77 26 Vitamin A supplementation 1,367 847 Clients with premalignant conditions for breast 0 0 Clients with premalignant conditions for cervix 0 0

FY 2015-16 1,890 1,075 5,743 0 1 620 8 599 0 0

ANC visits are organized in appointments given to the mothers according to their gestational age, but on average every two months: midwives proceed with abdominal palpation of the pregnant mother and heart auscultation. If they detect any problem they refer the pregnant mother to Maternity ward for further investigations. Post natal follow up is done both in the clinic with immunization of the child and weight check, but also at home during home visits where, beside the check of the baby, the midwives can support the new mothers with practical suggestions.

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Figure 6.5: ANC visits for the last 3 FYs

6,722 5,909

5,743

1,990

1,817

1,890

1,234

1,217

1,075

FY 2013-14

FY 2014-15

FY 2015-16

ANC 4th Visit

Total ANC visits

ANC 1st Visit

The slight increase in the number of ANC 1st visit did not balance the decrease in the number of ANC 4th visit and ANC total Visit (New ANC + Re-attendance).In the FY 2015-2016 the number of ANC 1st visit increased by 4%, while the total ANC attendance dropped by 11.6%. This is explained by the fact that LLUs are also providing ANC services and may represent a more convenient location for many mothers.

HIV/AIDS Clinic HIV/AIDS services are managed under the umbrella of the ACT Program (Aids Care & Treatment) funded by CDC through the Uganda Episcopal Conference and UCMB. These services were initiated in November 2005 and are substantially integrated into the hospital services. The Programme provides comprehensive HIV/AIDS care, including Antiretroviral Therapy, Prophylaxis for and Treatment of Opportunistic Infections, HIV Counseling and Testing, VCT, eMTCT, OVC, GBV related services and a Community Programme. The HIV/AIDS program is headed by a Medical Doctor who coordinates the activities of the Clinic. The personnel involved in the project activities in FY 2016-2016 included: 1 Medical Doctor, 1 Registered Midwife, 1 Enrolled Comprehensive Nurse, 2 Nurses, 1 Laboratory Assistant, 2 Pharmacy Assistants, 4 Counsellors, 1 Transporter, 1 Nursing Aid and 60 Community Health Volunteers. Moreover 1 Adherence Coordinator, 1 Monitoring & Evaluation Officer and 2 Record Assistants are responsible for the data collection and the monitoring of the project.

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The program registers an ever expanding number of HIV Clients every year. This is due to high number of new HIV/AIDS infection and the increasing referrals from other facilities. The higher number of patients implies an increased demand for HIV/AIDS services, often not commensurate with the available resources. The HIV/AIDS Clinic is located in a temporary structure used for dispensing drugs, nursing care, counselling, clinical consultation, storage of files, data entry and information management. The eMTCT component along with HCT/VCT activities of HIV/AIDS services is provided in the ANC Clinic adjacent to HIV/AIDS Clinic. The clients waiting space is in a movable tent that can barely provide safe cover against rain and sunshine during clinic days. A new shelter will be built in next FY to provide a waiting area.

HCT / VCT HCT/VCT is one of the strategies to fight HIV/AIDS: the aim is to provide free access to HIV counseling & testing and voluntary counseling & testing. HCT/VCT services are hosted in ANC Clinic. Moreover HCT/VCT activities are offered in community through the community outreach teams, in OPD and in all the wards. Table 6.5: Trend of HCT/VCT results in the last 5 FYs FY FY FY 2011-12 2012-13 2013-14

FY 2014-15

FY 2015-16

Number Tested Male

1,031

1,175

1,632

991

3,251

Female

1,484

1,679

1,886

1,683

5,028

TOTAL (Tested)

2,515

2,854

3,518

2,674

8,279

Male

123

78

118

54

243

Female

166

111

138

96

335

TOTAL (+ve Tests)

289

189

256

150

578

Male

12.0 %

6.6 %

7.2 %

5.4 %

7.5 %

Female

11.2 %

6.6 %

7.3 %

5.7 %

6.7 %

Both sexes

11.5 %

6.6 %

7.3 %

5.6 %

7.0 %

Tested +ve for HIV

Positivity Rates of HCT

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Figure 6.6: Trend of HIV Positivity Rate in HCT/VCT Clinic

The trend of HIV positivity among HCT/VCT clients has increased. More women access HCT/VCT services than man. In fact, the disaggregation results by gender of the HIV positive tests shows that females have the higher number of positive test results than their male counterparts; however in percentage female have a lower positive rate than man. However, with the emergence of new strategies like Provider Initiated Testing & Counselling (PITC), Routine Counselling & Testing (RCT), and mandatory HIV testing in ANC and Maternity for the elimination of Mothers to Child Transmission (eMTCT) a total of 12,334 clients accessed HIV counselling & testing services during FY 2015-2016. Table 6.7: HIV test by purpose during FY 2015 â&#x20AC;&#x201C; 2016 Types of test HCT Number of clients tested for HIV No. of HIV +ve tests Positivity Rate (%)

PMTCT*

Total

8,279

3,336

12,278

578

92

670

6.98%

2.76%

5.45%

The above figure is for total test done purely for HIV screening & excludes quality control tests done during the FY 2015-16. *Source: Laboratory records

It is rather interesting the difference between the prevalence in the PMTCT cluster (2.76%), compared with the prevalence in the HCT cluster (6.98%).

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PMTCT services Table 6.8 Performance indicators of the PMTCT Programme in FY 2015 â&#x20AC;&#x201C; 2016 Antenatal Indicators

Number

Mothers re-tested later in pregnancy, labour or postpartum

490

Mothers testing positive on a retest HIV positive pregnant women already on HAART before 1st ANC visit /Current pregnancy Pregnant women who received services at the health facility after referral from the community HIV (+) lactating mothers followed up in community for infant feeding, early infant diagnosis, or linkage into chronic care

54

HIV positive Pregnant women initiated on Cotrimoxazole Mothers assessed using CD4 Mothers assessed using WHO clinical staging only Maternity HIV positive deliveries initiating ARVs in Labour C. Postnatal Postnatal mothers newly tested for HIV

77 0 252 63 1 100

19 No. 177

Postnatal mothers testing HIV positive

9

Postnatal mothers initiating ARVs in PNC period Early Infant Diagnosis (EID)

8

HIV-exposed infants (<18 months) getting a 2nd DNA PCR

137

HIV-exposed infants initiated on Cotrimoxazole prophylaxis

121

1st DNA PCR results returned from lab within 2 weeks of dispatch

127

2nd DNA PCR results returned from lab within 2 weeks of dispatch Total HIV-exposed infants who had a serological/rapid HIV test at 18 months or older. Positive Number of HIV-exposed infants who had a serological/rapid HIV test at 18 months or older

99

DNA PCR results returned from the lab that are positive HIV-exposed infants whose DNA PCR results were given to caregiver Number of referred HIV positive-infants who enrolled in care at an ART clinic

Dr. Ambrosoli Memorial Hospital Kalongo Annual Analytical Report 2015-16

100 1 6 128 4

38


Antiretroviral therapy Table 6.9: PHAs eligible for ART and started on ART by age group and gender - last 5 FYs FY FY FY FY FY 2011-12 2012-13 2013-14 2014-15 2015-16 ELIGIBLE FOR ART <5 yrs 2 0 2 0 0 5-<18 yrs 4 1 5 0 0 Male 18 and above <5 yrs 5-<18 yrs Female 18 and above TOTAL ELIGIBLE FOR ART

20 1 3 26 56

24 0 0 21 46

102 0 1 71 181

20 0 0 15 35

10 0 0 11 21

STARTED ON ART <5 yrs Male 5-<18 yrs

11

7

18

4

3

9 112 7

5 117 9

15 142 15

7 108 5

5 137 9

3

7

25

4

10

18 and above

140

268

282

169

90

TOTAL STARTED ON ART

282

413

497

297

254

18 and above <5 yrs Female

5<18 yrs

ART Clinic operates as an outpatient clinic from Monday to Friday from 8.00 am to 5.00 pm excluding weekends and all public holidays. The number of patients started on ART dropped by 14.5% from 297 in FY 2014-2015 to 254 in FY 2015-2106. This is due to opening of ART sites in all the eight HCIIIs in the district, providing convenience to patients in and around the areas served by these health units. The number of patients eligible for ART reduced again from 35 in FY 2014-2015 to only 21 in FY 2015-2016 due to improvement in timeliness in ART enrolment for all clients. Besides ART services, ACT project also runs community programs which includes: 

Training of youths on life skills where abstinence is advocated for;

Training of married couples on being faithful in their marriages;

Adherence monitoring through home visits;

Community meetings for health talks;

Support to orphans and vulnerable children (OVCs) which includes psychosocial support and economic strengthening through SILC (Saving and Internal Lending in Community).

Gender Based Violence (GBV) support services to victims of GBV

Food security & livelihood support to PLWHA, especially to infected & affected Children.

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Table 6.10: Number of PLHAs started on ARV by age group and gender in FY 2015-2016

< 2years (24months)

Category

NEW PATIENTS ENROLLED

2â&#x20AC;&#x201C; 5years

5-14 years

15years and above

Total

M

F

M

F

M

F

M

F

1

4

2

5

6

7

93

146

264

56

56

PREGNANT WOMEN ENROLLED

0

CUMULATIVE INDIVIDUALS ON ARTEVER ENROLLED

2

6

17

17

98

99

931

1,684

2,854

HIV POSITIVE PATIENTS ACTIVE ON PRE-ART CARE

0

0

0

0

1

0

41

56

98

HIV POSITIVE CASES RECEIVING SEPTRIM/DAPSON AT LAST VISIT

4

7

14

14

73

73

721

1,313

2,219

ELIGIBLE PATIENTS NOT STARTED ON ART

0

0

0

0

0

0

10

11

21

NEW PATIENTS STARTED ON ART

1

4

2

5

5

7

90

140

254

56

56

PREGNANT WOMEN STARTED ON ART

0

HIV POSITIVE PATIENTS ASSESSED FOR TBAT LAST VISIT

4

7

14

14

73

73

721

1,313

2,219

HIV POSITIVE PATIENTS STARTED ON TB TREATMENT

0

0

0

0

0

2

51

23

76

NET CURRENT COHORT OF PEOPLE IN THE COHORT COMPLETING 12 MONTHS DURING THE YEAR

0

1

0

0

0

1

18

39

59

CLIENTS SURVIVING IN THE COHORT COMPLETING12 MONTHS ON ARTDURING THE YEAR

0

1

0

0

0

1

13

33

48

PEOPLE ACCESSING ARVS FOR PEP

0

0

3

0

10

8

0

0

21

INDIVIDUAL ON ART FIRST LINE

4

7

14

14

71

71

649

1,198

2,028

INDIVIDUAL ON ART SECOND LINE

0

0

0

0

1

2

31

59

93

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Orthopaedic Services Dr. Ambrosoli Memorial Hospital is currently offering limited orthopaedic services due to lack of an orthopaedic surgeon; however minor orthopaedic services are provided by an orthopaedic officer and a physiotherapist assistant. The most common procedure is the reduction of closed fracture due to trauma while the open fractures are in most cases referred to other specialised hospital. Physiotherapy sessions are also provided. Table 6.11: Main procedures in orthopaedics and physiotherapy done in the last 4 FYs

FY 2012-13

FY 2013-14

FY 2014-15

FY 2015-16

Plaster (POP)

565

582

622

236

Physiotherapy

83

106

72

62

Procedures

Tuberculosis Clinic Dr. Ambrosoli Memorial Hospital runs a TB Clinic where TB patients can register for treatment and follow up. The management and running of TB Clinic is merged into TB Ward which is located in an old building near to the Medical Ward. The staffs of Medical Ward are responsible for the treatment, management, follow up and reporting of Patients admitted in TB Ward and in TB Clinic. All TB patients, once diagnosed, are admitted in the TB Ward in the hospital for at least the first phase of intense treatment or as long as their general conditions allow them to go back home and come to receive their treatment for the continuation phase. To enforce TB/HIV co-infection management policies, 220 TB patients were tested for HIV (95.7%). A total of 92 TB patients tested HIV positive and 62 initiated ART in HIV Clinic. This put HIV positivity rate in TB Clinic at 39.5% during the FY 2015-2016.

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Table 6.12: TB patients registered for treatment in the last 4 FYs FY FY 2012-13 2013-14 No. of patients registered (all) 260 252 Children (< 5 yr.) 1 0 Disaggregation by Disease New Pulmonary Positive 123 89 Relapses Pulmonary Positive 5 6 Failure Pulmonary Positive 2 7 Default Pulmonary Positive 21 17 New pulmonary Negative 53 91 Relapses Pulmonary Negative 7 3 Default Pulmonary Negative 15 6 Pulmonary no smear done 6 0 Extra Pulmonary 28 33 Disaggregation by Treatment New Patients 208 213 Re-treatment 52 39 Other Patients Transferred in 6 2

FY 2014-15 192 11

FY 2015-16 233 9

97 4 8 9 26 4 4 0 0

154 5 3 7 26 2 3 27 6

161 25

213 20

0

3

During the FY 2015-2016, a total of 603 samples were collected from the LLUs and the hospital for MDR screening: last year they were only 27. This confirms the role of Dr. Ambrosoli Memorial Hospital laboratory as hub laboratory for the entire district. Out of the 603 sample collected, 150 tested positive for TB with no resistance and 8 tested positive for resistance to Rifampicin and referred to Kitgum Referral Hospital for management as required by the National TB control program. In fact, Dr. Ambrosoli Memorial Hospital does not have the required treatment for MDR cases. Table 6.13: MDR/MTB diagnosis during the FY 2015-16

Age group

Samples Collected

Samples Tested

< 15 years 15 yrs.& above Total

32 571 603

32 571 603

MTB positive Cases 0 150 150

MDR positive (Rifampicin Resistant TB) 0 8 8

MDR cases referred 0 8 8

TB Treatment Outcome The data below show treatment outcome of registered and enrolled TB patient in FY 20142015: as requested by the National TB and Leprosy Program their results are monitored 12 months after the start to see the final effects of the therapy. The success rate of treatment is the number of patients cured and completed treatment over the total of TB diagnoses in FY 2014-2015: the result is reported in FY 2015-2016. It was only 32.8% against 36% of the FY 2014-2015 that has already decreased from 48% of the previous FY. The number of treatment Dr. Ambrosoli Memorial Hospital Kalongo Annual Analytical Report 2015-16

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defaulters has remained high at 36.5% though it has decreased from the previous 39.7% in the FY 2014-2015. Table 6.14: Results of TB treatment in the last 4 FYs FY FY 2012-13 2013-14 Outcome of treatment No. No. Cured 22 52 Treatment Completed 67 73 Died 15 11 Failure 2 4 Defaulted 123 66 Transfer out 29 54 Total 258 260

FY 2014-15 No. 32 59 15 2 100 44 252

FY 2015-16 No. 44 19 13 1 70 45 192

FY 2015-16 (Percent) 22.9 9.9 6.8 0.5 36.5 23.4 100.0

The success rate among new smear positive pulmonary cases diagnosed in the FY 2014-2015 and assessed in 2015-2016 is 43.9% against 40% in previous FY. This is rather lower than the target success rate of 85% required by MoH and needed to attain a meaningful control of the disease. Table 6.15: Results of TB treatment smear positive Pulmonary TB patients in the last 4 FYs FY FY FY FY Outcome of treatment 2012-13 2013-14 2014-15 2015-16 Cured 18 39 28 38 Treatment Completed 13 17 17 16 Died 6 5 8 6 Failure 2 4 2 2 Defaulted 27 32 42 30 Transfer out 7 26 22 31 Total 73 123 119 123

Mental Health Clinic Mental Health Clinic in Dr. Ambrosoli Memorial Hospital is run within the OPD, where the services are provided by a Registered Psychiatric Nurse. During the FY 2015-2016, a total of 170 attendances have been registered against 382 attendances in the FY 2014-2015, i.e. a decrease of 55.5%. The decline in the number of cases can be attributed to the temporary interruption of AMREF support for specialised clinicians and drugs. The most common cases registered were epilepsy 130 cases (76.4% of the total) followed by drugs and alcohol abuse (19 cases, i.e. 11.2% of the total).

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Table 6.16: Mental health cases reviewed in OPD in the last 4 FYs FY FY 2012-13 2013-14 Diagnosis

FY 2014-15

FY 2015-16

No.

%

No.

%

No.

%

No.

%

Epilepsy

848

87.2

455

66.6

211

55.3

130

76.4

Drugs/alcohol abuse Depression & post-traumatic stress disorders Psychosis (schizophrenia)

26

2.7

62

9.1

13

3.4

19

11.2

32

3.3

15

2.2

38

9.9

6

3.5

3

0.3

3

0.4

4

1.0

3

1.8

Bipolar affective disorder

8

0.8

4

0.6

2

0.5

2

1.2

Attempted suicide

14

1.4

21

3.1

36

9.4

1

0.6

HIV related Psychosis

32

3.3

50

7.3

18

4.7

1

0.6

Other mental illnesses

10

1.0

73

10.7

60

15.8

8

4.7

Total

973

100

683

100

382

100

170

100

Challenges in mental health services The hospital tried to ensure continuity of mental health services, facing several challenges in particular:  Admissions of mental patients in Medical Ward leads to the risk of violence to other patients admitted.  Lack of availability of some essential drugs, such as fluoxetine and second generation antipsychotics  Ignorance and inadequate awareness in the general population  Poor community sensitization on mental health services causing increase of preventable conditions like alcohol and drug abuse.  Interruption of specialized clinic for mental health by AMREF and Ministry of Health Dental Clinic The Dental Clinic in the hospital is operational starting from April 2015 with a volunteer Public Dental Officer. A designated room with basic dental equipment is located in OPD and dental services are offered from Monday to Friday from 8:00 am to 1:00 pm and from 2:00 pm to 5:00 pm. More materials and equipment are required to expand the offer to patients. Palliative Care The palliative care program within the hospital covers patients suffering from terminal illness and having severe pain due to various conditions. There are two diploma nurses trained in clinical palliative care and supervising the program beside their normal activities and other responsibilities. The management of pain is done using oral morphine. Dr. Ambrosoli Memorial Hospital Kalongo Annual Analytical Report 2015-16

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Table 6.17: Number of Patients who received Palliative Care in the FY 2015-16 Clinical Condition Sickle Cell Crisis Cancer of the Cervix Liver Cirrhosis Liver Disease in HIV Congested Cardiac Failure Cryptococcus Meningitis in HIV Chronic Osteomyelitis HIV Psychosis Cancer of the Esophagus Cancer of the Prostate Cancer of the Breast Renal Failure Herpes Zoster in HIV Total

Number 21 11 9 7 6 5 4 3 2 1 1 1 1 72

The number of patients assisted has decreased substantially from last year: 72 against 130. Actually many patients are lost in the follow up and experience logistic problems (mainly the big distance and the high costs of transport). Ophthalmology The Ophthalmology Clinic in the hospital is not fully operational due to lack of qualified staff. The services were offered periodically by visiting ophthalmology specialist supported by AMREF, through its outreach program. During FY 2015-2016 Dr. Ambrosoli Memorial Hospital was not covered by their programmes.

Inpatients Department Summary of beds and qualified health personnel In FY 2015-2016 Dr. Memorial Hospital Kalongo maintained a total of 271 beds. 1 Specialist Doctor (Surgeon) and 5 Medical Officers are working in the 5 wards along with 50 Nurses and Midwifes. The average number of beds per nurse/midwife is 5.4, with Surgical Ward being the ward with highest number of beds per nurse/midwife (6.9) and Maternity Ward the lowest (4.4).

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Table 6.18: Summary of beds and qualified health personnel per ward Medical Personnel

No. of Nurses & Midwives

No. of beds per Nurse/MW

2 Medical Officers

9

6.6

76

1 Surgeon

11

6.9

Maternity Ward

75

1 Medical Officer

17

4.4

Pediatric Ward

61

2 Medical Officers

13

4.7

Total

271

1 Specialist Doctor and 5 Medical Officers

50

5.4

Ward

No. of Beds

Medical Ward

41

TB Ward

18

Surgical Ward

Key indicators in Inpatients Department In FY 2015-2016 Dr. Ambrosoli Memorial Hospital admitted a total of 22,274 patients with an increase of 74% of admissions from FY 2014-2015. This increment is due mainly to the Malaria epidemic affecting Northern Uganda after the suspension of the Indoor Residual Spray campaign. An increase of admissions was observed in all the wards. In particular: Medical ward increased by 50.4%, Surgical ward by 4.4%, Paediatric ward by 186% (it had almost three times the patients of previous year), Maternity ward by 27.9% and TB ward by 21.1%. Patient Days and Average Length of Stay The number of patient days has increased by 31% compared to a reduction of 7.3% in the previous FY. The Average Length of Stay has decreased: from 5.2 days in FY 2014-2015 to 3.9 days in FY 2015-2016. This is to be considered an indicator of efficiency in the management of patients, as a shorter period of hospitalisation attains the same level of cure. Bed Occupancy Rate (BOR) and Throughput per Bed The hospital Bed Occupancy rate (BOR) has increased from 68.0% in the previous FY to 87.9% in current FY. This result is related to the increased number of inpatients. The hospital target was a BOR of at least 85%. The Throughput per Bed has increased from 47.9% to 82.2% indicating a high improvement in the utilisation of the available beds. Number of deaths, Mortality Rate, Recovery Rate and self-discharged Dr. Ambrosoli Memorial Hospital Kalongo Annual Analytical Report 2015-16

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Number of deaths among admitted patients increased from 179 to 251 in FY 2015-2016, but the hospital Mortality Rate has decreased to 1.1%. This indicates the efficient improvement in the management of patientsâ&#x20AC;&#x2122; general conditions by carrying out proper procedures necessary from the time of admission until the final day of discharge from the hospital. The Recovery Rate has decreased a little but is still 98%, in line with previous years, while the number of admitted patients that self-discharged has been 14. This number does not account for all the patients escaping from the hospital without completing their treatment and without paying. Despite this, all the data expresses a positive image of the utilisation of curative inpatient services.

Table 6.19: Key indicators for the entire hospital in the last 5 FYs FY FY FY Indicator 2011-12 2012-13 2013-14 No. of beds 302 302 302 Total Admissions 11,374 11,835 13,805 discharged Patient days 62,340 63,798 76,758 Average Length of Stay 5.5 5.4 5.6 Turn over interval 4.2 3.9 2.4 Throughput per bed 37.7 39.2 45.7 BOR 56.6 57.9 69.6 No. Deaths 172 180 219 Mortality Rate 1.5% 1.5% 1.6% Recovery Rate 98.3% 98.3% 98.2% Self-discharges 16 15 34

FY 2014-15 271 12,799 66,386 5.2 2.5 47.2 67.1 180 1.4% 98.5% 11

Dr. Ambrosoli Memorial Hospital Kalongo Annual Analytical Report 2015-16

FY 2015-16 271 22,274 86,898 3.9 0.5 82.2 87.9 251 1.1 98.0% 14

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Table 6.20: Key indicators per ward in the last 4 FYs SURGICAL WARD9

MEDICAL WARD FY 12-13 No of beds

FY 13-14

FY 14-15

FY 15-16

FY 12-13 No of beds

FY 13-14

FY 14-15

FY 15-16

58

58

41

41

76

76

76

76

Total Admissions

1,554

3,410

2,053

3,088

Total Admissions

1,878

766

1,974

2,060

Patients days

Patients days

8,341

19,449

7,954

10,392

15,640

7,676

14,870

16,055

ALOS

5.4

5.7

3.9

3.4

ALOS

8.3

10

7.5

7.8

Throughput per bed

26.8

58.8

50.1

75.3

Throughput per bed

24.7

10.1

26

27.1

39.4%

91.9%

53.2%

69.4%

56.4%

27.7%

53.6%

57.9%

77

113

94

95

No of Deaths

24

7

22

40

BOR No of Deaths

BOR

Mortality rate

5%

3.3%

4.6%

3.1%

Mortality rate

1.3%

0.9%

1.1%

1.9%

Recovery rate

95.1%

95.1%

95.4%

95.3%

Recovery rate

98.1%

97.9%

98.4%

94.6%

Self-discharges

3

8

2

6

Self-discharges

10

25

10

7

PAEDIATRIC WARD

OBSTETRICS& GYNECOLOGY WARD

FY 12-13 No of beds Total Admissions Patients days ALOS Throughput per bed BOR No of Deaths

FY 13-14

FY 14-15

FY 15-16

FY 12-13 No of beds

FY 13-14

FY 14-15

FY 15-16

61

61

61

61

75

75

75

75

4123

4,607

3,741

10,706

Total Admissions

4,063

4,756

4,845

6,195

16,320

22,325

17,498

33,596

Patients days

4

4.8

4.7

3.1

67.6

75.5

61.3

73.3%

100.3%

65

78

18,386

21,987

22,173

22,673

ALOS

4.5

4.6

4.6

3.6

175.5

Throughput per bed

54.2

63.4

63.8

82.6

78.6%

150.9%

BOR

67.2%

80.3%

81%

82.8%

48

102

No of Deaths

6

6

8

4

Mortality rate

1.6%

1.7%

1.3%

1%

Mortality rate

0.14%

0.12%

0.16%

0.06%

Recovery rate

98.4%

98.3%

99.3%

98.6%

Recovery rate

99.8%

99.8%

99.8%

99.6%

Self-discharges

1

1

0

0

Self-discharges

1

0

1

0

FY 12-13

FY 13-14

FY 14-15

FY 15-16

TB WARD

No of beds

24

24

18

18

Total Admissions

217

266

186

225

Patients days

5,103

5,321

3,891

4,182

ALOS

23.5

20.0

20.9

18.6

9

11.1

10.3

12.5

Throughput per bed BOR

9

58.3%

60.7%

59.2%

63.7%

No of Deaths

7

13

8

10

Mortality rate

3.2%

4.9%

4.3%

4.4%

Recovery rate

95.8%

95.1%

95.7%

95.1%

Self-discharges

0

0

0

1

Source: HMIS 108 Male Surgical Ward + Female Surgical Ward + Other Wards (Children Surgical Ward)

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Inpatient referrals Table 6.21: Pattern of referrals to and from the hospital in the last 4 FYs FY FY FY 2012-13 2013-14 2014-15 Referrals to hospital 278 311 474 Referrals from hospital 75 81 87 Total 353 392 561

FY 2015-16 449 173 622

In reference to the above table, the need for strengthening the referral system is quite evident. The hospital currently does not have any support earmarked to cover the costs of referral especially for the vulnerable. The top ten cause of morbidity in all the wards The comparison between the number of total inpatients admissions in Dr. Ambrosoli Memorial Hospital and the total number of admitted Malaria cases clearly indicates the sharp increase of admissions for Malaria from early 2015, six months after the last round of IRS. Furthermore it represents the single determinant of the increase of the admissions in the hospital in FY 2015-2016 and the 40.2 % of the total case load. We recorded an increased from 791 to 1,030 cases of Septicaemia and from 299 to 1,015 of Anaemia, though the percentage for Septicaemia on total diagnosis decreased from 8.7% to 4.3%. On the contrary Anaemia has increased from 3.3% to 4.2% in line with the high number of Malaria cases that are associated with Anaemia. Injuries, Gastro-intestinal Disorders, Pneumonia, Skin Diseases, Abortion and Diarrheal Diseases have been stable compared in absolute numbers, but due to the high number of Malaria cases their percentage has decreased. Respiratory Tract infections have dramatically decreased: from 434 in FY 2014-2015 to 240 cases in FY 2015-2016.

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Table 6.22: Ten top causes of admission in all the wards in the FYs 2014-2015and 2015-2016 FY 2014-15 FY 2015-16 No. of % on all No. of % on all Causes of Morbidity cases diagnoses cases diagnoses 1 2 3 4 5 6 7 8 9 10

Malaria Septicaemia Anaemia Injuries Gastro-Intestinal disorder (non-infective) Pneumonia Skin Diseases Abortions Diarrhoea Diseases RTI All others (Tot diagnosis-top ten) Total

1,513 791 299 908 768 695 659 373 340 434 2,316 9,096

16.63 % 8.7 % 3.28 % 9.98 % 8.44 % 7.64 % 7.24 % 4.1 % 3.74 % 4.77 % 25.48 % 100%

9,609 1,030 1,015 853 718 629 576 394 321 240 8,542 23,927

40.16 % 4.3 % 4.24 % 3.56 % 3% 2.63 % 2.41 % 1.65 % 1.34 % 1% 35.72 % 100 %

In FY 2015-2016 Malaria cases admitted in the hospital represented 40.16% of all diagnosis: this is a drastic increment after the drop in the previous two FYs.

Table 6.23: Trend in Malaria admissions over the last 5 FYs FY FY FY 2011-12 2012-13 2013-14

FY 2014-15

FY 2015-16

Malaria cases

2,361

2,931

1,505

1,513

9,664

% of all diagnosis

21 %

25 %

11 %

6%

40.16 %

The top ten causes of death in all the wards Malaria was the main causes of death in the hospital with 55 deaths, i.e. a fatality rate of just 0.57%. Itâ&#x20AC;&#x2122;s worth noting that neonatal sepsis has the highest fatality rate (28%) and cardiovascular diseases, which had been the second leading cause of death in FY 2014-2015 and now ranking 7th, had a very high fatality rate: 19.67% this year, while it was 16.66% last year. Snake bites, which last year did notregister any death, in FY 2015-2016 registered 6 deaths with a fatality rate of 9.67% becoming the third cause of death in the hospital.

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Table 6.24: Top ten causes of death among inpatients all wards FY 2014-15 and FY 2015-16 FY 2014-15 FY 2015-16 No of No of cases Case No of No of cases Case Causes of Mortality disease admitted in Fatality disease admitted in Fatality among specific the hospital Rate specific the hospital Rate Inpatients deaths deaths 1 2 3 4 5 6 7 8 9 10

Malaria Anaemia Pneumonia Gastro-Intestinal disorder(all (nonInjuries types)10 infective) Septicaemia Cardiovascular diseases Tuberculosis Neonatal sepsis Snake Bites

14 15 24 8 12 7 17 10 4 0

1,513 314 695 768 908 791 102 219 35 56

0.92 4.77 3.45 1.04 1.32 0.88 16.66 4.56 11.42 0

55 17 15 15 13 12 12 10 7 6

9,609 1,015 629 718 853 1,030 61 225 25 62

0.57 1.67 2.38 2.08 1.52 1.16 19.67 4.44 28 9.67

Medical Ward Medical Ward has 41 beds and is located in one main block divided into male and female sections. It has also an adjacent wing which has four two-bed rooms and three self-contained rooms for private patients. Staff composition The ward is run by 2 Medical Doctors, 8 Nurses, 1 Midwife, 3 Nursing Assistants and 1 Nursing Aide. In an effort to enhance learning and clinical practices, at least two students of St. Mary's Midwifery Training School are also assigned on rotation for short periods to the ward. The same staffs cover also the TB Ward and support the functionality of OPD especially during weekends, public holidays and after 5.00 pm (when the OPD is closed). Table 6.25: Staff Composition in Medical Ward FY 2015-16 Cadre/ Discipline Qualification Medical Doctor Bachelor Degree in Medicine and Surgery Registered Midwife Diploma in Midwifery Registered Comprehensive Nurse Diploma in Comprehensive Nursing

Number 2 1 1

Enrolled Nurse

Certificate in Nursing

4

Enrolled Comprehensive Nurse Nursing Assistant

Certificate in Comprehensive Nursing Certificate in Nursing Assistant

3 3

Nursing Aid

Trained on the Job

1

Total

10

15

Source DHIS: 2 Jaw Injuries + Road Traffic Injuries + Trauma Injuries2

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Key indicators in the Medical Ward During the FY 2015-2016, a total of 3,088 patients were admitted representing an increment of 50.4%. The ward contributed 13.6% of total hospital admission during the current FY. The average length of stay (ALoS) has decreased from 3.9 in the last FY to 3.4 in the FY 20152016. The bed occupancy rate (BOR) has increased from 53.2% to 69.4% and the turnover interval has decreased from 3.4 to 1.5. These data confirm the increment of workload and efficiency of the ward. Table 6.26: Key indicators in Medical Ward in the last 5 FYs FY FY FY 2011-12 2012-13 2013-14 No. of beds 58 58 58

FY 2014-15 41

FY 2015-16 41

Total Admissions Bed days

1,575 8,703

1,554 8,341

3,410 19,449

2,053 7,954

3,088 10,329

ALoS BOR Throughput Turnover interval

5.5 41.1% 27.2 7.9

5.4 39.4% 26.8 8.3

5.7 91.9% 58.8 0.5

3.9 53.2% 50.1 3.4

3.4 69.4% 75.3 1.5

87

77

113

94

95

5.5% 94.3% 3

5% 95.1% 3

3.3% 95.1% 8

4.6% 95.4% 2

3.1% 95.3% 6

Deaths Death Rate Recovery Rate Self-discharges

The top ten cause of morbidity Malaria is still the leading cause of morbidity in Medical ward, accounting for 47.2% of total admissions. All the other diagnoses have lower percentage, Typhoid Fever being the commonest with 5.1%. Hypertension and cardiovascular diseases have increased in the last FY showing an upward trend of non-communicable diseases.

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Table 6.27: Top 10 causes of admission in Medical Ward - FYs 2014-2015 and 2014-2015 FY 2014-15 FY 2015-16 No. of % on all No. of cases % on all Causes of Morbidity cases admissions in admitted admissions in in admitted Medical Medical Medical Ward Ward Ward 1 2 3 4 5 6 7 8 9 10

Malaria Typhoid Fever Gastrointestinal disorders not infectious Pneumonia Septicaemia Hypertension Urinary Tract Infection Cardiovascular Disease Respiratory Tract Infections(not Pneumonia) Asthma

686 74

33.4 3.6

1456 156

47.2 5.1

376

18.3

136

4.4

153 245 68 97 76

7.5 11.9 3.3 4.7 3.7

102 87 75 60 54

3.3 2.8 2.4 1.9 1.7

168

8.2

46

1.5

62

3.0

38

1.2

The top five causes of death Liver cirrhosis was themain cause of death in the ward during FY 2015-2016 with 5 deaths out of 9 cases and a fatality rate of 55.5% which is the highest, cardiovascular diseases having the second highest fatality rate: 7.4%vs. 22.4% last year. Table 6.28: Top 5 common causes of death in Medical ward - FYs 2014-2015 and 2015-2016 FY 2014-15 FY 2015-16 No. of No. of Case No. of No. of Case Causes of Mortality disease cases Fatality disease cases Fatality in specific admitted Rate specific admitted Rate Medical Ward deaths deaths 1 2 3 4 5

Liver Cirrhosis Cardiovascular Disease Pneumonia Septicaemia Suicide

2

38

5.3%

5

9

55.5%

17

76

22.4%

4

54

7.4%

16 3 2

153 245 108

10.5% 1.2% 1.9%

3 2 0

102 87 6

2.9% 2.3% 0%

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Surgical Ward Surgical Ward is accommodated in a large building divided in two sections for female and male patients. One room is also available for children. This is one of the oldest buildings in the hospital and therefore it needs substantial renovation works. The collaboration with the Japanese Red Cross Society has continued also this year and the performance of the ward has increased thanks to the constant presence of specialist surgeons and nurses provided on a rotation basis. Their presence has helped the hospital to secure competent management of surgical cases until when the Surgeon now in charge has come back from studies, allowing also a constant on the job training for the Medical Officers and Nurses. Staffing composition The ward is run by a Surgeon who is the only specialist present in the hospital: he attended a Master in General Surgery in Makerere University for 3 years supported by Dr. Ambrosoli Memorial Foundation. 10 Nurses, 1 Midwife, 1 Orthopaedic Officer, 1 Physiotherapist Assistant and 1 Nursing Aide are completing the surgical team. Table 6.29: Staff composition in Surgical Ward in the FY 2015-2016 Cadre/ Discipline Qualification

Number

Surgeon

Bachelor Degree in Medicine and Surgery and Master in Surgery

1

Registered Midwife/Nurse

Diploma in Midwifery and Nursing

1

Enrolled Comprehensive Nurse

Certificate in Comprehensive Nursing

5

Enrolled Nurse

Certificate in Nursing

5

Nursing Aid

Trained on the job

1

Orthopedic Officer

Diploma in Orthopedic

1

Physiotherapist Assistant

Certificate of Physiotherapist Assistant

1

Total

15

Key indicators in the Surgical Ward The admissions in Surgical Ward registered a minor increase from 1,974 in the FY 20142015 to 2,060 in the FY 2015-2016 (4.4%) contributing for the 9.2% to the total admissions. The ALoS has also increased from 7.5 to 7.8 days: Surgical Ward is the only ward in the hospital that has increased this indicator. Despite the BOR has increased from 53.6% to

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57.9% due to the increasing number of admissions, the Surgical Ward has the lowest BOR in the whole hospital. Table 6.30: Key indicators in Surgical Ward in the last 5 FYs FY FY FY 2011-12 2012-13 2013-14 No. of beds 76 76 76

FY 2014-15 76

FY 2015-16 76

Total Admissions Bed days

1,648 16,799

1,878 15,640

766 7,676

1,974 14,870

2,060 16,055

ALoS BOR

10.2 60.6%

8.3 56.4%

10 27.7%

7.5 53.6%

7.8 57.9%

Throughput

21.7

24.7

10.1

26

27.1

Turnover interval Deaths

6.6 16

6.4 24

26.2 7

6.5 22

5.7 40

Death Rate

1%

1.3%

0.9%

1.1%

1.9%

98.5% 9

98.1% 10

97.9% 25

98.4% 10

94.6% 7

Recovery Rate Self-discharges

The top ten cause of admission Injuries account for 43.6% of total admissions in the ward during the FY 2015-2016, followed by abscesses (10%) and hernias (7.1%). Injuries due to burn have dramatically decreased (minus 90.5%) and in general all the diagnoses except hernias have decreased in absolute numbers. Table 6.31: Top 10 causes of admissions in Surgical Ward-FYs 2014-2015 and 2015-2016 FY 2014-15 FY 2015-16 Causes of Morbidity No. of % on all No. of % on all in cases admissions in cases admissions in Surgical Ward admitted Surgical admitted Surgical Ward Ward 1 Injury due to other causes 1,328 67.3 756 36.7 2 Abscess 223 11.3 206 10.0 3 Hernia 86 4.4 147 7.1 Injury due to Road Traffic 4 119 6.0 96 4.7 Accident (RTA) 5 Snake bite 54 2.7 59 2.9 6 Injury due to burn 475 24.0 45 2.2 7 Hydrocele 68 3.4 43 2.1 8 Intestinal obstruction 44 2.2 36 1.7 9 Osteomyelitis 44 2.2 16 0.8 10 Urinary tract infection 23 1.2 16 0.8

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The top five causes of death Injuries were the main causes of death in Surgical Ward during FY 2015-2016 with 13 deaths. Intestinal obstruction has the highest fatality rate (11.1%). Table 6.32: Top 5 common causes of death in Surgical Ward FY 2014-15 No of No of cases Case No of Causes of Mortality disease admitted Fatality disease in specific Rate specific Surgical Ward deaths deaths 1 2 3 4 5

Injury due to other causes Intestinal obstruction Injury due to Road Traffic Accident Injury due to Burns Complication of Hernia

FY 2015-16 No of cases admitted

Case Fatality Rate

7

650

1.1

8

756

1.1

3

43

7.0

4

36

11.1

6

218

2.8

4

96

4.1

1

134

0.7

1

45

2.2

0

113

0.0

1

147

0.7

Operating Theatre The new operating theatre, constructed with the support of the government of Japan and commissioned in the month of March 2015 hosts 3 operating rooms, recovery room, duty room, in-charge office, store, sluice room and sterilization room. Staffing composition Currently 2 Anaesthetic Officers, 7 Nurses, 1 Midwife 3 Nursing Assistants and 4 Nursing Aids are staffing the operating theatre. OneAnaesthetic Officer completed his Diploma at Uganda Institute of Allied Health and Management Sciences, Mulago, Lacor hospital branch and started to working in the hospital in July 2016.

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Table 6.33: Staff Composition in the operating theatre Cadre/ Discipline Qualification

Number

Anesthetist Officer

Diploma in Anesthesia

2

Registered Nurse

Diploma in Nursing

1

Enrolled Midwife

Certificate in Midwifery

1

Enrolled Nurse

Certificate in Nursing

2

Enrolled Comprehensive Nurse

Certificate in Comprehensive Nursing

4

Nursing Assistant

Certificate in Nursing Assistant

3

Nursing Aid

Trained on the Job

4

Total

17

Surgical Procedures Caesarean section is the leading major surgical procedure in the Hospital representing 35.7% as shown in Table 6.34. Table 6.34: Top major surgical procedures performed in the FY 2015-16 Top major surgical procedures Number of patients 1 2 3 4 5 6

Caesarean section Laparotomy Herniorraphy Evacuation ENT Surgical Procedures Other major procedures Total

315 119 112 5 3 107 661

Proportion (%) 47.6 18.0 16.9 0.8 0.5 16.2 100%

Debridement and wound care are the main minor surgical procedures (60.9%). Incision and drainage abscess is the second with 232 cases, 20.5% of all the minor operations. Table6.35: Top minor surgical procedures done in FY 2015-16 1 2 3 4 5 6

Top minor surgical procedures

Number of Patients

Proportion (%)

Debridement and wound care Incision and drainage of abscesses Minor ENT Surgery Safe Male Circumcision Oral Surgery Other Minor Procedures Total

687 232 34 11 4 159 1129

60.9 20.5 3.0 1.0 0.4 14.1 100%

Major operations have increased by 17%, while minor operations have decreased by 16.2%. Total emergencies have decreased by 13.8%, representing 42.7% of all the major operations.

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Table 6.36: Trend of surgical activities in last 5 FYs FY FY 2011-12 2012-13

FY 2013-14

FY 2014-15

FY 2015-16

Total Operations

2,468

3,017

2,886

1,913

1,790

Major operations (including C/S)

730

803

663

565

661

Minor operations

1,738

2,219

2,223

1,348

1,129

352

445

416

327

282

48.2%

55.4%

62.7%

57.9%

42.7%

Emergencies Emergencies as % of total major operations

The main type of anaesthesia is general anaesthesia with Ketamine (64.2%). Spinal anaesthesia was used for 18.7% of the operations, local anaesthesia for 15.4% and general anaesthesia with ETT for 1.7%. Table 6.37: Pattern of anesthesia used during the last 5FYs FY FY FY Type of Anesthesia 2011-12 2012-13 2013-14 Local Anesthesia

FY 2014-15

FY 2015-16

316

321

1,287

569

276

1,877

1,705

1,039

1030

1,149

Spinal Anesthesia

265

527

518

290

335

General Anesthesia with ETT

10

52

42

24

30

2,468

2,605

2,886

1,913

1,790

General Anaesthesia with IV Ketamine

Total

Paediatric Ward The Paediatric Ward complex is accommodated in two buildings with 61 beds: one main block where most cases are admitted, and one smaller wing designed as an isolation unit with separated rooms. With the closure of the Nutrition Unit in early 2012, the wing is used as an extension of the ward to provide additional space for excess admissions and to host a few children admitted with malnutrition. The entire complex requires major renovation works. Staff Composition The personnel assigned to this ward included 1 Medical Officer, 3 Midwives, 10 Nurses and 4 Nursing Assistants. In an effort to enhance learning and clinical practices, at least two students of St. Mary's Midwifery Training School are also assigned on rotation for short periods to the ward.

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Table 6.38: Personnel assigned to Paediatric Ward in FY 2015-16 Cadre/ Discipline Qualification

Number

Medical officers

Bachelor Degree in Medicine and Surgery

1

Enrolled Midwife

Certificate in Midwifery

3

Registered Nurse

Diploma in Nursing

1

Enrolled Nurse

Certificate in Nursing

7

Enrolled Comprehensive Nurse

Certificate in Comprehensive Nursing

2

Nursing Assistant

Certificate in Nursing Assistant

4

Total

19

Key indicators in Paediatric Ward The performance indicators of Paediatric Ward show significant performance improvements. The ALoS dropped from 4.7 in the FY 2014-2015 to 3.1 in 2015-2016. BOR has increased dramatically from 78.6% to 150.9% while death rate has decreased from 1.3% to 1%. Table 6.39: Paediatric Ward indicators over the last 5 FYs FY FY FY 2011-12 2012-13 2013-14 No. of beds 61 61 61

FY 2014-15 61

FY 2015-16 61

Total Admissions Bed days ALoS BOR Throughput Turnover interval

3,542 12,555 3.5 56.4% 58.1 2.7

4,123 16,320 4.0 73.3% 67.6 1.4

4,607 22,325 4.8 100.3% 75.5 0.0

3,741 17,498 4.7 78.6% 61.3 1.3

10,706 33,596 3.1 150.9% 175.5 -1.1

Deaths Death Rate Recovery Rate Self-discharges

43 1.2% 98.8% 2

65 1.6% 98.4% 1

78 1.7% 98.3% 1

48 1.3% 99.3% 0

102 1% 98.6% 0

During the FY 2015-2016, a total of 10,706 patients were admitted, representing 186.2% increase. The admission in Paediatric Ward alone contributed 48% of the hospital total admissions. The seasonal pattern of admissions remained similar with the previous financial year, characterised by sudden increments of admissions at the beginning of the rain season, with high peaks around November-December and June-July, as shown in the diagram below.

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Figure 6.7: Trend of Admissions in Paediatric Ward in the FY 2015-16

1,811 1,318

945 882 846

961

806 534

1,058 808 431 306

The top ten causes of morbidity Malaria still remains the leading cause of admission with 69.9% of diagnoses in the ward. The second cause of morbidity is Anaemia which is a consequence of Malaria and has increased from last FY by 618.8%: from 170 cases to 1,222. Septicaemia has more than doubled the number of cases, from 415 to 895, but in percentage has decreased due to the high number of Malaria admissions. Sickle Cell Disease increased by 192% from 38 cases to 111, whereas malnutrition has decreased by 73.3% from 101 cases to 27. Table 6.40: Top ten causes of admission in Paediatric Ward - FY 2014-15 and FY 2015-16 FY 2014-15 FY 2015-16 Causes of Morbidity No. of cases % on all No. of cases % on all admitted admissions admitted admissions 1 Malaria 797 21.3 7,488 69.9 2 Anaemia 170 4.5 1,222 11.4 3 Septicaemia 415 11.1 895 8.4 4 Pneumonia 410 11 620 5.8 Gastroenteritis / diarrhoeal 5 627 16.8 474 4.4 diseases Respiratory Tract Infection6 350 9.4 364 3.4 (not Pneumonia) 7 Urinary Tract Infection 17 0.5 269 2.5 8 Sickle Cell Disease 38 1.0 111 1.0 9 Severe Malnutrition 101 2.7 27 0.3 10 Neonatal septicaemia 25 0.7 16 0.1

The comparison between the total admissions per month and the admissions per month due to Malaria cases shows the big impact of the Malaria epidemic on morbidity in Paediatric Ward.

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1,058 888 306 130

225

431

808 350

989

961 260

534

642

806 553

657

846

882 466

723

945

1,318

1,811 1,604

Figure 6.8: Trend of Malaria admissions in Paediatric Ward in the FY 2015-16 by months

The top five causes of death Malaria was the main causes of death in the ward during the FY 2015-2016 with 47 deaths, but a very low fatality rate of 0.6%. Neonatal Septicaemia has the highest fatality rate (68.8%) and Sickle Cell Disease comes second with 2.7%. Table 6.41: Top five causes of death in Paediatric Ward in FY 2015-16 No of No of cases of the disease-specific disease admitted in Causes of Mortality deaths Paediatric Ward 1 2 3 4 5

Malaria Neonatal Septicemia Pneumonia Gastroenteritis Sickle Cell Disease

47 11 8 5 3

Case Fatality Rate

7,488 16 620 474 111

Dr. Ambrosoli Memorial Hospital Kalongo Annual Analytical Report 2015-16

0.6 68.8 1.3 1.1 2.7

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Maternity Ward (Obs & Gyn) The Maternity Ward is the largest ward in the hospital with 75 bed capacity. It is subdivided into various sections which include the Labour Room and Admission Rooms (Post Natal, Caesarean, and Gynaecology), Doctors office, Sister In-charge office, Duty Room, Private Rooms, Premature Nursery, Isolation and Pre-eclamptic unit, Treatment Room. Maternity ward is run by 1 Medical Officer and 17 Midwives who are directly responsible for management of admitted patients. It is also a practical training ward for students from St. Mary's Midwifery Training School: an average of 8 students every day is present in the ward for practice under the supervision of a qualified midwife/mentor. Staff Composition Maternity Ward has a registered midwife/nurse who is the ward in-charge and a core leader of all the staff: she manages the general activities needed for the patients and organizes the duties. The midwives in maternity work in shifts: Morning shift from 8.00am to 3.00pm, Afternoon shift from 2.00pm to 8.00pm and night shifts from 8.00pm to 8.00am. Table 6.42: Staff Composition in Maternity Ward in FY 2015-16 Cadre/ Discipline Qualification

Number

Medical officer

Bachelor Degree in Medicine and Surgery

1

Registered Midwife/Nurse

Diploma in Midwifery and Nursing

1

Registered Midwife

Diploma in Midwifery

1

Enrolled Midwife

Certificate in Midwifery

15

Total

18

Maternity ward indicators During the FY 2015-2016, a total of 6,195 patients were admitted in maternity (an increment of 27.9%). Maternity Ward admitted the second highest number of patients in the hospital after Paediatric Ward and contributed 27.8% of total hospital admission during the current FY. The average length of stay (ALoS) has decreased of 1 full day passing from 4.6 in the last FY to 3.6 in the FY 2015-2016. The bed occupancy rate (BOR) has increased from 79.9% to 82.8% and the turnover interval has decreased from 1.1 to 0.8. These data confirm the increment of workload and, at the same time, efficient results. Dr. Ambrosoli Memorial Hospital Kalongo Annual Analytical Report 2015-16

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Table 6.43: Key indicators in Maternity Ward (Obs & Gyn) in the last 5 FYs FY FY FY FY 2011-12 2012-13 2013-14 2014-15 No. of beds 75 75 75 75 Total Admissions 4,198 4,063 4,756 4,845

FY 2015-16 75 6,195

Bed days

19,801

18,386

21,987

22,173

22,673

ALoS BOR

4.7 72.3%

4.5 67.2%

4.6 80.3%

4.6 79.9%

3.6 82.8%

56.0 1.8

54.2 2.2

63.4 1.1

63.8 1.1

82.6 0.8

9

6

6

8

4

Death Rate Recovery Rate

0.21% 99.7%

0.14% 99.8%

0.12% 99.8%

0.16% 99.8%

0.06% 99.6%

Self-discharges

2

1

0

1

0

Throughput Turnover interval No. Deaths

The admission trends in Maternity Ward continued to increase every financial year. The number of deliveries equally increased from 3,247 in the FY 2014-2015 to 3,456 in the FY 2015-2016 (an increment of 5.8%). Figure 6.9: Trend of total Admissions in Maternity and Delivery

Maternal Death Rate has unfortunately increased by 1 unit: from 3 of last FY to 4 in the FY 2015-2016. Fresh Still Birth in units has decreased from 32 to 20. Early neonatal death has increased from 33 to 34, but slightly decreased in percentage: from 1.02% in FY 2014-2015 to 0.99% in the current FY.

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Some of the negative trends may be explained by the high attrition rate of qualified staff, particularly the senior midwives with many years of experience who left the hospital, often with not enough notice to be replaced: this affected the quality of work in the hospital. Table 6.44: Maternity Ward Deliveries & Births indicators in the last 5 FYs FY 2011-12

FY 2012-13

FY 2013-14

FY 2014-15

FY 2015-16

2,805 2,289 516 2,793

2,727 2,178 549 2,723

3,003 2,532 449 2,934

3,247 2,816 431 3,238

3,465 3,111 354 3,445

Babies born with low birth weight

292

278

283

384

443

Fresh Still births in unit Macerated still births in unit

11 16

19 18

22 18

32 28

20 26

New-born deaths (0-7 days) Maternal Deaths

23 7

52 5

34 5

33 3

34 4

2,466

2,448

2,598

2,860

2813

292 35

289 23

261 95

378 n.a.

572 60

21 384 405 14.4% 94.8%

48 363 411 15% 88.3%

46 360 406 13.5% 88.7%

42 327 369 11.3% 88.6%

26 292 318 9.2% 91.8%

Total deliveries Normal deliveries in unit Abnormal deliveries (incl. C/S) Live birth in units

Live Births Full term normal weight Full term low birth weight Premature cases Caesarean Sections Elective C/S Emergency C/S Caesarean Sections total C/S as % of total deliveries Emergency C/S as % of all C/S

All deliveries are conducted and assisted by qualified personnel. Being a teaching hospital, midwifery students are given a chance to participate in the follow up and monitoring of labour progress and learn how to conduct deliveries under the supervision of a qualified midwife or a medical doctor. Of the total 3,465 deliveries conducted in Maternity ward during the FY 2015-2016, 9.2% were by caesarean sections: this is a decrease compared to FY 2014-2015 when C/S represented 11.3% of all deliveries. The 10 top reasons for Caesarean Sections: 

Foetal distress

Previous scars

Obstructed labour

Abnormal presentation – breech and persistent occipital, posterior

Cord/arm prolapsed Dr. Ambrosoli Memorial Hospital Kalongo Annual Analytical Report 2015-16

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Prolonged labour and post term

Ruptured Uterus

Constricted pelvis in young primigravida (CPD)

Big baby

Severe Pre-eclampsia

A total of 272 mothers, who had caesarean section, were from Agago District and 43 cases from the neighbouring districts. Dr. Ambrosoli Memorial Hospital is the only health facility with a functional theatre and qualified medical personnel in the area and for this reason is the main referral facility for pregnant women with complications and risks. Due to the poor referral means (mostly Bodaboda/motorcycle) and conditions of roads, many pregnant mothers often arrive in the hospital in advanced stage of labour or in critical conditions, which requires emergency C/S. Table 6.45: Origin of mothers who delivered through C/S in the last 4 FYs11 Within the Catchment Area of Agago District (distances of 2 km to < 58 km) Sub-County 2012-13 2013-14 2014-15 Adilang 27 34 28 Kotomor 12 14 Patongo 23 38 32 Patongo T.C. Lukole 38 39 45 Lukole T.C. Kalongo T.C. 50 49 21 Paimol 23 17 25 Parabongo 38 30 14 Omot 30 14 Acholpii 19 15 11 Lamiyo 7 5 Lapono 36 49 36 Lira Palwo 25 28 17 Omiya Pacwa 24 26 19 Wol 35 24 30 Total 399 398 311

2015-16 20 10 15 13 29 4 23 19 18 14 5 7 34 24 12 25 272

11

Note: Data for Patongo town council and Patongo Sub county are not disaggregated; the same applies to Lukole Town Council and Lukole Sub county (source: Kalongo Hospital theatre, operation book FY 2011-2012 to FY 2015-2016)

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Table 6.45 continuation Outside the Catchment Area of Agago District (distances of 58 km and above) Sub-County 2012-13 2013-14 2014-15 Pader 29 30 26 Pajule 4 2 3 Namokora 2 1 1 Omiya Anyima 7 4 5 Awere 5 1 1 Orom 4 2 2 Abim 14 6 11 Corner Kilak 3 2 0 Other Districts 12 3 9 Total 80 51 58

2015-16 16 3 1 1 0 2 1 9 10 43

Poor infrastructures, including transport means and roads are the main factors preventing pregnant women to access the hospital at the right time. A waiting shelter is available for mothers attending ANC and detected with some problems or living far from the hospital. An average of 80 pregnant mothers are hosted in the shelter and are coming every day to the ward to check foetal heart from 3:00 pm to 5:00 pm, while doctors visit them weekly. This practice allows timely admission and actions.

Gynaecology ward Maternity Ward also provides gynaecological and neonatal services. In the FY 2015-2016 a total of 403 women were admitted with gynaecological conditions other than pregnancy (6.5% of all Maternity Ward admissions) as documented in the table here below. Table 6.46: Admissions in Maternity Ward not related to maternity conditions FY FY FY FY Diagnosis of admission 2011-12 2012-13 2013-14 2014-15 Pelvic Inflammatory 38 95 106 37 Disease Urinary Tract Infection 16 58 91 57 Cancer of cervix 30 30 25 10 Uterine Fibroid 8 15 16 7 Ovarian Cyst 20 9 12 23 Vaginal Candidiasis 5 7 6 5 Bartoliniâ&#x20AC;&#x2122;s Cyst n.a. 5 6 7 Peritonitis 8 2 2 1 Total 130 221 243 147

FY 2015-16 44 55 7 10 28 12 0 0 403

The Nursery In the Nursery are managed neonatal and perinatal conditionsin new-born babies. The department is run by Maternity Ward staff. The doctors of Maternity and Paediatric Ward provide the clinical management of the new-born babies in the nursery. Dr. Ambrosoli Memorial Hospital Kalongo Annual Analytical Report 2015-16

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The commonest causes of admission in new-born babies during the FY 2015-2016 were severe asphyxia, neonatal sepsis, jaundice, prematurity and congenital abnormalities. The Nursery is equipped with an incubator, a phototherapy machine, an oxygen concentrator and a warming light that unfortunately is currently not working. Kangaroo mother care therapy is very much practiced by midwives especially for premature children.

TB Ward TB Ward is accommodated in an old dilapidated building divided in two sections for female and male patients. It is managed by the same medical and nursing personnel of the Medical Ward, who supervise the TB Control Programme and the follow-up of patients on treatment. Activity data regarding the TB programme have been presented in the Specialist Clinic OPD section of this report; here are reported only the data concerning the admissions to the ward. Key indicators in TB ward The admissions in TB Ward registered a minor increase from 186 in the FY 2014-2015 to 225 in the FY 2015-2016 (21%) contributing 1% of the total admissions. The ALoS has decreased from 20.9 to 18.6 days and the BOR has increased from 59.2% to 63.7%. Unfortunately the death rate has increased to 4.4%: the highest of the whole hospital. Table 6.47: Key indicators in TB Ward in the last 5 FYs FY FY FY 2011-12 2012-13 2013-14 No. of beds 24 24 24 Total Admissions 258 217 266

FY 2014-15 18 186

FY 2015-16 18 225

Bed days

3,754

5,013

5,321

3,891

4,182

ALoS BOR Throughput

14.6 42.9% 10.8

23.5 58.3% 9

20.0 60.7% 11.1

20.9 59.2% 10.3

18.6 63.7% 12.5

19.4

17.3

12.9

14.4

10.6

15 5.8% 94.2% 0

7 3.2% 95.8% 0

13 4.9% 95.1% 0

8 4.3% 95.7% 0

10 4.4% 95.1% 1

Turnover interval Deaths Death Rate Recovery Rate Self-discharges

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Diagnostic Services Laboratory Services Since May 2014, Dr. Ambrosoli Memorial Kalongo hospital laboratory is a hub laboratory supported by MoH and UCMB. It serves ten lower health unit laboratories in Agago and Pader districts. The hub renders a complete ART care package of laboratory tests for HIV infected patients: CD4 testing, chemistry haematology analysis and collecting Dry Blood Spot for DNA-PCR. These processes are interlinked through the hub riders who pick the specimen samples from and distribute results to facilities. Other samples that cannot be analysed at the hub (Viral Load) are referred to the Central Public Health Laboratory (MoH). Posta Uganda is the means through which referred samples are dispatched and results sent to and from the Central Public Health Laboratory (MoH). The Laboratory and Blood Transfusion services have been conducted by 1 Laboratory Technologist, 3 Laboratory Technicians, and 4 Laboratory Assistants. Table 6.48: Trend of laboratory testing workload in the last 5 FYs Type of Tests

FY 2011-12

FY 2012-13

FY 2013-14

FY 2014-15

FY 2015-16

Malaria Microscopy, Malaria RDTs, Other Haemoparasites, Stool Microscopy.

11,379

12,161

14,319

16,178

33,969

HB, WBC Total, WBC Differential, Film Comment, ESR, RBC, Bleeding time, Prothrombine time, clotting time, blood transfusion tests, & Others

6,861

10,311

10,980

26,917

102,373

Biochemistry

Urea, Calcium, Potassium, Sodium, Creatinine, ALT, AST, Albumin, Total protein, Triglycerides, Cholesterol, CK,LDH, AlkalinePhos, Amylase, Glucose, Uric Acid, Lactate, Others

1,872

3,308

2,813

6,242

11,729

Bacteriology

ZN for AFBs, Cultures and Sensitivities, Gram, Indian Ink, Wet Preps, Urine Microscopy

2,431

2,419

6,438

11,141

9,510

VDRL lRPR, TPHA, Shigella Dysentery, Syphilis Screening, Hepatitis B, Brucella, Pregnancy Test, Vidal Test, Rheumatoid Factor

5,629

7,785

16,300

21,186

12,111

1,223

1,647

2,373

4,432

3,916

10,841

12,993

11,301

12,897

16,057

40,236

50,624

64,524

98,993

189,665

7

7

8

8

8

5,748

6,835

7,934

12,290

23,708

Parasitology

Haematology

Serology

Immunology HIV tests by purpose

CD4 tests & others HCT, PMTCT, Quality control and clinical diagnosis Total tests Total lab staffs Average tests per Lab staff

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There has been an increment of 92.9% in the number of tests performed in FY 2015-2016 FY compared to FY 2014-2015. It appears that the demand for laboratory testing by the clinicians has increased as well as the compliance with protocols requested by projects and health programmes: in particular parasitology tests have almost doubled due to the Malaria epidemic; the haematology tests have increased almost 5 times (280% increase) in order to understand what can be the cause of fever, if it is not Malaria. The productivity of the laboratory staff has increased from 7,934 in FY 2013-2014 to 12,290 in FY 2014-2015 to reach 23,708 tests per staff in FY 2015-2016.

Table 6.49: Percentage of positive findings per selected examinations in the two last FYs FY FY Type of Test 2014-15 2015-16 Total Positive % Positive Total Positive % Positive Malaria (both slide and RDT) VDRL/RPR Hepatitis B Brucella

14,999 4,791 2,585 2,056

2,331 242 260 54

15.5 5.1 10.1 2.6

26,919 3,891 2,219 1,371

11,380 226 287 78

Table 6.50: Proportion distribution of blood groups and Rhesus factor D FY FY 2014-15 2015-16 Group Group Group Group RH RH Group Group Group Group A B AB 0 + A B AB 0 29.8%

18.3%

4.8%

47.1%

98%

2%

34.4%

16.2%

5.2%

44.2%

42.3 5.8 12.9 5.7

RH +

RH -

98.7%

1.3%

X-Rays Department The X-Ray department is staffed with three trained on the job X-Ray operators. This situation is not ideal and, despite many years of working experience, the lack of professional qualification and supervision affects the quality of the service.

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Table 6.51: X-Ray examinations done in the last 5 FYs FY FY 2011-12 2012-13 Chest 2,206 2,246 Upper extremities 897 854 Lower extremities 789 846 Vertebral column 143 283 Skull and mandible 184 166 Shoulder and clavicle 163 156 Pelvis and hip 184 154 Abdominal â&#x20AC;&#x201C; plain 160 169 Abdominal -contrast 16 8 Screening 26 0 Total 4,768 4,882

FY 2013-14 3,176 1,118 1,067 336 330 221 142 142 4 0 6,536

FY 2014-15 2,974 1,172 959 314 269 234 276 226 1 0 6,423

FY 2015-16 2,752 1,022 1,160 390 351 195 258 175 1 0 6,304

Ultrasound investigations Currently the hospital has one sonographer and two ultrasound machines; one machine is in Maternity Ward and the other is placed in OPD. The major challenge is the lack of probes for vaginal and rectal examination and for cardiovascular Doppler investigation. Table 6.52: Ultrasound examinations conducted in the last 2 FYs FY 2014-15 Obstetrics 1,470 Gynaecology 1,463 Abdomen 1,715 Liver Soft tissues (Small Parts) 141 Heart 0 Total 4,789

FY 2015-16 1,426 1,718 2,068 420 0 5,632

Figure 6.10: X-Ray and Ultrasound examinations done in the last 2 FYs

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ECG The hospital has also an ECG machine used by routine in the Medical Ward and according to the need also in other wards. The Hospital has conducted training for all the Medical Officers and Clinicians in order to use and interpret ECG results. Endoscopy The endoscopy machine is not currently used. This is due mainly to lack of spare parts, but also to the absence of a proper training of the staff.

Pharmacy Activities The Pharmacy since the beginning of 2014 is located in the new structure behind Paediatric Ward The collaboration with the Japanese Red Cross in the FY 2014-2015 assisted the hospital pharmacy staff to adopt new and more effective procedures to manage and control the drugs stock and to improve the drug management both in the pharmacy and the wards. Under this technical assistance the Management accepted the introduction of the Unit Dose System (UDS) for distribution and dispensing of therapies to inpatients in Surgical and Maternity wards. The new system was supposed to be extended during the FY 2015-2016 to the other wards and departments, but due to the lack of human resources the process has not been completed. To manage all the hospital with UDS the Pharmacy needs to have a dedicated department for UDS, a dedicated space and dedicated staff. Table 6.53: Staff composition in Pharmacy and General Store in 2015-2016 FY Cadre/ Discipline Qualification

Number

Pharmacy Technician

Diploma in Pharmacy

2

Pharmacy Assistant

Certificate in Medical Pharmacy

5

Enrolled Midwife

Certificate in Midwifery

1

Nursing Aid

Trained on the Job

1

Store Assistant

Diploma in Store Management

1

Store Attendant

Trained on the Job

2

Total

12

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Pharmaceutical supplies The supplies are mainly ordered from Joint Medical Stores (JMS). Items not available at JMS are bought from Abacus. JMS and Medical Access Uganda Limited (MAUL) are main suppliers for the antiretroviral drugs for the HIV Clinic. Procurement system Drugs and sundries are procured in most cases on a quarterly basis. The items to be purchased are selected according to the needs of the hospital in line with the Essential Drugs list of Uganda and the treatment policies. The quantity to be purchased is based on the quantity at hand, average monthly consumption and the available finances.

Inventory management There is a manual and computerized inventory system that helps to manage purchase and stock movements. Stock taking is done annually and physical count monthly to ensure accountability. Storage Drugs are stored on shelves and the heavy ones are placed on floor pallets: tablets and capsules are kept on the same shelves, while separate shelves are used for parenteral, oral liquids and topical creams and liquids. The concept of FEFO (first expiry first out) is applied in order to minimize losses due to expiry. Cold storage items are kept in the fridge and the temperature is monitored every day to ensure it is within the desired range of 2°C to 8°C. The instrument for monitoring temperature and humidity in the general pharmacy store is broken but one is available in the store for antiretroviral drugs, where the temperature and humidity are checked every day. The readings are taken 3 times a day because of variations during the day. An average value is obtained at the end of the month. The temperature, starting from the afternoon, often exceeds the 30°C which creates a lot of risks and problems for the storage of drugs.

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The hospital plans to procure additional temperature monitoring equipment to be availed to all the rooms in the pharmacy were drugs are kept. Table 6.54: Average temperature and humidity recorded in Pharmacy Department Reading Time Temperature Humidity 8:15 am 28.85° C 53.0 % 12.00 pm 30.45° C 52.4 % 5.00 pm 31.19° C 48.5 %

Stocks are checked regularly during the monthly counts for near expiry and expired drugs. The near expiry drugs are consumed or donated before they expire. The expired drugs are removed from the store and prepared for collection by National Medical Stores through the Health Sub District, though this is done quite irregularly. Distribution and use The Pharmacy issues drugs to the different ward and departments according to their consumption and average number of patients. The wards and clinics can request for drugs using ward order or requisition books. Table 6.55: Most used drugs (excluded HIV/AIDS clinic) - FY 2014-2015 and FY 2015-2016 Drug description Paracetamol 500mg Metronidazole 200mg Amoxicillin 250mg Folic acid Multivitamins Erythromycin 250mg Diclofenac 50mg Prednisolone 5mg Ferrous sulphate +folic acid Ciprofloxacin 500mg Carbamazepine 200mg Ampi/Cloxacillin 500mg Ibuprofen 200mg Vitamin B complex Cloxacillin 250mg Ampicillin 500mg injection Chloramphenicol 250mg Magnesium trisilicate 250mg Pyridoxine 25mg Mebendazole

Total

Quantity issued in FY 2014-2015 tablets/vial

Monetary value for FY 2014-2015 (UGX)

Quantity issued in FY 2015-2016 tablets/vial

Monetary value for FY 2015-2016 (UGX)

305,442 202,387 237,131 104,164 151,761 114,337 53,387 82,592 103,574 79,023 94,278 87,311 104,149 84,228 36,400 60,415 35,776 39,228 27,355 30,608

4,920,670.62 6,201,137.68 13,094,373.82 505,195.40 3,481,397.34 10,525,864.22 826,430.76 3,406,094.08 1,697,577.86 6,037,357.20 4,551,741.84 9,842,569.03 2,698,500.59 1,132,866.60 2,475,564.00 23,363,688.80 2,846,696.32 496,626.48 301,452.10 470,751.04 98,876,555.78

402,652 263,315 208,190 160,068 141,124 130,950 111,581 110,980 96,863 96,078 94,350 77,665 56,763 54,668 48,434 43,913 42,850 42,590 41,540 37,976

6,759,077.65 15,808,921.50 3,546,258.56 957,206.64 14,236,663.30 2,297,372.43 2,186,662.45 2,932,765.70 4,949,119.79 1,273,555.98 7,609,418.32 8,482,335.33 27,700,586.26 2,492,159.88 1,405,294.99 2,143,104.04 3,513,575.93 2,925,182.01 800,151.93 5,770,785.42 117,790,198.11

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Intravenous fluid consumption The general consumption of intravenous fluids in FY 2015-2016 has almost doubled in value. Table 6.56: Consumption of IV fluids in FY 2014-2015 and FY 2015-2016 Quantity (in bottles) 2014-15

Quantity (in bottles) 2015-16

Value (UGX) for 2014-2015

Value (UGX) for 2015-2016

Water for Injection 10 ml

51,924

74,521

4,284,768

6,507,711.90

Sodium Chloride 0.9% IV 500 ml

16,541

17,318

19,742,511

21,278,952.83

Dextrose 5% IV 500 ml

5,496

13,131

6,694,183

15,790,465.09

Dextrose 5% IV 250 ml

1,236

11,906

1,432,833

13,455,593.46

Sodium Lactate Compound IV 500 ml

1,922

2,660

2,367,558

3,258,889.41

651

910

1,208,432

1,701,116.34

Gelatine/polygeline Solution 3.5% IV 500 ml

71

144

1,720,654

3,579,259.68

Darrowâ&#x20AC;&#x2122;s Half Strength 500 ml

95

41

234,546

44,134.68

37,685,485

65,616,123.39

Fluid Description

Dextrose 50% IV 100 ml

Total

Drug and therapeutic committee The Drug and Therapeutic Committee was established with Terms of Reference and a clear mandate to address the various aspects of drug management. Its activity has been quite fluctuating and management is committed to support its activities.

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CHAPTER SEVEN: SUPPORT SERVICES Pastoral care Pastoral care is provided in Dr. Ambrosoli Memorial Hospital to all patients by a Social Worker, a Catechist and a Priest as Chaplain. Table7.1: Activities trend in clinical pastoral care of the sick during the last 5 FYs FY FY FY FY Activity / Indicator 2011-12 2012-13 2013-14 2014-15 No. patients visited and 394 55 120 228 counselled No. of patients given 0 0 0 0 sacrament of Marriage 2 25 11 4 No. of patients anointed

FY 2015-16 243 1 3

Ambulance service The hospital uses two Land Cruisers for the provision of Ambulance service. One is quite old and can be used only for short distances. The second one was fairly new, but unfortunately a big accident had caused major damages to this vehicle and is still under repair. In the FY 2015-2016, a total of 47 referrals were registered as having utilized the Ambulance service of which; 29 were from LLUs to the hospital, 1 patients from Dr. Ambrosoli Memorial Hospital to Kitgum General Hospital, 3 referred to Kumi hospital, 13 patients to St. Maryâ&#x20AC;&#x2122;s hospital Lacor in Gulu and 1 referred to Mulago National referral hospital. Currently patients are required to contribute to the cost of fuel except in case of lifethreatening emergencies.

Technical services The Technical and Maintenance Department (TD) of the hospital is mandated to ensure the ordinary maintenance of all structures and equipment, including vehicles, for both the hospital and the school. It provides also technical assistance and supervision any time extraordinary renovations and bigger scale constructions are contracted out. Moreover the TD carries out some limited income generating activities in order to contribute to the sustainability of the hospital.

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Table 7.2: Consumption of fuel by destination in the last 5 FYs FY FY FY 2011-12 2012-13 2013-14 DIESEL TOTAL 34,917 38,413 40,509 Board of Governors Fuel 40 0 140 Refund to members Generators 12,646 13,656 18,618 Vehicles 15,984 21,586 20944 Workshop 20 18 47 Incinerator 265 260 255 Others 5,962 2,893 505 PETROL TOTAL 1,692 1,523 2,020 Donation 160 0 59 Generators 0 0 0 Vehicles 583.5 247 184 Motorcycles 331 556 1,340 Workshop 13.5 65 64 Others (Sales) 604 655 373 KEROSENE TOTAL 171 196 171 Workshop 67 49 7 Pharmacy 0 0 0 Main store 0 21 1 Others 104 126 164

FY 2014-15 33,128 417 11,890 19,769 26 260 766 2,709 0 0 15 2,275 0 419 105 78 3 0 24

FY 2015-16 29,242 205 8,961 19,265 47 750 60 3,474 40 10 338 2,551 37 499 58 19 0 5 34

Water supply The hospital water supply is provided by three wells that serve also the School, the Comboni Fathers and the Convent of the Little Sisters of Mary Immaculate. The wells are located at approximately 1,300 metres from the hospital. The water is pumped to two main tanks with a total capacity of 90,000 litres. The distribution and storage of water is provided by a network of pipelines that were installed many years ago and currently show signs of wearing with frequent leakages that increase the costs of the supply. A number of wards are provided with reserve tanks of different capacity. Small repair works has been done during the year to ensure the proper functionality of the system, but there is there is still need to renovate the distribution system to eliminate leakages and secure regular and more cost-effective water supply management. A complete analysis of the yielding capacity of the wells and on the quality of the water pumped was conducted as a basis for further planning and interventions.

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The government pipeline has reached the main entrance of the hospital but is still not functioning. Once working, the hospital shall also connect to it but shall also continue to maintain the private wells for backup. Power supply The hospital has been receiving power from the national electricity grid since March 2010. However the supply is not constant and the hospital has still to rely on other sources to provide sufficient power. Small solar systems are installed on the Laboratory, Doctor's Quarter houses and Guest House, to provide additional lighting power. The two generators are the main providers of extra power supply in the hospital and are barely sufficient for the current needs. They are under-dimensioned in relation to the requirements that are expected in the near future (new laboratory and new Imaging Unit). Lacor Hospital in Gulu donated two generators to Dr. Ambrosoli Memorial Hospitals. The required works to install them shall be completed in the next FY. Sewage system The sewage system serves the entire hospital, St. Mary's Midwifery Training School, the staff houses, the nearby parish and convents. All sewage is disposed through a lagoon at about 600 m from the hospital. A project financed by Wamba Anthena Onlus-Cariparo through Ambrosoli Foundation started in April 2014 and ended in May 2016 aimed at the rehabilitation of the lagoon. A new pre-treatment unit (PTU), a treatment wetland plant (TWP) and a sludge drying reed bed (SDRB) has been completed and now the sewage system is functional, efficient and environmentally friendly. Toilets and showers are still insufficient to equate the number of users in the hospital.

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Waste disposal A lot of waste is generated in the hospital, but unfortunately the capacity to manage the waste is very minimal. The project of the sewage system provided also to build a new and bigger incinerator constructed near the lagoon. There is still need to build the capacity of staff in charge of the waste management as there is still inefficiency to properly manage the system and maintenance of the new incinerator. Segregation of waste is still a major issue as in the wards there is still poor attitude towards proper management of waste. This is a big challenge because it needs a change in the mindset of the staff. The waste that cannot be burnt in the incinerator are collected and brought to the disposal site of the town council.

Internet System Internet connectivity in the hospital is insufficient and often unreliable. The Internet connection speed has never been faster than 30 KB/s measured by a direct connection to the satellite receiver. This is very poor, taking into account the number of users and volume of data involved. A new internet Wi-Fi system network has been studied, designed and the bid for the construction of the infrastructure and the provision of the service has been launched. The completion of the project is expected for the FY 2016-2017. Intercom Telecommunication The hospital intercom telecom system was hit by lightning that have destroyed the motherboard: less than 20 lines, out of the original 80, are available and this is quite insufficient to serve well the entire hospital. A new system should be realized because intercommunication especially among wards is important for a more effective work.

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CHAPTER EIGHT: QUALITY OF CARE AND PATIENTSâ&#x20AC;&#x2122; SAFETY Quality indicators The quality improvement initiatives were harmonized and institutionalized within the national quality improvement framework through the technical support of the team of nurses from the Japanese Red Cross and UCMB.

Availability of clinical qualified staff In FY 2015-2016 the number of qualified staff has decreased in absolute number, but proportional indicators have increased. The proportion of clinical qualified staff over the total staff of the hospital is 53.1%, for the first time in the last 5 years it has overcome the 50%. The Management is gradually phasing out Nursing Aides transferring them to non-clinical responsibilities. Moreover efforts have been made to recruit more qualified staff in some departments, in particular in the HIV clinic, Surgical Ward, Paediatrics, OPD, Theatre and Maternal related services. Table 8.1: Proportion of clinical qualified staff in the hospital in the last 5 FYs FY FY FY FY Indicators 2011-12 2012-13 2013-14 2014-15 Total No. of employees 213 220 212 239 12 Qualified staff 113 120 138 194 Clinical qualified staff13 100 88 97 108 14 Total Clinical staff 119 116 123 126

FY 2015-16 245 168 130 148

Proportion of clinical qualified staff over all qualified staff

88.5%

73.3%

70.3%

55.7%

77.4%

Proportion of clinical qualified staff over all clinical staff

84.0%

75.9%

78.9%

85.7%

87.8%

Proportion of clinical qualified staff over the total hospital staff

46.9%

40.0%

45.8%

45.2%

53.1%

12

Qualified staff includes all staff with a degree in line with their role in the hospital. Clinical Qualified Staffincludes: Medical Doctors, Paramedics, Nurses and Midwifes. 14 Clinical Staff includes: Medical Doctors, Paramedics, Nurses, Midwifes, and Nursing Assistants. 13

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Quality of care Maternal Death Rate has unfortunately increased both in absolute numbers from 3 to 4, and also in percentage from 0.06% to 0.10%. Infection rate for caesarean section is 1.27%. In the Annual Report FY 2014-2015 it was reported a caesarean section infection rate of 10% which seems to be incredibly high: this data is not supported by any official source and cannot be confirmed. Data collection on these indicators should be improved. Early Neonatal Death Rate increased from 0.86% to 0.89%. Some of these negative trends may be explained by the high attrition rate of qualified staff, particularly the medical personnel that affected the quality of work in the hospital, especially in Maternity ward. The stability and adequate qualification of human resources is a prerequisite to have effective improvement measures for quality achievement.On the other hand, recovery rate on discharge improved from 97.8% to 98.1% and fresh still birth rate decreased from 0.99% to 0.58%. Table 8.2: Indicators for the quality and safety measures FY FY FY FY Indicators 2011-12

2012-13

2013-14

2014-15

FY 2015-16

Recovery rate on discharge

98.3%

96.5%

97%

97.8%

98.1%

Maternal death rate after admission in maternity

0.17%

0.07%

0.11%

0.06%

0.10%

Fresh still birth rate

0.39%

0.7%

0.6%

0.99%

0.58%

Caesarean sections infection rate

7.2%

1.0%

4.0%

na

1.27%

Early neonatal death rate

0.8%

1.0%

1.4%

0.86%

0.89%

Explanation Recovery rates on discharge: annual percentage of patients discharged as clinically recovered from a specific episode of disease (from all wards) following treatment. Maternal death rates: it is not the population based maternal mortality rate or ratio that is generally used by statisticians. It is a hospital indicator. Fresh still birth rate: Fresh Still births have intact, smooth and not macerated skin, Infection rate of caesarean sections: if mothers are discharged before the 8th day, information is also collected from the post-natal clinic, where the mothers will show up if they get infections. Early neonatal death rate. Number of babies who die within the 7th day of life, divided by the total number of deliveries in the hospital in that year, expressed in percentage.

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Patient satisfaction survey Attempts have been continuously made to improve the level of satisfaction of patients. Overall, the patient satisfaction score has decreased to 75.2% in FY 2015-2016 compared to 79.3% in FY 2014-2015. Table 8.3: Satisfaction levels per core area for the last 4 FYs Financial Year Clinical outcomes Humanity of care Organization of the care / waiting time healthcare (OPD) environment The General opinion Overall score

FY 2012-13 96% 80% 42% 62% 73% 66%

FY 2013-14 95% 100% 78% 100% 96% 77.6

FY 2014-15 94% 85% 56% 99% 97% 79.3%

FY 2015-16 100.0% 85.1% 50.0% 99.2% 100.0% 75.2%

Drugs prescription and dispensing survey In the internal survey conducted to evaluate the drugs prescription in the hospital, as requested every year by UCMB, the score was 18/20 points for Poly-Pharmacy. For use of Antibiotics, the hospital scored 16/20 Points, four levels below the highest score achieved in the previous FY. The best clinical practice in this hospital is the use of injectable drugs in Outpatient Department, which was found to be 0.01 per total number of drugs prescribed. The survey findings also show that in the FY 2015-2016 Dr. Ambrosoli Memorial Hospital has improved in the distribution of prescribed drugs: 99% of them were actually dispensed, in FY 2014-2015 it was 97%, meaning that just 1% were not dispensed due to stock out. Out of 80 medical forms examined, just 58% contained record of Objective Medical Examination: this has decreased from last year, when it reached the 83%. 97.5% of the examined medical forms contained record of history and 97.5% contained the diagnoses of the patients. Overall, the hospital scored 77% for quality of drugs prescription, in the FY 2014-2015 it was 82%.

Standard Unit of Output and Faithfulness to the Mission The Standard Unit of Output (SUOop) is a composite indicator that provides a general idea of the volume of the main services provided by a health unit. It is an indicator developed by Uganda Catholic Medical Bureau (UCMB) in the FY 1988-1989 to assess the performance of the hospitals and health units of the network. Dr. Ambrosoli Memorial Hospital Kalongo Annual Analytical Report 2015-16

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The formula of the SUOop (utilised by MoH) is: 1 SUOop = 1*Outpatients contacts + 15*Inpatients + 5*Deliveries + 0.2*Immunizations in children + 0.5*(ANC+Post Natal Attendance + Family Planning clients)

With SUOop it is possible to calculate different performance indicators in the last 4 FYs to understand the trends of Dr. Ambrosoli Memorial Hospital concerning accessibility, equity, efficiency and productivity. Accessibility As showed below, the accessibility of the hospital has dramatically increased in the last FY: SUOop increased from 237,527 to 384,902 (62 % increase). Due to the nature of the formula used to calculate SUOop, the increase is obviously a clear consequence of the increased number of outpatients and inpatients in FY 2015-2016.

258,084

237,527

FY 2012-13

FY 2013-14

FY 2014-15

384,902

221,983

Figure 8.1: Trend of SUOop (do more people come?)

FY 2015-16

Equity The proxy indicator for equity is calculated dividing the total fees collected in the hospital by SUOop. The average fee per SUOop has decreased by 24.3%, reversing the previous yearsâ&#x20AC;&#x2122; trend: equity has increased. User fees in Dr. Ambrosoli Memorial Hospital are still the lowest among the PNFP (private non for profit) health facilities.

FY 2013-14

FY 2014-15

1,397

1,549

FY 2012-13

1,808

1,443

Figure 8.2: Trend of Average Fees per SUO (do people, on average, pay more or less?)

FY 2015-16

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Efficiency The hospital economic efficiency has also impressively improved by 26.8%, as the cost of producing one SUOop decreased from 15,951 to 11,671. Expenditures have increased by 18.6%, but the increase of SUOop (by 62%) has produced the reduction of the average expenditure.

16,003

15,951

FY 2012-13

FY 2013-14

FY 2014-15

11,527

15,026

Figure 8.3: Trend of Average Expenditure per SUO (do we spend more or less to produce our services?)

FY 2015-16

Productivity Each clinical staff has produced in the FY 2015-2016 2,601 SUOop. This represents an increase by 38% from last year, indicating a major rise of staff productivity.

2,098

1,885

FY 2012-13

FY 2013-14

FY 2014-15

2,601

1,914

Figure 8.4: Trend of Average SUO per staff (with the same resources, do our staff produce more or less?)

FY 2015-16

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CHAPTER NINE: ST. MARY'S MIDWIFERY TRAINING SCHOOL Introduction St. Mary’s Midwifery Training School, is part of Dr. Ambrosoli Memorial Hospital. The school was founded in 1959 as an Enrolled Midwifery School by Fr. Dr. Giuseppe Ambrosoli, then Director of Kalongo Hospital. The school offers two courses: 1. Diploma in Midwifery (D/M) 2. Certificate in Midwifery (C/M) The total capacity of 150 students has been maintained and in this financial year the number of diploma midwives has increased from 8 to 14 students. Since its beginning, the school has qualified so far a total of 1,312 competent staff serving in various parts of the country as well as outside Uganda: 

1,053 Enrolled/Certificate Midwives (EM/CM),

219 Registered/Diploma Midwives (RM/DM),

40 Enrolled Comprehensive Nurses/Certificate Comprehensive Nurse (ECN/CCN)

Human resources management and development The school does not have yet sufficient teaching staff and sometimes has to hire part time experts in the different disciplines to ensure that the syllabus is fully covered and students get all the necessary knowledge and skills. Table 9.1: School staff and support staff establishment FY 2015-2016 Qualified Staff Tutors Trained clinical mentor Untrained clinical instructors Accountant Accountant Assistant Cashier Record Assistant Total Qualified Staff Support Staff Store Assistant/Library Attendant Office Attendant Cooks Driver Watchmen Total Support Staff Total Staff

Established 6 5 0 1 1 1 1 15 Established 1 1 6 1 2 11 26

Actual 5 1 1 1 1 1 1 11 Actual 1 1 6 1 2 11 22

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Shortage 1 4 0 0 0 0 0 5 Shortage 0 0 0 0 0 0 5

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Staff attrition In the FY 2015-2016 no staffs has left the school: therefore the turnover rate was zero. Currently there are only five tutors and one clinical mentor. The school needs one more tutor and 4 more trained clinical mentors. In the FY 2015-2016 the school recruited one Clinical Instructor. One support staff was recruited to manage both store and the library. The support staffs have always been more stable in their work places because they are trained on the job with no formal qualification and live in Kalongo.

Staff development One staff from the hospital is pursuing a course for Tutorship in Mulago Health Tutorsâ&#x20AC;&#x2122; College. The Clinical Mentor who went for a Diploma in Nursing, successfully completed in November 2015. Other staff participated in professional refresher courses in different subjects, organized by different stakeholders. The staff had always used the information received from these seminars or workshop for teaching or Continuous Medical/Professional Education/Development (CME/CPD). Workshops and meetings organized by UNMEB, MoH, MoES, UCMB, and UNFPA were attended by the different staff in rotation as indicated in table 9.2. Table 9.2: Workshops and courses attended by the teaching staff Workshop Update on OSCE/OSPE (Objective Structured Clinical 1 Examination/Objective Structured Practical Examination) Update of nursing and midwifery 2 records 3 Review of midwifery curriculum

Organized by

Number of staff

Duration

UNMEB (Uganda Nurses and Midwife Examination Body)

One tutor and one clinical mentor

1 week

UNFPA

One tutor

1 week

UNFPA

1 week

4 Mentorship update

UNFPA

5 Curriculum review and partograph

IntraHealth

6 Students online registration

IntraHealth

One tutor One mentor as facilitator, one tutor and one clinical instructor One tutor One tutor and one record officer

MoH

Two tutors

1 week

IntraHealth

Principal tutor

1 week

7

TOT workshop on using a nutrition module and a trainers manual

8 Leadership and management training for managers

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School Performance Table 9.3: Student Enrollment in years 1st -2nd -3rd and success rate in the FY 2015-16

Course

C/M D/M Total

Enrolled Students

Student s year 1

Student s year 2

Students year 3

Number of students currently present

51 (May) 14 in Feb 65

51 14 65

36

40 8 48

135 14 149

36

Students who sat for final exams

Students who passed final exams

Success rate

54 7 61

54 7 61

100% 100% 100%

The number of candidates applying for Diploma in Midwifery is dwindling each year. For this reason, the places for certificate course could be increased. In the FY 2015-2016 three Certificate (2 unexpected pregnancy and an episode of forgery of academic documents) and one Diploma Midwife (personal social problem) were dismissed from year one. The enrolment of students has been driven by the actualcapacity of the school. Although the success rates for both Certificate and Diploma Midwifery have improved to 100%, the quality of passing is not satisfactory. The school administration together with the school staff need to help the students not only academically, but also in other aspects of their lives affecting their performance. This calls for a more intense education and counselling of students who show signs of reluctance in their studies and psychological problems.

Achievements 

The following plans were implemented or accomplished in the FY 2015-2016:

Improvement of Teacher-Student ratio

Professional upgrading of clinical mentor / instructor

School capacity maintained

Community health care services training carried out (mental health, natural family planning, sensitization on substance abuse workshops).

Acquisition of a new 30-seater coaster bus, donated by UNFPA through MoES.

5th graduation on the 23rdof January 2016.

Kalongo Midwifery and Nursing Alumni Association (KAMNAA) launched.

External students from Denmark and USA hosted for their experiences in developing countries. Dr. Ambrosoli Memorial Hospital Kalongo Annual Analytical Report 2015-16

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School Finances St. Mary’s Midwifery training school is a cost centre in Dr. Ambrosoli Memorial Hospital. All the school’s accounts are being controlled by the Principal Tutor of the school and she is one of the signatories of all the bank accounts. She is the overall controller of the school’s activities and she reports to the CEO. Each financial year the school’s prepares its own budget and year plan. The hospital engages an external auditor for both the hospital and the school and provides two separate audited financial statements. Income The actual realization from school fees and donors still represents the main source of funding. This donor dependency is posing a major challenge as some donors support is diminishing and sustainability is seriously threatened. Table 9.4: Planned, actual and unrealized income in the FY 2015-2016 Planned Income Actual Income Sources (UGX) (UGX) Other School Income (e.g. rent) 142,078,076 158,975,775 School fees – Other Donors 148,769,815 221,057,907 School Fees – Private 170,394,988 88,087,800 PHC government grants 56,468,347 53,939,020 TOTAL 517,711,226 522,060,502

Budget Gap (UGX) (16,897,699) (72,288,092) 82,307,188 2,529,327 (4,349,276)

Support for school fees comes from UNFPA, MOH-DP Bursary (Baylor), Copeland Foundation, Dr. Ambrosoli Foundation, IntraHealth – Uganda Capacity Building Programme, Light Ray and Gretta Foundations. Other sources of income are sales, hire of halls, internet fee and interests from Treasury Bill, fines, retake of examinations and renting. Income from these sources is not consistent since activities are erratic and interests’ rates can change anytime. School fees from private students did not reach the estimated figure. However in the coming year they have to increase considering the fact that Baylor Uganda’s project has come to an end. Therefore most students will be expected to register as private students, as donors are no longer interested in supporting big number of students due to limited funding. Income from the Government was not released up to 100%, leaving an income gap of 2,529,327 UGX. Actually estimates are planned prior to any communication from the government and based on the previous years’ inputs. Dr. Ambrosoli Memorial Hospital Kalongo Annual Analytical Report 2015-16

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Expenditures At the end of the financial year the gap between the planned and actual expenditures revealed an excess of 9,342,420/= UGX, as the school spent more than what was estimated. This was due to: 

The repair of the old bus which needed unplanned major repairs

Increase of food prices in the open markets, due to poor harvest

The students who are under private sponsorship did not fulfil their commitments

Table 9.5: Planned, actual expenditure and unspent balance in the FY 2015-2016 PLANNED EXPENDITURE

ACTUAL EXPENDITURE

517,711,226/=

OVERSPENT BALANCE

527,053,646/=

(9,342,420)

Support from Dr. Ambrosoli Memorial Hospital 

The Hospital and the School share a Management Team.

Supervision of students in the wards is jointly done by the hospital’s and school’s staff.

Rotation of staff is done and some hospital staff can be posted to work in the school.

CEO is the main signatory of both the School’s and the Hospital’s Banks accounts.

Hospital’s administrator is the head of finance for both the School and the Hospital.

Lobbying for fund from donors is done by both School and the Hospital.

Relations with external partners The school has become also a clinical site for midwifery experiences for students from other countries. In the FY 2015-2016, 2 students midwives from Denmark had their three weeks experience in Maternity and Antenatal Clinic (ANC) in September 2015; 4 students with 2 faculty staff from Kansas University had two weeks in February 2016; and 7 students with 2 faculty staff from Johnson County College and Research Medical Centre also came for one week in June 2016. The school also enjoyed the support of the local community, the parents and guardians of the students and external partners like UCMB, UNMEB, UNMC, MoH/DP and MoES.

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Donors such as Dr. Ambrosoli Foundation, UNFPA, Baylor-Uganda, Gretta Foundation, Copeland Foundation, Light ray, Intra-Health Uganda and HTI in the PNFP supported the School during the year. These external partners continued to play vital roles in the evaluation and performance improvement of the school in terms of financial support through sponsoring of students, technical assistant, donation of teaching and learning materials, and training of staff. In addition, the more the partners involved themselves, the more staffs are exposed to new information and networking that they can transfer to their colleagues with the new knowledge acquired during the weekly CME.

PHC Activities The school carried also PHC activities in the community through health promotion sessions such as Mental Health, Natural Family Planning and sensitization on alcohol abuse. These workshops have been organized targeting the community leaders and Village Health Teams from 5 different counties near Kalongo. One of the school staff was also invited to facilitate mentoring on these topics at national level. These activities contributed to enhance the competences of the staff from the school, the hospital and the District on some of the current health problems affecting the communities and on how to address them.

Faithfulness to the Mission To evaluate the adherence of St. Maryâ&#x20AC;&#x2122;s Midwifery Training School to the mission four indicators have been used during the years: Access - percentage of total school capacity used Total number of students/ total capacity of the school (149/150 x 100) = 99.3% The 0.7% drop is due to a student who left late in the year to give the school the possibility to take a replacement. The trend in the past years is to reach the maximum capacity to provide a training opportunity to the students that are requesting it. It must be noted that 20.5% of the students in the last five years came from Agago District. Dr. Ambrosoli Memorial Hospital Kalongo Annual Analytical Report 2015-16

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Equity - average student fee (total fees collected divided by total number of students enrolled) Total fees collected/total number of students (321,012,707 UGX/149) =2,154,448 UGX Figure 9.1: Trend of Fees Equity

FEES PER STUDENT IN UGX

Fig 9.1: TREND IN EQUITY 2011 - 2015 2,484,574.0

1,577,637.0

1,723,653.0

2011/2012

2,154,448.0

1,852,223.0

2012/2013

2013/2014

2014/2015

2015/2016

FINANCIAL YEARS

The trend of the indicator depends mainly on the sponsorships. The decrease by 15.3% of the indicator in 2015-16 is due to the fact that some sponsors withdrew their support and the available fees/sponsorships spread to support the students (who were trained with less). It is necessary to guarantee an adequate number and amount of sponsorships to maintain such a level of fees.

Efficiency - average recurrent cost per student Total recurrent costs/total number of students (467,472,094 UGX /149) =3,137,397UGX Figure 9.2: Trend of Efficiency

COST PER STUDENT IN UGX

3,137,397

2,368,136.0

2,576,172.0

2,484,574.0

2,064,820.0

2011/2012

2012/2013

2013/2014

2014/2015

2015/2016

FINANCIAL YEARS

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The school’s recurrent expenditure increased by 21%. This was mainly due to a) fluctuation in prices and consequent higher cost of living and b) major repair of the school’s old bus which was beyond that foreseen. Figure 9.3: Trend of Percentage Efficiency PERCENTAGE VARIATION IN COST PER STUDENT

100%

82%

80% 60% 40% 15% 9%

20%

-4% 0% -20%

2011/2012

2012/2013

2013/2014

2014/2015

2015/2016 -21%

-40%

FINANCIAL YEARS

The trend indicates the need of optimizing the management of recurrent expenditures in a rapidly changing environment. Quality: Average rate of students passing their final exams (success rate) and tutor/student ratio Total number of students who passed/total number of Students who sat (61/61 x 100) = 100% Figure 9.4: Trend of Student' Pass Rate

PASS RATES IN PERCENTAGE

Fig. 9.4: TREND IN STUDENTS' PASS RATES OVER FIVE YEARS 101.0

100%

100%

100%

100.0 99.0 98.0 96.2%

97.0 96.0

96.5%

95.0 94.0 2011/2012

2012/2013

2013/2014

2014/2015

2015/2016

FINANCIAL YEARS

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This year the pass rate is 100% and it has increased from last year when it was 96.5%. Although the success rates for both Certificate and Diploma Midwifery have improved in the last years, the quality of passing is not so good: looking at the results of the different papers there are fewer distinction.

Student’s satisfaction survey A student’s satisfaction survey was carried out in the month of October 2015. Questionnaires were administered to both diploma and certificate midwives who completed their training in November 2015. The results of the questionnaire showed that 97% of the students are confident that the teachers, tutors and instructors available at the institution are competent in delivering their lectures and 92%affirmed that they are always available and easily accessible by the students in case of need. 75% of the students agreed that the teachings were timely delivered according to the course syllabus and feedbacks were provided about the learning/academic progress of each one. Concerning the school’s facilities, 55% responded that they have access to the school’s library, computer laboratory, and that they have enough class rooms. Security was respected: 97%of the students agreed that the instructors were always concerned about their safety during clinical teaching and in the school. 97%of the students stated that the school provided quality meals, entertainment, cocurricular activities and students’ basic medical care. Concerning the overall satisfaction of the experience in the school; 57% of the students recommend the school for other students and agreed that school fees are affordable, while 43% did not agree with the statement. Students appreciate the competency of the staff, the lectures and practices in the ward, the environment that is conducive for study and clean and the relationship created between tutors and students. The suggestions to the school were to add more teaching staff and mentors to avoid overload, update sports activities, give more freedom to the students and a better diet. Dr. Ambrosoli Memorial Hospital Kalongo Annual Analytical Report 2015-16

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CHAPTER TEN: CONCLUSIONS The issue of sustainability is still at the centre of all activities and initiatives that the Hospital will implement or introduce. In order to meet all these challenges the Hospital strives to strengthen its governance bodies and its managerial capacity and embark in substantial reorganizational efforts. Thanks the donors (especially Ambrosoli Foundation, Comboni Missionaries and UCMB/CDC) representing more than 75% of the income of the hospital. We ask them to continue their support that it is still very much necessary. Figure 10.1: Trend of Income by Sources

The hospital is grateful to the Ministry of Health and the Government of Uganda, representing 13% of the income in 2015-16. We ask the Government to increase the support that is sure and constant, but it is not increasing when costs are going up. The support of local and national authorities is key to face the challenge of sustainability: we again appeal for seconding staff as promised in several occasions. The contribution from the user fees amounted to the 14% in the last financial year. Any increment in user fees will be done after a concerted consultation with stakeholders and above all the authorities and the community. Dr. Ambrosoli Memorial Hospital Kalongo Annual Analytical Report 2015-16

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The hospital needs the support of all, as for the first time in the past 4 years expenditures overcame income. This was due to the fact that some donors withdrew (NuHealth for instance) and were not replaced. Figure 10.2: Trend of Income vs. Expenditure

To face all these challenges the hospital is committed to the development of a new Strategic Plan based on 4 strategic Objectives: 1. Health (including primary) care services delivery adapted to changing environment and quality demands; 2. Institutional development (including Financial Sustainability, Development of transparent and results oriented administration, Sustainable Capacity Building of the Human resources); 3. Infrastructure renovation and maintenance (including rehabilitation of wards, rehabilitation and construction of staff houses, strategic plan for water and energy supply, upgrade of solid and liquid waste disposal and management); 4. Teaching and Training Services upgraded (St Maryâ&#x20AC;&#x2122;s School and on the job continuous education and staff development)

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The hospital has embarked in a major exercise of revision of procedures and processes and it is now focusing on the greatest resource, the staff. We want to support them and we need your help and participation. We all want the hospital to “fly high as in the times of Fr. Dr. Ambrosoli”. This depends on the responsibility and commitment of all to be faithful to the mission and the vision of the hospital, following our motto, “Service with love and humility”. The Hospital continued to be faithful to the mission and it was more accessible, equitable, efficient, providing quality services. There is still need to invest in building the human resource capacity as well as in other resources of financial management, infrastructural development in order to attain the required level of service delivery. Some essential positions in the hospital still lack qualified personnel, management is making efforts to ensure that qualified personnel are recruited or opportunities for further studies accorded depending on need and merit. The hospital after 59years of its existence needs urgently a facelift in many of its structures, some of which are old, dilapidating and need major renovation. About half ofthe staffs are accommodated within the hospital premises but the housing conditions need to be improved through concerted efforts to raise funds. At national level, the hospital has once again performed quite well in terms of activity output as noted in the Annual health sector performance report 2015-2016 League Table released by the Ministry of Health. The hospital ranked 3rd out of 132 general hospitals in the country and among PNFP hospitals it ranked 1st. This is quite commendable and we want to sustain and maintain our achievement, through the help of all. For God and my Country

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ANNEXES Annex 1. Members of Board of Governors and designation as per 30th June 2016 Name

Designation

Title

1

H.G. John Baptist Odama

Chairperson

Archbishop of Gulu

2

Sr. Liberata Amito

Member

Diocesan Health Coordinator Gulu

3

Msgr. Mathew Odong

Member

Vicar General Gulu

4

Ms. Giovanna Ambrosoli

Member

Representative Ambrosoli Foundation

5

Fr. Hategek'Imana Sylvester

Member

Provincial Superior Comboni Missionaries

6

Fr. Guido Miotti

Member

Parish Priest Kalongo

7

Mr. Louis Odongo

Member

Lawyer - P.O. Box 800, Gulu

9

Anywar John Kennedy

Member

District Local Councillor 5 - Kalongo T.C

10

Rose Ogaba

Member

Representative of the Local Community

11

Dr. Emmanuel Otto

Member

DHO Agago District

12

Sr Susan Dezu Clare

Member

Superior General LSMIG

13

Dr. Filippo Ciantia

Member

Chief Executive Officer

14

Dr. Pamela Atim

Member

Med. Sup. St Joseph's Hospital - Kitgum

Annex 2. Members of the Management Team and designation as per 30th June 2016 Name

Title

1

Dr. Filippo Ciantia

Chief Executive Officer

2 3 4 5 6

Mr. Alex Obonyo Mr. Alex Ojera Dr. Myango Patient Sr. Carmel Abwot Sr. Mary Alice Amal

Administrator Senior Nursing Officer Medical Director Principal Tutor Deputy Senior Nursing Officer

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Annual Report 2015-2016 - Dr. Ambrosoli Memorial Hospital  

Rapporto Annuale di gestione 2015-16 del Dr. Ambrosoli MemorialHospital di Kalongo,Uganda - english version