INDEX page 1

Chapter 1 EXECUTIVE SUMMARY page 2

Chapter 2 Human Resources page 3

Chapter 3 Management and financial Resources page 6

Chapter 4 Outpatient services page 11

Chapter 5 Inpatient services page 15

Chapter 6 Support services page 21

Chapter 7 Training page 27

Chapter 7 Primary Health Care page 29

Conclusion and Acknowledgements page 36

St Kizito Hospital - Matany is a private not-for-profit institution with social and spiritual aims belonging to the Catholic Diocese of Moroto (Northern Uganda).

It was built at the beginning of the 70’s and has since then provided essential medical/health services to the population of the Karamoja Region, an extremely underdeveloped region of the Country.

The Hospital is presently equipped with 226 beds. Various services are provided by the Hospital including: surgery, laboratory, diagnostic imaging, and physiotherapy. The Hospital deals with an average of 7,000 admissions per year. Of these, 350-400 include major surgical operations and 25,000 - 30,000 outpatient consultations. The Hospital ensures regular supervision for the Health Units of Bokora Health Sub-District.

The Hospital operates in accordance with the policy guidelines of the Ministry of Health of the Republic of Uganda and in co-operation with the local Health Authorities.

Within this report the activities will be related to the Government financial year (July to June the following year) which was introduced in the accounting system of the Hospital in 1996. Where it is possible, the activities of previous financial years will be presented for the sake of comparison.

The health and medical services provided by the Hospital cover a wide spectrum:

• preventive care (vaccinations, ante-natal clinic, growth monitoring and under 5 clinic, epidemiological surveillance)
• curative care (diagnosis and treatment of the most common diseases and of referred cases within and beyond the catchment area, emergency and elective surgery)
• promotive care (health education, training of professional and lay personnel)
• rehabilitative care (physiotherapy, occupational therapy).

About 80% of the infants of the area covered by the Hospital vaccination service receive a complete course of vaccinations before the first year of life. Vaccination coverage is above the target for the 6 killer diseases. Less than 20% of the numerous TB patients abandon treatment. More than 30% of the surgical operations performed are emergencies.

The Hospital opened a Nurses Training School in 1984 which is recognised by the MoH. Approximately twenty nurses qualify each year as Enrolled Nurses and fifteen as Registered Nurses every second year. It is the only recognised professional training offered in the entire Region of Karamoja.

A centre for research on health management and for permanent training of health personnel (Karamoja Human Resources Development Centre for Health) is attached to the Hospital. It is open to all those who wish to utilise it. It began to operate in 1994. This initiative sprang from a double need: the need to provide a structure for ongoing training and health management research and to generate income for the Hospital’s recurrent costs. The structure was completed with an additional Hostel during the past financial year.

Since its foundation, the Hospital has relied on the presence of expatriate medical and managing personnel linked to the Italian Co-operation for Development (CUAMM) and to the Comboni Missionary Societies (Sisters, Fathers and Brothers). Dwindling external funding has severely affected the Hospital, depriving it of both skilled personnel and financial support. The employment of local medical personnel and the introduction of living wage salary levels by Government in 1996, has remarkably increased salaries, bringing the Hospital to the verge of financial collapse, from which it was rescued by an emergency intervention of the Royal Danish Embassy during FY 96/97, and in FY 97/98, through the release of Delegated Funds from Government. Delegated Funds from Government have increased yearly since their introduction in FY 97/98.

Extraordinary expenses (buildings, major equipment, and extraordinary maintenance) are exclusively financed by external aid. Ordinary expenditure (recurrent costs) are covered by patients' fees, recoveries and income generating activities (training centre, workshops, hospital guest house) and delegated funds from Government. The remaining costs are covered by donations and aid (from catholic organisations, international aid, NGOs, private benefactors). Since the beginning of 1997 the Hospital has operated without reserve funds.

Due to the extreme poverty of the population, all attempts at increasing the quota of income generated by fees has resulted in a reduction of the demand for service by the weakest sectors of the population (women, children and the destitute; women and children represent 80% of the admissions). This reached its climax with the introduction of a new fee structure in August 97, when the impact on utilisation was dramatic. Fees were reduced in November 97, after the release of delegated funds and an extraordinary fund raising mission abroad. Further reduction of fees took place in September 1998, July 2000, and July 2002.

The cost of the services offered has been analysed and will be presented in chapter 3. On average the cost of one IP activity unit is now 46,200 Ushs versus the average fee charge of 7,300 Ushs. The cost of one OPD activity unit is 7,700 Ushs versus an average fee charge of 1,300 UShs. Both activities are subsidised with the aim of maintaining the Hospital’s accessibility to all strata of the population, thus remaining faithful to its mission statement. The effect of the increase of fees has closely been monitored and has lead to a reversal of policy in November 1997 and in September 98, the result being another reduction of user fees. Due to a higher release of delegated funds from Government, a further reduction of user fees was effected in July 2000. The financial year 2001/02 closed with a fair situation of the finances of the Hospital as compared to previous years. This gave a better outlook to the on-going financial year.

The 2001/2002 annual report compares the activity reports to financial years in order to relate input and output. Therefore the comparison with previous years will be, wherever possible, presented with the activities of the corresponding FY.

The data presented here will be commented on and interpreted. Whenever possible a working hypothesis will be offered to explain data with controversial interpretation. The hypothesis proposed will be, where possible, tested in the course of 2002/03. Policy issues arising from the information presented will be highlighted. Points requiring action will be identified at the end of each chapter and compared with the points of action identified in the previous edition of the report. Therefore it is hoped that all data presented can be placed and viewed in a dynamic perspective, thus making the reading of this report more attractive and enlightening.

The recruitment of staff and its retention have always represented a serious challenge to the management of the Hospital. The harshness of living conditions in Karamoja, its many years of insecurity, its remoteness: all this concurs in rendering work in Matany less than attractive. Nevertheless, the Hospital has managed to have enough Medical Officers. During FY’s 2001/02 an average of 4-5 Medical Officers were present in the station, one Ugandan; three expatriate volunteers (one from Italy, one from Austria / Horizont 3000 and one Medical Officer from CUAMM.) Two Ugandan Doctors left within their probation period and one Ugandan Doctor left at the end of June 2002 as he had applied for further training.

On the side of administrative staff the situation remained stable. The expatriate VSO volunteer appointed as Office Supervisor is of great help and his inputs are highly appreciated.

The opening of the training school for nurses in 1984 has managed to secure the needed qualified nursing staff. A challenge remains for all categories of allied medical professionals (for whom the

opportunities of employment in large cities are many and very attractive) and for capable indigenous technical cadres. The technical department still has to rely on the supervision of one expatriate staff.

An additional problem is posed by the lack of qualified cadres from among the ranks of Karimojong indigenous. Despite the generous investment of the Hospital management in the training of young Karimojong the results are still poor. The low academic standards of schooling offered in Karamoja makes it more difficult for people there trained to have access to professional training. Another problem is that staff sponsored by the Hospital, honour their bonding agreements, but often leave soon after for more attractive places.

In addition to this, the lack of well established career development schemes and promotional outlets makes employment in Matany a temporary arrangement for most people who acquire professional qualifications.

The Hospital Management is trying to follow the Government Salary scale. At present, thanks to government intervention in the form of Delegated Funds, the Hospital Administration has been able to maintain salary levels of 95%. But the Hospital staff enjoy other benefits, like free medical care and free housing, thus reaching 100% of Government remuneration.

At the end of June 2002, Government posted Officers were three (one Health Educator, one Health Inspector for the Public Health Department and one Enrolled Nurse – currently under training as an Anaesthetic Nurse). The expatriate staff comprise three Medical Officers (CUAMM, Horizont 3000 and one privately contracted), the Administrator (mccj), the Senior Nursing Officer (cms), the Office Supervisor (VSO), one Technical Supervisors (mccj Lay missionary), the Domestic Officer (cms), the Assistant Tutor (cms), one Store Keeper (cms), one secretary (volunteer), and one theatre nurse (volunteer).

The total number of employees is 247. Karimojong are 184 (74.5%). The distribution by department appears in table 2.1. The number of qualified staff (employees holding a diploma, certificate or degree) is 74 (30%).

With the exception of nursing, administrative, PHC and teaching staff, the number of employees decreased in 1995 (graphic A, table 2.1) and increased again in 1996 and 1997. From 1998 onwards there was a marked increase in the overall number of employees, especially Nursing Staff, in order to face the increase demand for health care services. The number of Karimojong Staff (184) is the highest level noted ever. The institutional policy of favouring the employment of indigenous personnel is well established as it can be seen in the last years. The Technical Department maintained its staff level and continues to be a necessary department. On one hand this department is essential for the proper running of the Hospital; on the other side the department provides services to the public and to projects, generating additional income. Its growing importance in the hospital economy justifies its size.

In the period covered by the report the hospital has continued promoting the up-grading of staff: more details are given in Table 2.3.

The salaries paid to the employees are slightly lower than in Government Hospitals but the housing provided seems to be better. All employees are covered by NSSF (National Social Security Fund) insurance. With the exception of some of the Technical department staff (casual or seasonal labourers), all employees are paid on a salary basis. The salary is composed of a basic salary to which some incentives have been added (in order to reach the salary scale of Government). Other payments (overtime, calls, stand-by allowance and specific tasks related allowances) are then added. The average salaries paid at the end of the year for the stated categories of staff are in Table 2.2.

The Hospital operates under the direction of the Board of Governors (BoG), which takes its mandate from the Board of Trustees of the Diocese through its Chairman, the Bishop. It is managed by the Hospital Management Team (HMT -Graph A) with its executive body (the daily board formed jointly by the Hospital Officers –Administrator (HA), Medical Superintendent (MS) and Senior Nursing Officer (SNO). Contrary to the present arrangement in Government Hospitals, the function of the Chief Executive Officer is not statutorily exercised by the MS. The Chief Executive Officer is at present the Hospital Administrator. However, the Constitution of the Hospital allows this office to be held by any of the Hospital Officers on the Bishop’s nomination. The BoG is held twice during a financial year, as per Constitution.

Graph A: ORGANOGRAM OF MATANY HOSPITAL MANAGEMENT

The Chief Executive Officer has direct access to the Bishop in case of need and ensures the function of liaison with the Diocesan, District and National Health Authorities. The Nurses’ School Staff operates under the supervision of the Daily Board (more specifically of the Senior Nursing Officer) and reports through it to the Hospital Management Team (HMT).

The rescue of the situation (caused by the shortage of funds against a very high workload of heavily subsidised services of 1997) was explained in the previous editions of this Report. The financial situation of the Hospital has greatly improved with the release of Delegated funds from Government which have increased annually, starting from FY (financial year) 1997/98. Various capital development projects carried out by the technical department of the Hospital have also helped the financial situation to improve.

FY 2001/2002 ended in an equitable way and the possibility for a further reduction of user fees will be proposed during the next Board of Governors meeting. With the increased release of Delegated Funds from the Ugandan Government, we were enabled to maintain our Mission statement to provide services at accessible levels to the poor.

The determination of Government to continue increasing the allocation of Delegated Funds, together with the ongoing capital development projects and a fairly steady flow of donated funds from benefactors, allows us to make good projections for the new financial year.

The cost centre structure is operating since the start of the financial year 98-99. The tables below present this better:

Apart from the Cost Centre Accountability, the Hospital Administration has to report to Government in their given format. This is attached in the following spreadsheet, showing the comprehensive figures for the three Financial Years 1999/00, 2000/01 and 2001/02.

For FY 2001/02 a surplus of 238.6 million Ushs can be noted. This figure contains funds for projects received, but not yet spent, like the Home Care Project funded by the EU and the semi detached tutors’ houses not yet built, but the funds were already made available.

Over the last three years a continued decrease of income from user fees is evident, especially due to the reduction of fees. If we compare the sources of income in percentage of the last three financial years (Graph 3.1), it is demonstrated that Government support in form of Delegated Funds has continually increased, while the dependency on abroad in the form of offerings and donations in kind has reduced.

Graph 3.1 – INCOME –

A remarkable increase in absolute terms can be noticed for the Nursing Training School due to the support in the form of sponsorship from Danida/HSSP. In FY 2001/02 the KHRDCH was utilised more and brought added income to the Hospital. (See Table 3.2 on page 7)

The overall expenditure shows an increase of approximately 13% each financial year. This increase is related mainly to two factors:

• Hospital expenditure due to the increase of salaries, drugs and medical sundries.
• The expenditure for the capital development projects, which on the other side are the causes of the increase of income.

The comparison in percentage is shown in the Graph 3.2, where it shows that expenditure for PHC activities has doubled from FY 1999/00 to FY 2000/01 mainly due to commissioned training activities from the District. This remained at that level in FY 2001/02.

Graph 3.2 – EXPENDITURE -

The Cost Centre Structure demonstrates stock consumed for service and not stock purchased. This gives a better idea of the relative cost of each centre. Items bought still have their value and are not spent. Expenditure only takes place when an item out of the stock is consumed.

As a rough indicator of costs (table 3.5), the cost of a Hospital bed has increased about 11 % compared to 2000/01 (calculated on Hospital plus 30% of Administration expenditure). This is comparable to the general annual expenditure increase of 12 %. The cost per IP activity unit (n.OPD/6 + n.IP) and the OPD activity unit (6*n.IP + n.OPD) had increased by 22 %. The cost of training a Nurse has also increased (given that the Nursing Training School qualifies on average 25 nurses per year, and cost= NTS cost centre expenditure + 15% of Administration cost centre expenditure). The figure for 2001/02 was higher, because of extra costs incurred for the three months specialised training of the Registered Nurses in Kampala, which takes place every two years.

As mentioned before Government’s support of the Hospital has been substantial beginning with FY 97-98 and thereafter. This has been the result of the Memorandum of Understanding signed with the District Authorities, which is renewed on a yearly basis. The Hospital continues to have a good working relationship in the District. These two factors have assisted the Hospital in meeting various objectives.

Appreciation should be given to the Government not only for the financial support but also because the level of co-operation has been outstanding. The release of funds by the District Authorities, once received from the centre, is for the most part very punctual. The Government has shown great trust in us.

In FY (financial year) 1998/99 Government also implemented the Health Sub District policy. They selected Matany Hospital to head Bokora HSD, and therefore made us officially responsible for the implementation of the health activities in Bokora County. These responsibilities were actually being carried out by the Hospital prior to this Policy. Some provision of funds and guidelines on their use, were made available by the Government. Unfortunately, they were not as clear as those for Delegated Funds. Since FY 2000/01 yearly a Memorandum of Understanding between the District Local Government and the Hospital for the use of the public funds is signed.

The critical situation reached in the year 1997 seems a long way away from today’s situation. The trend to increase expenditure will continue, considering the "free market" policy adopted by the Government. There is a fair hope that Government will continue the implementation of the new Health Policy with the strengthening and integration of the PNFP sector in "One Health System". This highlights their concern and the need of supporting institutions other than Government with the overall view of the common goal of improving Health for the people of Uganda. Along these lines, there is hope that the network of external support thus far created can continue providing substantial support and income to the Hospital.

Therefore the outlook of the ongoing financial year is better than the previous ones, yet the financial stability of the hospital will remain very uncertain for the next few years.

As points of action for the ongoing financial year 2002/03 the following are carried forward from the previous year:

• Continue the dialogue with the Government at District and at National level through the strengthening of co-operation and mutual trust.
• Continue looking for other ways of funding the running costs of the Hospital, starting with the reestablishment of a reserve fund.
• Refining the cost centre structure apportioning costs on a more accurate departmental basis.

The Hospital has a separate OP Department with two wings: one for adults and the other for children. The Building also hosts the Ophthalmology and ENT services, as well as the ANC and the immunisation services. The Dental and Private Service, though part of the OPD, are in separate buildings. The laboratory and radiological examinations are carried out on the Hospital premises. The arrangement is such that they can be accessed from the Hospital courtyard. Here follows data focused on the curative function of OPD services. The PHC function exercised is reported in chapter 7, as a global report for the Zone.

According to its established function in the District Health System the Hospital should offer to the public Outpatient consultations of first contact (exclusively for the immediate catchment area of the hospital), Outpatient consultations of referral level (for referred patients only), Inpatient and emergency (medical and surgical) services and a package of preventive and promotive services (for the immediate catchment area). Things are much less clearly defined, and the Outpatient Department delivers a mix of services, pertaining to two different levels of care.

Matany Hospital OPD covers two separate functions within the Health System of the District: it serves as first contact for the patients of the immediate catchment area (the sub-county of Matany; Lokopo and Lopei were considered as immediate catchment area, because the new Health Units were opened during FY 2001/02). It also serves as a referral centre for patients who have first consulted elsewhere and have either been referred or have reported to the Hospital because their problem was not solved elsewhere. It serves as a first contact level for patients who bypass their first contact unit. The first two functions may be considered in line with a correct use of the health system. The third utilisation pattern (bypass of first contact near home) goes against a correct and cost-effective utilisation of the system. A study carried out in 1995 showed that about 72% of the patients seen in Matany OPD did not move correctly within the health system.

All OPD workload data from 1994 onwards are reported in table 4.1. OPD activities were quite high in 1994, and then dropped in 1995. It increased again in 1996, and dropped sharply in 1997/98 as a consequence of an increase in user fees due to the financial crisis the Hospital was experiencing at that time. It increased again in FY 1998/99 and remained at an average of 30,000. In FY 2001/02 there was again a sharp drop, which can be explained due to the opening of the two Health Centres Lokopo and Lopei, which has an attendance of about 4,000 each in that period.

The Above table and graph below show the provenance at Matany Hospital over the past four years. Patients seeking services from outside the immediate catchment area consist of about one third of adults and one fifth of children. These figures show the referral function of the Hospital.

As far as the epidemiology is concerned the main diagnosis reported for FY 2001/02 is still malaria (9,180 episodes). In accordance with the points of action established in 1996, a more detailed classification of diseases in OPD has been introduced. The second most frequent diagnosis is URTI (5,009 episodes). The third most frequent pathology reported is LRTI (2,596), followed by Trauma (1,554) and Diarrhoea (1,064).

In the following graph C, the percentage of the five top causes of attendance is compared to the previous years:

There are no significant changes in the epidemiological pattern, and the more "obvious" diseases remain to be the five top diseases. Some differences occur in some years concerning the fifth one. This is very difficult to explain, It can be trauma, worms, gastrointestinal diseases or splenomegally.

The points of action for the ongoing financial year 2002-03 remain as in the previous year:

Actions

• More effort on the accuracy of the data "production", collection and analysis should be made in order to have epidemiological data to plan for the future.
• Improvement and updating of guidelines and standards of diagnosis and treatment.

Matany Hospital in-patient service has the function of referral for the District and also for a wider functional catchment area for referral of emergency surgery. The Hospital bed strength at the end of the year was 220 beds over 5 Wards: Male Ward and Female Ward with 41 beds each (medical and surgical mixed together), Maternity Ward with 25 beds (ante-natal, post-natal, septic patients), Paediatric Ward with 55 beds including 5 beds for premature intensive care and 10 isolation beds, TB Ward with 58 beds. As remarked in OPD, the utilisation of the Hospital In-patient service dropped in August 97 while an increase has been registered overall FY 98/99. During the following years the utilisation went back to its average coverage. The global bed occupancy rate of FY 2001/02 was 94%.

Table A (workload of years 1996/97-’02) shows the inpatient workload from 1995 up to June 2002. 1998/99 was a year with a very high workload and the following years have gone back to the average of the past years. The amount of major surgery, as well as minor surgery has increased in FY 2001/02. Matany Hospital has been without a permanent surgeon since August 2000 and has failed to contract one. The visit of short term surgeons, almost without interruption has clearly shown the necessity of a permanent surgeon, because after some weeks of their presence patients arrived in good number for surgical interventions.

Matany Hospital due to its unique location and its good reputation has always been functioning as a referral hospital, also due to the tradition of specialised and committed doctors.

After very high utilisation in 1998/99 the above figures show a slight decrease of utilisation patterns. Children Ward being the busiest ward, followed by Male and Female Ward. TB Ward had a noteworthy increase compared to recent years with a bed occupancy rate of 67%, due to the long average duration of stay of each patient. The high number of TB children (178) raised the average duration of stay also in Children Ward.

It is clear that the overall indicators show for FY 2001/02 good efficiency in the utilisation of the Hospital with a B.O.R. of 94 % and a throughput per bed of 30 patients (if we consider "good" when BOR>=80% and throughput per bed >=30).

The following graph 5A shows that there are some significant differences between the Wards. While Children Ward and Maternity are beyond or at a throughput per bed of 30, the B.O.R. for Maternity and Female Ward is lower than 80% due to shorter duration of stay.

Children ward is clearly on the other side but too far from the average, which means an over-loaded ward with a risk of compromising the quality of care and the outcome. TB Ward due to the long stay of TB patients in the hospital has the lowest rate of throughput per bed.

Graph 5A

Few quality indicators are available. Those available are based on the outcome of the patient’s admission and classified as follows:

Using the fees structure we are now able to distinguish between patients from the immediate catchment area (pts of the System: Lopei, Lokopo and Matany sub counties) and from all other areas. Therefore an analysis of the 5 top causes of admission in each ward was completed and is presented in the following table: