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Assessing Malaria Treatment and Control in Selected Health Facilities

2009 4th Quarter Support Supervision Report

July 2010

The Stop Malaria Project (SMP), funded by the U.S. President’s Malaria Initiative (PMI), is managed by Johns Hopkins University Bloomberg School of Public Health Center for Communication Programs (CCP), Malaria Consortium (MC), the Infectious Diseases Institute (IDI), and the Communication for Development Foundation Uganda (CDFU). SMP is designed to assist the Government of Uganda reach the PMI and Roll Back Malaria (RBM) goal of reducing malaria-related mortality by 50% by 2010, and subsequently contribute to the attainment of the Millennium Development Goals (MDGs).

Plot 2 Sturrock Road, Kololo Opposite Lohana Academy P.O.Box 8045 Kampala, Uganda Tel: +256 (0) 312 300450 Tel: +256 (0) 312 300421 Fax: +256 (0) 312 300425

Stop Malaria Project Uganda

Assessing Malaria Treatment and Control in selected health facilities ii

Acknowledgements

Stop Malaria Project with consultancy support from Focus Development

Associates performed the activities that led to the compilation of this

assessment report. The Assessment report is based on information collected

by Stop Malaria Project (SMP), analyzed and reported by Focus Development

Associates a management and Development Consultancy Firm. The

consultancy team comprised of Patrick Nsamba Oshabe, Prosper Behumbiize

and Dr. Kayita Godfrey. Special Thanks goes to Dr. William Katamba, Ambrose

Muhumuza, and Flora Gombe from SMP who aided the smooth completion of

this report. In addition we appreciate the efforts of supervisors, District Health

Officers and the in-charges and staff of visited facilities that fully supported

the assessment activities and cooperated with the supervisors.


Assessing Malaria Treatment and Control in selected health facilities iii

Table of Contents ACKNOWLEDGEMENTS......................................................................................................................................... II TABLE OF CONTENTS ........................................................................................................................................... III ACRONYMS USED ............................................................................................................................................... IV SUMMARY OF KEY FINDINGS................................................................................................................................. V

1.0 INTRODUCTION ............................................................................................................................................. 1

1.1 THE STOP MALARIA PROJECT ........................................................................................................................ 1 1.3 INTRODUCTION TO THE ASSESSMENT............................................................................................................... 3 1.4 APPROACH AND METHODOLOGY ................................................................................................................ 3

2.0 ASSESSMENT FINDINGS ............................................................................................................................... 5

2.1 IPTP/ANC ASSESSMENT................................................................................................................................ 5 2.1.1 Access to ANC Services on a daily basis ................................................................................. 5 2.1.2 Access to IPTp during ANC visists ............................................................................................... 5 2.1.3 Access to Folic acid/De-worming of pregnant women ..................................................... 7 2.1.4 Availability of ANC materials....................................................................................................... 7

2.2 HEALTH MANAGEMENT INFORMATION SYSTEMS ............................................................................................ 9 2.2.1 Existence of Registers/information systems ........................................................................... 10 2.2.3 Existence of HMIS/records staff................................................................................................. 11 2.2.4 Existence of a Health Unit Data base ..................................................................................... 11 2.2.5 Proportion of facilities that conducted self assessment .................................................... 11 2.2.6 Support supervision to lower health facilities ........................................................................ 12 2.2.7 Meetings of the Health Unit Management Committee .................................................... 12

2.3 CASE MANAGEMENT ............................................................................................................................ 13 2.3.1 Existence of staff trained in Management of Malaria Cases .......................................... 13 2.3.2 Appropriateness of malaria Treatment .................................................................................. 15 2.3.4 Appropriateness of Malaria Diagnosis.................................................................................... 16 2.3.5 Access to Guidelines and Standards required .................................................................... 16 2.3.6 Referral system for emergency cases..................................................................................... 17 2.3.7 Existence and visibility of IEC materials for health workers ............................................... 18

2.4 LABORATORY MANAGEMENT ............................................................................................................ 19 2.4.1 Availability of skilled laboratory personnel ............................................................................ 19 2.4.2 Techniques Used to Diagnose Malaria in Health Facilities ............................................... 20 2.4.3 Functionality of Microscopes in Health Facilities ................................................................. 21 2.4.4 Availability of Job Aids at Laboratory..................................................................................... 21 2.4.5 Preparation of stains used in the laboratory......................................................................... 21 2.4.6 Availability of an established System for Quality Assurance............................................ 22 2.4.7 Lab Records/data Management ............................................................................................ 22 2.4.8 Replenishment of Lab supplies ................................................................................................. 22

2.5 DRUG VERIFICATION ............................................................................................................................. 23 2.6 IEC VERIFICATION .................................................................................................................................. 23

2.6.1 Access to Health education talks about malaria ............................................................... 24 2.6.2 Community Awareness Activities............................................................................................. 24

2.7 SUPPORT SUPERVISION ......................................................................................................................... 25

3.0 DISCUSSION AND IMPLICATIONS OF ASSESSMENT FINDINGS ........................................................ 26

3.1 ACTION POINTS FOR FURTHER ASSESSMENT ACTIVITIES................................................................................. 26 3.2 CONCLUSION .............................................................................................................................................. 26

END NOTES .......................................................................................................................................................... 28

STATISTICS ........................................................................................................................................................... 29


Assessing Malaria Treatment and Control in selected health facilities iv

Acronyms Used ACT Artemesinin-based Combination Therapy ANC Antenatal Care BS Blood Smear CO Clinical Officer DHO District Health Officer DOT Direct Observed Therapy DSS Demographic Surveillance System HC Health Center HF Health Facility HMIS Health Management Information System HUMC Health Unit Management Committees HW Health Worker IEC Information, Education, and Communication IMCI Integrated Management of child illnesses IPTp Intermittent Preventive Treatment in pregnancy ITNs Insecticide-Treated Nets JMS Joint Medical Stores LLNs Long Lasting Insecticide-Treated Nets M&E Monitoring and Evaluation MFP Malaria Focal Person MO Medical Officer MoH Ministry of Health NA Not Applicable NR No response OPD Out Patient Department QBC Quantitative Buffy Coat RDT Rapid Diagnostic Test SMP Stop Malaria Program SP Sulfadoxine-Pyrimethamine USAID United States Agency for International Development


Assessing Malaria Treatment and Control in selected health facilities v

Summary of Key findings Improvement in the quality of services is a key component of Stop Malaria Project. Improved service delivery and quality of care is one of the major components of the five year project. As support supervision is a key intervention for improving and maintaining service quality, this activity is extremely timely. Below is a rundown of key findings in the report. Access ANC/IPTp services

o Majority of Health Facilities (HF) were found to be offering IPTp with exception of 6 HCIIIs in Kiboga, 2 facilities in Masaka, 3 facilities in Mityana, 3 facilities in Rakai and 8 facilities in Sembabule district.

o 20 facilities; 8 from Sembabule, 8 from Masaka 3 from Kiboga and 1 from Nakaseke district indicated that they do not provide IPTp under supervision.

o 18 facilities; 5 from Sembabule, 2 from Rakai, 4 from Mityana, 3 from Masaka, 2 from Kiboga and 1 each from Mubende and Mukono Indicated that they do not have reliable safe water in the ANC clinic

o Although most facilities were found to be providing folic/deworming services regular stock outs of Folic Acid were recorded in almost all health facilities.

o 24 facilities; 6 HC IIIs from Mityana, 6 HC IIIs from Masaka and 6 HC IIs from Sembabule district indicated that they had inadequate cups for administration of IPTp.

o Kiboga District had almost half of her facilities supervised lacking IEC Materials on ANC services including 2 HC IVs and 5 HC IIIs. Also 3 facilities in Mityana and 3 in Mpigi exhibited absence of IEC materials.

o With exception of 10 facilities; 3 from Mukono, 2 each from Nakasongola, Mpigi and Kayunga and 1 facility from Kiboga district, almost all facilities donot dispense ITNs/LLINs.

HMIS o With exception of 6 facilities in Mityana and 4 in Kiboga which never

gave their opinion on client registers, the rest of the facilities in the data set indicated that they have up-to-date client registers.

o Majority of health facilities indicated that they make monthly summary reports. It was only 2 facilities in Kiboga, 3 facilities each in Mityana and Masaka and 2 facilities in Mukono that indicated that they were not making monthly reports.

o There was a significant number of facilities that failed to show whether they had summary reports. These included 11 facilities in Masaka, 12 facilities in Rakai, and 9 facilities in Mityana. Kiboga and Mubende had 5 facilities each, Mukono, Nakaseke and Sembabule had 3 facilities each and Kayunga 2 facilities.

o Sembabule had the highest number (22) of facilities that have a records management officer followed by Masaka (14), Mpigi (11),


Assessing Malaria Treatment and Control in selected health facilities vi

Kiboga (9) and Mubende (9). Others included Mityana (6), Rakai (3) and Nakaseke (2)

o A big number (21) of health facilities in Masaka, 14 facilities in Sembabule, 11 facilities in Mukono and 8 facilities in Rakai had no database that could be used in management of health unit information.

o Majority of facilities did not have a computer on which an electronic database could be run. Only 1/10 facilities in Kayunga, 7/14 facilities in Kiboga, 8/35 facilities in Masaka, 5/20 facilities in Mityana, 6/30 facilities in Mpigi, 7/29 in Mukono, 3/11 in Nakaseke, 1/9 facilities in Nakasongola, 4/23 in Rakai, 1/23 in Sembabule facilities indicated that they had a data management computer

o Although many facilities indicated that they carry out self assessment in most facilities there was no evidence to show consistent assessment records/reports for at least 2 years

o Rakai had 12/23 facilities, Nakasongola had 6/9 facilities, Mityana had 8/20 facilities, Mukono had 7/29 and Masaka had 7/35 facilities that indicated that their Health Unit Management Committees never met in previous quarters to review their performance.

Case Management o Most facilities especially in Mpigi expressed the need to have refresher

courses in Malaria case Management. o Mpigi district had the highest number (28) of facilities who were not

sure whether they had any training in severe Malaria o Majority of health facilities indicated that they have the capacity to

provide technically appropriate treatment of malaria cases. o Only 5 facilities from Masaka, 2 facilities from Sembabule and Kiboga,

indicated that their health providers are not at the facility all the time. o 13/23 facilities in Sembabule, 5/9 facilities in Nakasongola, 15/30

facilities in Mpigi, 18/36 facilities in Masaka indicated that they carry out presumptive management of malaria cases not based on laboratory diagnosis

o It was only 3 facilities in Kiboga, Mityana and Masaka that indicated that they had not had access to any type of malaria guidelines the rest of health facilities had them.

o Some facilities especially hospitals and sometimes HC IVs had access to ambulance services; however it was noted that most of these facilities experienced continuous breakdown and most of the times lacked fuel.

Laboratory Management o Masaka (11/36) and Sembabule (11/23) districts had the highest

number, Mpigi district had 8/30 facilities, Mubende 5/17 facilities, Nakaseke 4/11 facilities and Mukono with 3/29 facilities indicating that they did not have a functional laboratory space.

o 4 facilities in Mubende, 4 facilities in Sembabule, 4 facilities in Nakaseke, 2 facilities in Masaka, 3 facilities in Mityana and 3 facilities in Mukono indicated that they did not have personnel with capacity to run a laboratory.


Assessing Malaria Treatment and Control in selected health facilities vii

o 7 facilities in Mpigi, 6 facilities in Mityana, 3 facilities in Masaka and Mukono had no job aids in the laboratory.

o Majority of health facilities indicated that stains used in their labs come already prepared either from the district or from Joint Medical Stores

o Only 6/14 facilities in Kiboga, 7/36 facilities in Masaka, 5/20 facilities in Mityana, 12/30 facilities in Mpigi, 12/29 facilities in Mukono indicated that they have functional systems for quality assurance

o In Kayunga District 5 facilities indicated that they experience stock outs, in Mpigi 11 facilities indicated the same, in Mukono 10 facilities, in Rakai 16 facilities and in Sembabule 6 facilities

Drug Verification o With exception of 9 facilities in Masaka, 2 facilities in Rakai and 2

facilities in Sembabule majority of facilities had updated stock cards at the facility stores.

o Most facilities that had updated stock cards, indicated that they experienced regular stock outs of essential malaria drugs.

IEC o It was only 4 facilities in Mityana, 4 facilities in Nakasongola, 3 facilities in

Nakaseke and 2 facilities in Kiboga that indicated that they do not provide sensitization of communities on malaria prevention, control and treatment

o Although facilities indicated that they conducted health education talks, supervisors failed to find documented records/reports on attendance, response and achievements that could have been shared among staff or submitted to the district.

o Masaka had 8/37, Mityana 7/20 facilities, Mpigi and Kiboga had 5 facilities each that indicated that they lacked materials for health education talks

o Majority of health facilities in the assessment indicated that they often sensitize communities on key malaria areas.


Assessing Malaria Treatment and Control in selected health facilities viii

Support supervision o The biggest number (197) of facilities assessed indicated that they

received routine support supervision from upper levels o Many facilities could not prove that their supervision was done

because they neither had minutes documented, nor reports to use as a reference.

o It was only Kayunga district which had 8/10 facilities indicating that they carry out routine supervision to lower health facilities. In Kiboga, none of the 14 facilities indicated that they carry out supervision to lower health facilities. In Masaka only 14/36, in Mityana only 2/20, in Mpigi only 6/30, in Mubende only 4/17, in Nakaseke 6/11 facilities in Nakasongola 4/9 indicated that they carry out supervision of lower health facilities.


Assessing Malaria Treatment and Control in selected health facilities 1

1.0 Introduction Today, malaria is responsible for more illness and death than any other single disease in Uganda. While those with low immunity- pregnant women, children under five years and people living with HIV/AIDS- are particularly vulnerable, all people living in Uganda are at risk of being infected with malaria parasites and suffering from resulting illness. According to the WHO World Malaria Report 2009, there was an estimated 12 million malaria cases in Uganda in 2006. On average, 10.7 million malaria cases were reported annually during 2004–08, with no declining trend, and transmission occurs all year round in most parts of the country. According to Ministry of Health (MOH) records, malaria is endemic in 95% of the country. Malaria accounts for 25-40% of outpatient visits to health facilities and is responsible for nearly half of inpatient pediatric deaths. According to the 2006 Demographic and Health Survey, 16% of households nationwide owned one or more insecticide-treated nets (ITNs) and 10% of pregnant women and children under five had slept under an ITN the night before the survey. The proportion of children under-five treated with an antimalarial drug within 24 hours of onset of fever was 29%. The proportion of women receiving two doses of intermittent preventive treatment in pregnancy (IPTp) was 16%.

1.1 The Stop Malaria Project

The Stop Malaria Project is a five-year program (2008-2013) of development assistance funded by the Presidential Malaria Initiative and United States Agency for International Development (USAID). The overall goal of the project is to assist the Government of Uganda to reach its goal of reducing malaria-related mortality. During the five years, the project endeavors to reach 85% coverage of children under five years of age and pregnant women in the 45 partner districts, with proven preventive and therapeutic interventions:

• Artemesinin-based Combination Therapy (ACT) for treatment of uncomplicated malaria,

• Intermittent Presumptive Treatment (IPTp) of malaria in pregnancy, and • Long-lasting Insecticide Treated Nets (LLINs).



The objectives of the stop malaria project are to support Government of Uganda through the National Malaria Control Program (NMCP) strategies in three result areas

• To improve and implement malaria prevention programs in support of the national malaria strategy.

• To improve and implement Malaria diagnosis and treatment activities through laboratory strengthening.

• To strengthen the capacity of the national malaria control program thus improving monitoring, evaluation and supervision of malaria activities.

In the first 3 three years the project intends to extend its services to cover the districts enlisted above. By the time of this report, the project is in its second year of operation.

As a way of monitoring and evaluating project activities, SMP collects data on a number of interventions including rapid assessments, support supervision and facility Assessments This report is a product of facility assessments carried out during support supervision in districts where the project operated in year one.

Districts where SMP intends to Operate Year 1 Year 2 Year 3 Rakai Kibaale Mbarara Sembabule Hoima Ntungamo Masaka Buliisa Kasese Mpigi Masindi Kamwenge Mubende Amuria Kyenjojo Kiboga Katakwi Kamuli Luwero Kaberamaido Jinja Mityana Soroti Iganga Kampala Kumi Pallisa Kayunga Bukedea Tororo Mukono



1.3 Introduction to the Assessment

SMP instituted this assessment in the last quarter (September-December 2009) as part of her routine supervision activities in the 11 districts of central Uganda which were targeted by the project in year one. The purpose of the assessment was to investigate the capacity and gaps of selected health facilities in controlling and treatment of malaria related cases. The assessment desired to investigate issues related to availability of services, quality of services, and utilization of services. Key services investigated included; ANC/IPTp services, Health Unit Management systems, Case Management, Laboratory management, Drug Verification, IEC verification and Support Supervision. The assessment was carried out in Government, NGO/PNFP, and Private Health facilities especially those at the level of Hospitals, HC IVs, and HC IIIs.

1.4 Approach and Methodology

A check list was used as a supervisory tool for the activity. It was adopted from the ministry of health and was reviewed and revised in the supervisory orientation meetings. In each district Supervisors comprised of two team members from SMP, a district malaria focal person, the HMIS focal person and Laboratory technician. These could be joined with other members who were previously trained as facilitators in IPTp. A team of two would visit two facilities in each district in one day. While at the facility, the team divided into two subgroups, case management and drug management. The assessment collected data in 12 districts of central Uganda, but data analysis captured information from 222 facilities from 11 districts with Luwero data missing. Masaka District had the highest number (36) of facilities visited, followed by Mpigi (30) and Mukono (29). Nakasongola (9), Kayunga (10) and Nakaseke (11) had the least number of facilities assessed. 14 HFs in Kiboga, 17 in Mubende, 20 in Mityana, 23 in Rakai, and 23 in Sembabule were also assessed. Of the 222 facilities 177 were government aided, 30 were NGO-PNFP aided, and 6 were privately owned. These facilities comprised of 24 hospitals, 25 HC IVs, and 153 HC IIIs. Although the SMP’s basic level for assessment in this aactivity was HCIII, a total of 20 HCIIs were visited because in some places



Like Butoloogo sub-county in Mubende district would be HCIII is still at the level of a HCII. So supervisors found it important to capture information from such health facilities.



2.0 Assessment Findings

2.1 IPTp/ANC Assessment

In the malaria control strategic plan 2005/6-2009/10 IPTp was to be implemented using a Directly Observed Treatment (DOT) strategy. Pregnant women were to be targeted for the distribution with ITN/LLIN particularly through ANC services. This was expected not only to increase the protection of this vulnerable group but also help to improve the uptake of ANC services in general. Treatment of clinical malaria cases during pregnancy and the management of severe malaria were part of the general approaches towards case management.

2.1.1 Access to ANC Services on a daily basis

In Kayunga district all facilities where found to be providing ANC services and most (169) facilities indicated that they provided it on a daily basis.In Kiboga district only 9 of the 14 health centers provided ANC services and in almost all these facilities that provided the services, ANC services are only provided on Wednesdays. In Masaka of the 25 HCIIIs visited 6 don’t provide ANC services on a daily basis, of the 5 HC IVs supervised 2 do not provide services on a daily basis. Those that do not provide the services on a daily basis in Masaka were found to provide the services on specific days of the week. In Mityana district of the 20 health facilities visited 9 of them were found to provide ANC services on weekly basis. Mpigi district had the highest number (29) of facilities providing ANC services on a daily basis. Mubende district had 3 HC III and 1 HC II that indicated that they do not provide ANC services on a daily basis. Nakaseke district also appeared with 10 of her 11 health facilities providing ANC services on a daily basis with only 1 indicating that they were running a weekly ANC clinic. Rakai and Sembabule had 7 and 5 health facilities respectively that do not provide ANC services on a daily basis. However, of the 5 from Sembabule 4 where HCIIs and only one was a HCIII. In Sembabule 5 HFs indicated that they do not provide ANC services, 4 of these were HCIIs and one was a HCIII.

2.1.2 Access to IPTp during ANC visists

Objective 9 of the malaria control strategic plan 2005/6-2009/10 was to Increase coverage with at least two doses of intermittent preventive treatment (IPT), using Directly Observed Treatment (DOT) among pregnant women attending public as well as private sector health services as part of a



comprehensive reproductive health package implemented during focused ANC services. Emphasis was to be on at least 4 visits for each pregnant woman in order to provide all the services needed and allow timely delivery of at least two doses of IPT. Majority of HFs were found to be offering IPTp with exception of 6 HC IIIs in Kiboga, 2 facilities in Masaka, 3 facilities in Mityana, 3 facilities in Rakai and 8 facilities in Sembabule of which 5 are HCIIs. SMP intended to find out whether those that provide IPTp render the services using DOT. 20 facilities; 8 from Sembabule, 8 from Masaka 3 from Kiboga and one from Nakaseke district indicated that they do not provide IPTp under DOT. 12 facilities never gave their opinion and 13 facilities do not provide ANC services at all 11 of which are HCIIs. However majority (176) of the facilities assessed indicated that they use directly observed treatment during ANC. SMP also desired to find out whether facilities have reliable and clean supply of water safe for drinking in the ANC clinic. Only 18 facilities 5 from Sembabule, 2 from Rakai, 4 from Mityana, 3 from Masaka, 2 from Kiboga and one each from Mubende and Mukono Indicated that they do not have reliable safe water, other wise 191 facilities where found to have safe water in the ANC clinic. Majority of facilities that indicated that they have safe water were found to be using Aqua-safe tablets which were found to be put in Jericans. However there was a significant number of facilities where safe water meant borehole water although there is no evidence to prove that borehole water is safe for drinking.



2.1.3 Access to Folic acid/De-worming of pregnant women

With exception of Mpigi, Kiboga and Mukono where 5 HC IIIs, 4 HC IIIs and 2 HC IIIs respectively indicated that they do not provide folic acid to pregnant women, the rest of the facilities do routinely provide folic acid. Stock outs of Folic Acid were recorded in almost all health facilities including those that indicated that they provide it routinely. Majority (130) of health facilities indicated that they provide de-worming services to pregnant women except for only 2 facilities in Mukono, 2 in Mpigi and 1 in Kayunga where de-worming services were not provided on a routine basis citing inconsistency in the supply of albendazole. However most of them indicated that they sensitize pregnant women about the advantages of de-worming a pregnant woman.

2.1.4 Availability of ANC materials

Cups for IPTp: only 24 facilities indicated that they had inadequate cups for administration of IPTp; 6 of the 24 where HC IIIs from Mityana, 6 HC IIIs from Masaka and 6 HC IIs from Sembabule. Others included 1 HCIV and 1 HCIII from Mubende and one HCIII from Mpigi, Mukono, Kiboga and Rakai. ANC/IPTp cards: In most facilities there was a general lack of ANC/IPTp cards. 2 HC IVs and 6 HC IIIs in Kiboga didn’t have IPTp/ANC cards, 1 hospital, 5 HC IVs and 13 HCIIIs in Masaka did not provide IPTp/ANC cards. Mubende district had 2 HC IV and 11 HC III that had no cards. Rakai district had 6 HC III and 2 HCII without cards. Sembabule had 2 HCIV, 2 HC III and 7 HC II without cards. It was only Mukono District that had all the 29 facilities visited having IPTp/ANC cards followed by Nakaseke district with only 1 facility without cards. It was noted that in the absence of preprinted ANC/IPTp cards some facilities where found to be using exercise books which are purchased by clients themselves. In Masaka some facilities requested clients to photocopy existing cards and all those that failed they resorted to exercise books. In most facilities that had cards it was observed that IPTp cards, were properly used and information was recorded correctly with exception of 3 HC IIIs in Kiboga, 2 HC IIIs in Mpigi and 2 HC IIIs in Mityana.



ANC/IPTp IEC Materials: the supervisors who collected information in this assessment where able to observe IEC materials in ANC centers in majority of health facilities. However, Kiboga district had almost half of her facilities supervised lacking IEC Materials including 2 HC IVs and 5 HCIIIs. Also 3 facilities in Mityana and 3 in Mpigi exhibited absence of IEC materials. Others that lacked IEC materials included 2 facilities in Kayunga, and one facility each from Mukono, Mubende and Nakaseke districts. It should be noted that even in facilities where posters/IEC materials existed; there is a likelihood that they made negligible impact because most of them where in English henceforth clients who do not understand the language may not comfortably understand them. IEC materials in local languages would have impacted the minds of people more. Dispensation of Insecticide Treated Mosquito Nets: The impact of malaria on a pregnant woman and her foetus differs with the intensity of malaria transmission but in any case represents a significant burden on the health of mother and child. In order to reduce maternal morbidity and mortality and improve the newborn’s chances of survival the malaria control strategic plan 2005/6-2009/10 targeted pregnant women for the distribution of ITN/LLIN particularly through ANC services. This was expected not only to increase the protection of this vulnerable group but also help to improve the uptake of ANC services in general. In the Assessment it was discovered that almost all facilities (115/135) did not dispense ITN/LLIN with exception of 10 facilities, 3 from Mukono, 2 each from Nakasongola Mpigi and Kayunga and one facility from Kiboga district. In these facilities that indicated that they dispense mosquito nets, at the time of the assessment, nets were out of stock. Facilities however indicated that they advise pregnant women to buy mosquito nets although majority of clients complain about the cost being too high. In Kayunga district facilities that dispense mosquito nets indicated that priority is given to pregnant women with HIV. 2.1.5 Provision of Health Education Talks during ANC

In all districts majority of health facilities (122) sensitize pregnant mothers

about, prevention, control and treatment of malaria during pregnancy. It

was only 1 HCIII in Kiboga, 3 HCIII in Mityana, 1 in Mpigi, 2 in Mukono, 2 in



Nakaseke and 1 in Nakasongola that indicated that they do not provide

health education talks to pregnant mothers.

It was however noted that education talks are not malaria Specific, pregnant

women were found to be sensitized about other topics such as nutrition,

immunization, breast feeding, and proper hygiene. The challenge health

facilities get is difficulty in getting the pregnant women into group talks since

they don’t all come in at the same time. Educational programs would have

been more effective if all women come together on a common day so that

they could also share experience and provide a feedback on what is working

for them and what is not working.

2.2 Health Management Information Systems

Objective number 18 of the malaria control strategic plan 2005/6-2009/10 was to improve collection, quality and utilization of routine data to monitor the implementation of malaria related interventions through the Health Management Information System (HMIS) and other sources including Malaria Indicator Surveys, Demographic Surveillance System (DSS), sentinel sites and the private sector. Information currently used from HMIS for informational markers include:

o The number of outpatient clinical malaria cases o The number of malaria blood tests o The number of malaria-positive blood tests o The number of ANC first visits o The number of pregnant women with malaria o The number of pregnant women receiving IPTp-1 and IPTp-2 o Stock out of albedanzole and quinine at time of form’s completion and

duration of stock out. This assessment reviewed the existence of data registers at the facilities supervised, whether reports were made, quality of data collected, existence of personnel, a database and utilization of data. The assessment also reviewed support supervision done and activities of Health Unit Management Committees (HUMC).



2.2.1 Existence of Registers/information systems

At the facility level, the importance of accurate and timely data collection needs to be recognized so that reports and action plans are produced from the data that are submitted. From the assessment, only 3 HC IIIs, 2 from Mpigi and 1 from Kayunga had registers which are not up-to-date. With exception of 6 facilities in Mityana and 4 in Kiboga which never gave their opinion on client registers, the rest of the facilities indicated that they have up-to-date client registers. The health facilities which did not provide information to this assessment was because their records personnel were present at the facility during the supervision exercise. Recording data and formulating reports for utilization are two different things. The checklist provided for whether information recorded in registers was transformed into reports for utilization by the facility. Majority of health facilities indicated that they make monthly summary reports. It was only 2 facilities in Kiboga, 3 facilities in Mityana and Masaka each and 2 facilities in Mukono that indicated that they were not making monthly reports. However, it should be noted that there was a significant number of facilities that failed to show whether they had summary reports. These included 11 facilities in Masaka, 12 facilities in Rakai, and 9 facilities in Mityana, 5 facilities each for Kiboga and Mubende, 3 facilities each Mukono, Nakaseke and Sembabule and 2 facilities in Kayunga that had no responses on HMIS reporting.



2.2.3 Existence of HMIS/records staff

Majority (132/222) of facilities indicated that they had records management staff, and those that didn’t have indicated using records assistants for data managment. A records officer is expected to facilitate proper and timely data recording, processing, utilization and storage. From the assessment Sembabule had the highest number (22) of facilities that have records officers followed by Masaka (14), Mpigi (11), Kiboga (9) and Mubende (9). Others included Mityana (6), Rakai (3) and Nakaseke (2). SMP also wanted to find out whether records officers in different health facilities received any training. Although majority of facilities had their assistants trained, there were a significant number (65/221) of facilities that indicated that their staff had never received training in HMIS. Majority (18) are from Sembabule, 15 facilities from Mpigi, 10 facilities from Masaka and 5 facilities from Mityana district.

2.2.4 Existence of a Health Unit Data base

Modern day data management activities requires a database, however a big number (21) of health facilities in Masaka, 14 facilities in Sembabule, 11 facilities in Mukono and 8 facilities in Rakai had no database that could be used in management of health unit information. This implies that these facilities continue to rely on manual records management systems. For an organization to run an electronic database there is need to have a computer. Majority of facilities did not have a computer on which an electronic database could be run. Only 1/10 facilities in Kayunga, 7/14 facilities in Kiboga, 8/35 facilities in Masaka, 5/20 facilities in Mityana, 6/30 facilities in Mpigi, 7/29 in Mukono, 3/11 in Nakaseke, 1/9 facilities in Nakasongola, 4/23 in Nakasongola, 1/23 indicated that they had a computer. No facility in Mubende district had a data management computer. Even facilities that indicated to have a computer in many instances computers were found to be non functional either because they lacked maintenance. Some facilities lacked computers because they had no main grid electricity or solar power supply.

2.2.5 Proportion of facilities that conducted self assessment

Masaka district had the highest number of facilities (23/35) that conducted self assessments in the last quarter but proportionately Sembabule district fared better with 16/23 of her facilities indicating that they conducted self



assessments. Mpigi district had only 13/30 facilities, Mukono had only 12/29 facilities, Kayunga only 5/10 facilities, Mityana only 5/20 facilities, Kiboga 4/14 facilities, Nakaseke 4/11 and Nakasongola 5/9 facilities that indicated to have conducted self assessments. In all these facilities, there was no evidence to show consistent assessment records/reports for at least 2 years. There was also no evidence to show how assessment reports are share/utilized.

2.2.6 Support supervision to lower health facilities

Higher health facilities are mandated to supervise lower level health facilities, 3 HC III in Kiboga, 2 HC IV and 6 HC III in Masaka, 9 HC III in Mityana, 3 HCIII in Mubende, 5 HCIII in Mukono and 6 HCIII in Rakai indicated that they hardly carry out support supervision to lower level health facilities. It should be noted that a significant number of health facilities (45/204) thought it was not their role to supervise lower level health facilities while 18 never responded. Among the facilities reporting conducting lower health unit supervision, majority of health facilities there was no evidence of periodic supervision reports for supervisors to see. Health facilities that never conducted supervision gave the excuse of lack of funds.

2.2.7 Meetings of the Health Unit Management Committee

The biggest number of health facilities in most districts with exception of Rakai and Nakasongola indicated that their HUMCs met every quarter to review the performance of respective health facilities. Rakai had 12/23 facilities, Nakasongola had 6/9 facilities, Mityana had 8/20 facilities, Mukono had 7/29 and Masaka had 7/35 facilities that indicated that their HUMCs never met in previous quarters to review the performance of the health unit. In majority of health facilities there was evidence of recorded minutes to prove the existence of these meetings. Some facilities were found to hold meetings though not regularly.



2.3 CASE MANAGEMENT

In the Malaria Control Strategic Plan 2005/6-2009/10 MOH aims at providing prompt and highly effective anti-malarial combination therapy for uncomplicated malaria episodes to complement efforts of malaria prevention by:

• Reducing the number of cases progressing to severe malaria • Preventing or at least delaying development of parasite strains resistant against used Anti-malaria combinations • Contribute to reductions of malaria transmission by reducing the reservoir of parasite stages transmissible by the mosquito vector (gametocytes)

The focus of this strategy was to gradually phase out the availability and use of mono-therapies for uncomplicated malaria, while rapidly providing access to treatment with ACTs for all segments of the population.

2.3.1 Existence of staff trained in Management of Malaria Cases

MOH statistics shows that Training on malaria case management, including severe malaria, and the provision of supportive supervision was provided to

over 10,000 health workers, including almost 3,000 workers from the private sector. In this Assessment only a few health facilities (17/220) indicated not to have received training in Case Management. It was only 2 HC III facilities in Kiboga, 5 HC III facilities in Mityana and 3 HC III facilities in Mukono that indicated that they did not have trained staff in management of both severe and uncomplicated malaria. Most facilities especially in Mpigi expressed the need to have refresher courses in Malaria case Management.

Table 1: Number of facilities with personnel trained in uncomplicated Malaria NR 1-3 staff 4-6 staff 7-9 staff 10+ staff KAYUNGA 2 1 2 1 3 KIBOGA 8 4 1 0 1

MASAKA 5 7 15 5 3 MITYANA 2 10 0 1 0 MPIGI 11 12 3 4 MUBENDE 4 5 4 2 1

MUKONO 7 7 6 4 3 NAKASEKE 1 3 4 0 2 NAKASONGOLA 4 2 2 0 1

RAKAI 2 10 6 3 2 SSEMBABULE 3 17 0 2 1 Total 38 77 52 21 21



The assessment desired to find out the number of health personnel who received training in both uncomplicated and severe Malaria. The tables below shows that Mityana had an average of 10 facilities indicating that 1-3 of their staff trained in uncomplicated Malaria. Majority (12) of facilities in Mpigi indicated that they had 4-6 staff trained followed by 11 facilities indicated that they had 1-3 members trained in uncomplicated malaria. 15 facilities in Masaka indicated that they had 4-6 members of staff and 7 indicated that they had 1-3 members who trained in uncomplicated malaria. Kayunga, Masaka, Mpigi and Mukono district had 3 or more facilities that indicated that they had more than 10 members of their staff who received training in uncomplicated Malaria

Mpigi district had the highest number (28) of facilities who were not sure whether they had any training in severe Malaria hence they never responded. The district had only 2 facility one indicating that they had 1-3 members and the other indicating 4-6 members who trained in Severe Malaria. Masaka district had 10 facilities indicating that they had 1-3 staff and 13 HF had 4-6 staff members who trained in severe Malaria. Mityana had 10 facilities indicating that they had an average of 1-3 staff who trained in Severe Malaria. Sembabule district had the highest number of facilities with 1-3 members of staff trained in severe malaria.

Table 2: Average number of personnel trained in Severe Malaria Non

Response 1-3 staff 4-6 staff 7-9 staff 10+ staff

KAYUNGA 4 1 2 1 1 KIBOGA 7 6 1 0 0 MASAKA 6 10 13 4 2 MITYANA 3 10 0 0 1 MPIGI 28 1 1 0 0 MUBENDE 4 5 4 2 1 MUKONO 8 9 3 4 3 NAKASEKE 1 5 2 0 3 NAKASONGOLA 3 3 3 0 0 RAKAI 2 10 5 3 2 SSEMBABULE 4 16 0 2 1

Total 70 76 34 16 14



2.3.2 Appropriateness of malaria Treatment

In spite of all efforts to reduce malaria infections and prevent progression of uncomplicated malaria to complicated forms of the disease, severe malaria will still occur. In the malaria Control Strategic plan, the case management strategy focuses at the management of all forms of severe malaria (cerebral malaria as well as severe malarial anemia) through;

o Introduction of suitable and easily applicable pre-referral treatment (e.g. rectal Artesunate) at peripheral health facilities (HC II) as well as at community levels where this can be shown to be feasible and effective.

Improving availability of safe blood and blood products for transfusing severely anaemic patients as well as other relevant IV fluids and ancillary treatments

Improvement of the management of severe disease at higher level health facilities (HC III & IV) and hospitals which not only involves availability of medicines and commodities but also skills and processes including patient triage.

Technical Appropriateness: from the assessment majority of health facilities indicated that they have the capacity to provide technically appropriate treatment of malaria cases. It was only 3 facilities from Mpigi, 2 facilities each from Kiboga, Masaka and Mukono that indicated they could not provide appropriate treatment. However, it should be noted that a significant number of health facilities 6 from Masaka, 5 from Sembabule, 4 from Kiboga and 4 from Mityana never gave their opinion. Most facilities (184/221) had access to malaria management guidelines as supplied by the ministry of health. A challenge of stock out of supplies and drugs was mentioned in Mukono and Masaka which sometimes hinder technical management of malaria cases. Timely Appropriateness; majority of assessed Health facilities indicated that that their health providers are available most of the time. It was only 5 facilities from Masaka, 2 facilities each from Sembabule and Kiboga, which indicated that their health providers are not at the facility all the time. In some facilities due to lack of duty rosters it was not possible to verify whether Health Unit staff were available all the time. It was important to find out



whether timing of medication was appropriate, but there was no means of verification to show that drugs were given to patients timely.

2.3.4 Appropriateness of Malaria Diagnosis

With the introduction of ACTs the need is increasing to minimize unnecessary treatment while at the same time providing maximum coverage with treatment access. Coverage of high quality clinical and parasitological malaria diagnosis was expected to increase. Parasitological diagnosis was to be either through microscopy or rapid diagnostic tests (RDT). A significant number of facilities that indicated that malaria treatment is not based on laboratory diagnosis. 13/23 facilities in Sembabule, 5/9 facilities in Nakasongola, 15/30 facilities in Mpigi, 18/36 facilities in Masaka indicated that they carry out presumptive management of malaria cases. Major reasons advanced for lack of diagnosis based treatment are; lack of functional laboratory facilities, stocks of lab reagents, and sometimes absenteeism of laboratory assistants/technicians to carry out the diagnosis.

2.3.5 Access to Guidelines and Standards required

Majority of facilities indicated that they have access to the Uganda Clinical guidelines in OPD and IPN and only a few had access to IMCI guidelines. It was only 3 facilities each in Kiboga, Mityana and Masaka that indicated that they had not had access to any type of guidelines. However, 5 facilities Mityana, 4 in Kiboga and 3 in Masaka where not sure whether they use such guidelines. Some health facilities in Kayunga and Sembabule lacked wall charts.



2.3.6 Referral system for emergency cases

In Kayunga district majority (7/10) facilities indicated that they had a referral plan while 2 facilities indicated not applicable. In Kiboga district majority of health facilities had a referral plan; it was only 2 facilities that indicated to

have a referral mechanism to higher level health facilities. In Masaka district 16 facilities indicated that they had a referral plan, although there was a significant number of 16 facilities indicating that they had no consistent plan on management of referral cases. It was 9/20 facilities in Mityana, only 7/30 facilities in Mpigi, 11/16 facilities 21/29 facilities in Mukono, 6/11 facilities in Nakaseke, 3/9 facilities in Nakasongola, 8/23 facilities in Rakai and 3/23 facilities in Sembabule that indicated that they had a referral mechanism for complicated malaria cases. It should be noted that some facilities especially hospitals and sometimes HC IVs had access to ambulance services. However, most of these facilities experienced continuous ambulance breakdown and fuel shortages. In many facilities where the assessment was done it was noted that it is the referred clients are required to pay for fuel for the ambulance.

Table3; Number of facilities with a Referral Mechanism for Emergency cases District NR Yes No NA Total

KAYUNGA 1 7 2 10 KIBOGA 4 2 8 14 MASAKA 3 16 16 1 36

MITYANA 5 9 6 20 MPIGI 7 23 30 MUBENDE 2 11 3 16 MUKONO 3 21 5 29

NAKASEKE 1 6 4 11 NAKASONGOLA 1 3 5 9 RAKAI 3 8 11 1 23

SSEMBABULE 4 3 16 23 Total 27 93 99 2 221



2.3.7 Existence and visibility of IEC materials for health workers

In majority of health facilities visited IEC materials on management of uncomplicated malaria and severe malaria where available and displayed where health workers could visibly see them. Its only 3/10 facilities in Kayunga, 4/14 facilities in Kiboga, and 3/36 in Masaka that indicated that they had no IEC materials on management of malaria. IEC on Uncomplicated malaria; It was only 2 facilities each in Kayunga, Mityana and Mpigi districts that lacked charts on management of uncomplicated malaria in the OPD section. 3 facilities each in Sembabule, Mpigi, and Masaka, 2 facilities each in Kiboga and Nakaseke that lacked IEC materials on uncomplicated malaria in IPN. IEC on Severe Malaria; Majority health facilities (39/221) did not respond to this checklist, only 4 facilities in Mityana, 3 facilities in Mpigi, 2 facilities each in Kayunga and Mukono that indicated that they lacked IEC materials on management of severe malaria in OPD. 3 facilities each in Sembabule and Mpigi, 2 facilities each in Nakaseke, Kiboga and Masaka indicated lack IEC materials for severe malaria in IPN. It should be noted that many of the facilities had outdated IEC materials. Many of the facilities indicated the desire to have IEC materials in their local language.



2.4 LABORATORY MANAGEMENT

Majority of health facilities (143/222) indicated that they had functional laboratory space. Masaka and Sembabule districts that had the highest

number 11 each of facilities indicating they did not have a functional laboratory space. Mpigi district had 8/30 facilities, Mubende 5/17 facilities, Nakaseke 4/11 facilities and Mukono with 3/29 facilities indicating they did not have a functional laboratory space. It was noted in Masaka that, some facilities had functional laboratory facilities but lacked technical personnel to run them. Some facilities lacked supplies of reagents and other chemicals required to carry out the common diagnosis and on many cases experienced breakdown of microscopes and other equipment.

2.4.1 Availability of skilled laboratory personnel

The biggest number (144) of health facilities indicated having trained personnel to run laboratory services. It was only 4 facilities each in Mubende, Sembabule and Nakaseke, 2 facilities in Masaka, 3 facilities each in Mityana and Mukono which indicated not to have personnel with capacity to run a laboratory. The assessment desired to find out whether the mentioned laboratory staff are available at the health facility all the time when needed, ie a qualified health provider is assigned 24 hours a day 7 days a week. Although majority of health facilities (121/222) showed that laboratory personnel are available all the time, a significant number of health facilities (37/222) indicated that

Table 4: Number of facilities with a functional Laboratory Space

District Name NR YES NO NA Total KAYUNGA 9 1 10

KIBOGA 3 8 2 1 14 MASAKA 4 16 11 5 36 MITYANA 5 15 20

MPIGI 21 8 1 30 MUBENDE 10 5 2 17 MUKONO 26 3 29

NAKASEKE 1 6 4 11 NAKASONGOL 8 1 9 RAKAI 3 18 1 1 23

SSEMBABULE 3 6 11 3 23 Total 19 143 47 13 222



their personnel are not available all the time. Mukono district had the highest number (12), followed by Mubende and Nakaseke (5 each), 4 from Nakasongola and 3 from Mpigi district.

2.4.2 Techniques Used to Diagnose Malaria in Health Facilities

There are several techniques used in diagnosing malaria cases in health facilities, these include microscopy, Rapid Diagnostic Tests (RDTs), Quantitative Buffy Coat (QBC) among others. This assessment desired to find out the most common techniques used. From table 5; it can be seen that most health facilities use microscopy techniques in all districts. RDTs were mentioned in 3 facilities in Masaka, 2 facilities each in Mpigi, and Mukono and 1 facility each in Kiboga, Mubende and Nakaseke. It was only 3 facilities

in Kayunga, 1 facility each Masaka, Nakaseke and Masaka that indicated clinical diagnosis. SMP desired to find out the number of laboratory personnel who were trained in microscopy and /or RDT techniques of malaria diagnosis. Facilities that had 1 person who received the training included 7 facilities in Kayunga and indicated that they had 2 or more personnel trained in malaria diagnosis (4 facilities in Kiboga, 5 facilities in Masaka, 3 facilities in Mityana, 4 facilities in Mpigi, 8 facilities in Mukono, 5 in Nakasongola, 3 each in Nakaseke and Rakai. The major challenge indicated by health facility in use of RDTs was that strips get out of stock and most facilities have no consistent replenishment mechanisms.

Table 5: Types of Malaria Diagnosis Techniques used in health facilities Microscopy RDTS QBC CLINCAL

DIAGNOSIS GREMASA STAIN

KAYUNGA 9 3 KIBOGA 9 1 1 MASAKA 13 3 1 MITYANA 16 MPIGI 21 2 MUBENDE 9 1 MUKONO 27 2 1 NAKASEKE 7 1 1 NAKASONGOLA 6 RAKAI 20 SSEMBABULE 8 1 Total 145 11 1 5 1



2.4.3 Functionality of Microscopes in Health Facilities

They have been repeated attempts to improve availability and quality of laboratory diagnosis of malaria through training and provision of microscopes. Though efforts have registered limited success, HMIS reports in 2008 reported increased availability of functional microscopy services. This was also revealed in the assessment, most of health facilities had their microscopes in good condition although the assessment further desired to find out the longevity in time the non functional microscopes spend at the facility without maintenance. From the assessment it was one facility in Mukono that mentioned that they had a microscope which had taken 10 years without maintenance, Kayunga had 2 facilities with microscopes which had broken down in the last 6 months and 2 facilities that had their microscope broken down in the previous 3-5 years. Nakaseke also reported 1 facility that had its microscope which had broken down in the last 3-5years without maintenance.

2.4.4 Availability of Job Aids at Laboratory

From the assessment most facilities (118) had job aids displayed in their respective laboratories. It was only 7 facilities in Mpigi, 6 facilities in Mityana, 3 facilities each in Masaka and Mukono that had no job aids for laboratory technicians. Furthermore 2 facilities each in Kayunga, Kiboga, Nakaseke and Ssembabule also indicated that they had no access to job aids in the laboratory.

2.4.5 Preparation of stains used in the laboratory

Majority of health facilities indicated that stains used in their laboratories come already prepared either from the district or from Joint Medical Stores (JMS). It was only 2 facilities each from Kayunga and Rakai that indicated that stains are prepared by laboratory assistants. Some facilities indicated that they purchase stains from pharmacies or from JMS already prepared. Almost all health facilities that had laboratory technicians indicated that they knew how to prepare standard stains used in laboratory. It was only 4 facilities each in Sembabule and Mpigi, 2 facilities each in Kiboga and Mukono districts that indicated that they lacked the capacity to prepare standard stains.



2.4.6 Availability of an established System for Quality Assurance

Internal quality control and assurance are key in ensuring that laboratories results are accurate, therefore the need for well established QA&C systems. A significant number of facilities (47/127) indicated that they didn’t have an established system to carry out quality assurance. Only 6/14 facilities in Kiboga, 7/36 facilities in Masaka, 5/20 facilities in Mityana, 12/30 facilities in Mpigi, 12/29 facilities in Mukono indicated that they had functional systems for quality assurance. In Mubende only 7/17 facilities, 3/11 in Nakaseke, 4/9 facilities in Nakasongola and 4/23 facilities in Sembabule indicated that they had systems for quality assurance. Furthermore 13 facilities in Mukono indicated that they didn’t have systems for quality assurance. Note: An insignificant number of facilities in Rakai indicated that they get system slides from national laboratories for quality assurance.

2.4.7 Lab Records/data Management

All facilities in Kayunga, Kiboga, Mpigi and Masaka that have functional lab facilities where found to have a lab register. In Mityana and Nakasongola districts only 1 facility each did not have a register, in Mukono and Nakaseke only 2 facilities each, the assessment team was not able to access their registers. It’s mandatory for all health facilities to submit monthly reports to the district health office. This requirement has given a chance to majority of facilities to compile, analyze and write monthly reports from laboratory data. In the assessment, only 2 facilities each from Masaka, Mpigi and Nakaseke indicated that they didn’t prepare monthly reports from the laboratory data. It should however be noted that apart from preparing reports for the district, there was no mechanism for sharing data internally among the respective departments.

2.4.8 Replenishment of Lab supplies

The assessment desired to find out whether laboratories at respective health facilities experienced stock outs of laboratory supplies in the previous quarter. In Kayunga district 5 facilities indicated that they experience stock outs, in Mpigi 11 facilities indicated the same, in Mukono 10 facilities, in Rakai 16 facilities and in Sembabule 6 facilities. Supplies which are mostly out of stock are stains, gloves, strips for RDT and reagents of Malaria.



2.5 DRUG VERIFICATION

Proper inventory management of malaria drugs is essential in the malaria control program. All health facilities are required to have stock cards to assist health center staff to monitor supply of selected essential malaria treatment supplies. In this assessment quantities on stock cards were compared with actual physical count at facility stores. With exception of 9 facilities in Masaka, 2 facilities in Rakai and 2 facilities in Sembabule majority of facilities had updated stock cards at the facility stores. Although almost all facilities had updated stock cards, most facilities indicated that they had stock outs of essential malaria drugs. 12 facilities each in Rakai, Mukono and Mpigi districts and 8 facilities in Masaka indicated that they had stock out of IV quinine. Stock outs of Coartem for children under-5 were reported from 21 facilities each in Rakai, and Mpigi, 10 facilities each in Mubende and Mukono districts. Furthermore 16 facilities in Rakai, 14 facilities in Mukono and 14 facilities in Mpigi indicated that they experienced stock outs of SP. From general comments made by health facilities, most health centers experienced continuous stock out of coatem. Some facilities indicated that coartem gets finished quickly, while others indicated that the district/NMS take long to restock coatem.

2.6 IEC VERIFICATION

Mobilizing the communities, local, regional and national as well as political and religious leaders to play an active role in malaria control and ensuring proper understanding of the core interventions by the population and promoting positive change of behaviors is the major purpose of advocacy, IEC & social mobilization as part of the malaria control strategy. Objective 12 of the Malaria control strategic plan 2005/6-209/10 is to raise the profile of and demand for malaria control interventions through targeted, well designed advocacy and communication campaigns and activities with special emphasis on the biologically and economically vulnerable.



2.6.1 Access to Health education talks about malaria

Almost all facilities were found to be providing health education talks about malaria. It was only 4 facilities each in Mityana and Nakasongola, 3 facilities in Nakaseke and 2 facilities in Kiboga that indicated that they weren’t carrying out community sensitization activities on malaria prevention, control and treatment. It should however be noted that although facilities indicated that they conducted health education talks, supervisors failed to find documented records/reports on attendance, response and achievements that could have been shared among staff or submitted to the district. It was only Mpigi district with only 9 facilities, Kayunga and Mukono with 6 facilities each and Masaka with only 3 facilities reporting to have written health education talks reports and submitted them to the district. Most of these facilities expressed the opinion that they were not informed about the requirement to submit health education talk reports to the district. Availability of Teaching Materials; SMP desired to find out whether health facilities use charts, leaflets, posters, and flip charts during the process of conducting health education talks. Majority of facilities where found to have these materials although not specifically as mentioned above. Some facilities indicated that they lacked materials for health education talks and these included; Masaka had 8/37, Mityana 7/20 facilities, Mpigi and Kiboga had 5 facilities each. Others that did not have materials were; Sembabule and Nakasongola with 3 facilities each and Mubende with 2 facilities.

2.6.2 Community Awareness Activities

The IEC strategy aims at supporting active community participation in malaria control activities. Majority of health facilities in the assessment indicated that they often sensitize communities on key malaria prevention, control and treatment. Use of ITNs/LLINs was mentioned in almost all facilities with exception of 4 facilities in Mityana, 3 facilities in Sembabule, and 2 facilities each in Kiboga, Nakaseke and Mukono districts. Sensitization on sanitation, IPTp and Malaria treatment was also mentioned in most facilities with exception of 5 facilities in Mityana, 3 facilities in Sembabule, 3 facilities in Nakaseke, and 2 facilities in each of Kiboga, Mukono and Rakai. A number of facilities indicated that they find problems with mobilization of communities due to lack of facilitation and poor attitudes of people who are



often invited for such meetings and don’t respond. Hence facilities reported in this assessment that they now rely on village health teams (VHT)’s outreaches or immunization days to sensitize people. Posters and brochures were also being used to promote malaria community awareness activities.

2.7 SUPPORT SUPERVISION

The biggest number of facilities (197) assessed indicated that they received routine support supervision from upper levels. From Masaka, Mubende, Mukono and Rakai only 2 facilities in each of these districts reported that they did not receive support supervision. In addition, 1 facility each in Kiboga and Nakaseke reported the same. Support supervision was found to be carried out as a mandate from the DHO’s office or from the health sub district. It should be noted however that although some facilities could show supervision reports, many facilities could not prove that supervision was done because they neither had minuted documents, nor reports to use as reference. It should also be noted that not all facilities that received support supervision from upper levels extend supervision to lower level health facilities. It was only Kayunga district which had 8 of her 10 facilities indicating that they carry out routine supervision to lower health facilities. In Kiboga none of the 14 facilities indicated that they carry out supervision to lower health facilities. In Masaka only 14/36, in Mityana only 2/20, in Mpigi only 6/30, in Mubende only 4/17, in 16/28 facilities, in Nakaseke 6/11 facilities in Nakasongola 4/9 indicated that they carry out supervision. Rakai had 11/23 facilities and Sembabule 7/21 facilities that carry out routine support supervision.



3.0 Discussion and Implications of Assessment Findings

Generally the results of the assessment vary across and facilities, it imperative for SMP technical staff to identify areas of strength, weakness and specify tailored district needs for further on-the-job training and supervision. Findings from this assessment should augment other routine field reports of SMP for better interventional planning.

3.1 Action Points for Further Assessment Activities

The consultant proposes that further assessment requires a triangulated approach or methodology of gathering information. Using different methods to obtain assessment information will give SMP a more complete picture of the issues related to malaria services. Relying on only the checklist for data collection gave room for inconsistent reporting which may lead to misleading action plans. Methods like, group discussions, records reviews, staff peer assessment, exit interviews and others may need to be considered. A more specific data collection tool (s) which remains within the MOH objectives should be developed to reduce on the ambiguity observed in the checklist used. Tools designed should be more diverse and user friendly as many fields were left blank due to the complexity of capturing the data. More time should be given to orienting people who are going to collect the data so that they can understand properly the objectives of the assessment and the expected results. Selection of data collectors and training should be given a lot of attention because in this assessment some questionnaires were incomplete and logical checks were not adhered to. Dissemination of assessment findings is crucial before another assessment is conducted in the same districts. A 1 day workshop with health facility In-charges, and district supervisors can generate significant feedback and insight to interventional planning.

3.2 Conclusion

The data in this assessment was collected in the last quarter of the year 2009; SMP staff working with district supervisors collected the information. The information was analyzed and reported by Focus Development Associates. The Activity focused on assessment of malaria prevention and treatment services in 11 Districts of central Uganda.



The purpose of the assessment was to investigate the capacity and gaps of selected health facilities in controlling and treatment of malaria related cases. The assessment desired to investigate issues related to availability of services, quality of services, and utilization of services The assessment collected data in 12 districts of central Uganda, but data analysis captured information from 222 facilities from 11 districts with Luwero data missing. Masaka District had 36 facilities visited, Mpigi 30 and Mukono 29. Nakasongola 9, Kayunga 10 and Nakaseke 11. 14 HFs in Kiboga, 17 in Mubende, 20 in Mityana, 23 in Rakai, and 23 in Sembabule were also assessed. Assessment results were presented to SMP staff in a one-day workshop at which participants identified priority areas for improvement.



End Notes MOH: Malaria Control Strategic Plan 2005/6-209/2010 MOH: Malaria Operation Plan WHO: World Malaria Report 2009



Statistics

Are ANC services provided on a daily basis? No Response Yes No Not Applicable

Total

KAYUNGA 10 10 KIBOGA 2 9 3 14 MASAKA 27 9 36 MITYANA 11 9 20 MPIGI 29 1 30 MUBENDE 13 4 17 MUKONO 24 5 29 NAKASEKE 10 1 11 NAKASONGOLA 8 1 9 RAKAI 15 7 22 SSEMBABULE 13 5 5 23 Total 2 169 45 5 221

Does the facility offer IPTp No Response Yes No Not Applicable

Total

KAYUNGA 10 10 KIBOGA 2 8 3 1 14 MASAKA 34 2 36 MITYANA 17 3 20 MPIGI 30 30 MUBENDE 17 17 MUKONO 29 29 NAKASEKE 11 11 NAKASONGOLA 9 9 RAKAI 19 3 22 SSEMBABULE 2 13 2 6 23 Total 4 197 13 7 221



Do you administer IPTp under DOT?

No Response Yes No Not Applicable

Total

KAYUNGA 10 10 KIBOGA 2 9 3 14 MASAKA 1 25 8 2 36 MITYANA 2 18 20 MPIGI 30 30 MUBENDE 2 15 17 MUKONO 2 27 29 NAKASEKE 10 1 11 NAKASONGOLA 8 1 9 RAKAI 1 19 2 22 SSEMBABULE 2 5 8 8 23 Total 12 176 20 13 221

Is there a reliable clean supply of water?

No Response Yes No Not Applicable Total

KAYUNGA 10 10 KIBOGA 2 10 2 14 MASAKA 33 3 36 MITYANA 2 14 4 20 MPIGI 30 30 MUBENDE 16 1 17 MUKONO 1 27 1 29 NAKASEKE 11 11 NAKASONGOLA 9 9 RAKAI 20 2 22 SSEMBABULE 11 5 7 23 Total 5 191 18 7 221



Are there cups for IPTP DOT administration?


KAYUNGA 10 10 KIBOGA 2 11 1 14 MASAKA 29 6 1 36 MITYANA 14 6 20 MPIGI 29 1 30 MUBENDE 15 2 17 MUKONO 2 26 1 29 NAKASEKE 11 11 NAKASONGOLA 9 9 RAKAI 21 1 22 SSEMBABULE 12 6 5 23 Total 4 187 24 6 221

Do you provide any malaria materials?


KAYUNGA 6 4 10 KIBOGA 2 4 8 14 MASAKA 17 19 36 MITYANA 16 4 20 MPIGI 28 2 30 MUBENDE 4 13 17 MUKONO 29 29 NAKASEKE 10 1 11 NAKASONGOLA 1 5 3 9 RAKAI 14 8 22 SSEMBABULE 6 11 6 23 Total 3 139 73 6 221



Is IPTp recorded


KAYUNGA 10 10 KIBOGA 2 9 3 14 MITYANA 1 17 2 20 MPIGI 27 2 1 30 MUBENDE 16 16 MUKONO 28 1 29 NAKASEKE 11 11 NAKASONGOLA 8 8 RAKAI 1 1 SSEMBABULE 1 1 Total 3 128 7 2 140

Does the facility have IEC materials displayed?

No Response Yes No Total

KAYUNGA 8 2 10 KIBOGA 2 5 7 14 MITYANA 1 16 3 20 MPIGI 27 3 30 MUBENDE 15 1 16 MUKONO 2 26 1 29 NAKASEKE 10 1 11 NAKASONGOLA 8 8 RAKAI 1 1 Total 5 116 18 139

Does the facility dispense LLTNs/ITNs/


KAYUNGA 2 6 2 10 KIBOGA 2 1 11 14 MITYANA 1 15 4 20 MPIGI 2 26 2 30 MUBENDE 14 2 16 MUKONO 3 26 29 NAKASEKE 11 11 NAKASONGOLA 1 2 5 8 RAKAI 1 1 Total 4 10 115 10 139



Are health Education talks about malaria given during

ANC services No Response Yes No Not Applicable

Total

KAYUNGA 10 10 KIBOGA 2 11 1 14 MITYANA 2 15 2 1 20 MPIGI 29 1 30 MUBENDE 1 15 16 MUKONO 1 26 2 29 NAKASEKE 9 2 11 NAKASONGOLA 1 6 1 8 RAKAI 1 1 Total 7 122 9 1 139

Do you provide folic acid?


KAYUNGA 9 1 10 KIBOGA 2 8 4 14 MITYANA 19 1 20 MPIGI 25 5 30 MUBENDE 16 16 MUKONO 1 26 2 29 NAKASEKE 11 11 NAKASONGOLA 8 8 RAKAI 1 1 Total 3 123 13 139

Do you routinely de-worm pregnant women?

No Response Yes No

Total

KAYUNGA 9 1 10 KIBOGA 2 12 14 MITYANA 18 18 MPIGI 28 2 30 MUBENDE 16 16 MUKONO 27 2 29 NAKASEKE 11 11 NAKASONGOLA 8 8 RAKAI 1 1 Total 2 130 5 137



Do client registers exist?


KAYUNGA 8 1 9 KIBOGA 4 10 14 MASAKA 35 35 MITYANA 6 14 20 MPIGI 28 2 30 MUBENDE 1 16 17 MUKONO 29 29 NAKASEKE 11 11 NAKASONGOLA 9 9 RAKAI 1 22 23 SSEMBABULE 23 23 Total 12 205 3 220

Where Monthly HMIS reports completed?


KAYUNGA 2 8 10 KIBOGA 5 7 2 14 MASAKA 11 19 3 3 36 MITYANA 9 6 3 2 20 MPIGI 30 30 MUBENDE 5 10 1 1 17 MUKONO 3 24 2 29 NAKASEKE 3 8 11 NAKASONGOLA 1 8 9 RAKAI 12 10 1 23 SSEMBABULE 3 19 1 23 Total 54 149 11 8 222



Does the facility have a records officer?


KAYUNGA 10 10 KIBOGA 2 3 9 14 MASAKA 1 19 14 2 36 MITYANA 14 6 20 MPIGI 16 11 3 30 MUBENDE 7 9 1 17 MUKONO 1 26 2 29 NAKASEKE 9 2 11 NAKASONGOLA 9 9 RAKAI 19 3 1 23 SSEMBABULE 1 22 23 Total 5 132 78 7 222

Has the HMIS ever received any training in records systems


KAYUNGA 6 4 10 KIBOGA 3 5 3 3 14 MASAKA 2 16 10 7 35 MITYANA 2 9 5 4 20 MPIGI 14 15 1 30 MUBENDE 2 11 1 3 17 MUKONO 2 21 6 29 NAKASEKE 10 1 11 NAKASONGOLA 2 7 9 RAKAI 1 18 2 2 23 SSEMBABULE 3 18 2 23 Total 14 120 65 22 221



Does the facility have a health unit database?


KAYUNGA 7 3 10 KIBOGA 2 11 1 14 MASAKA 3 9 21 2 35 MITYANA 5 8 7 20 MPIGI 1 21 7 1 30 MUBENDE 10 5 2 17 MUKONO 2 16 11 29 NAKASEKE 1 8 2 11 NAKASONGOLA 8 1 9 RAKAI 3 12 8 23 SSEMBABULE 2 7 14 23 Total 19 117 80 5 221

Does the facility have a data management Computer?


KAYUNGA 1 9 10 KIBOGA 2 7 4 1 14 MASAKA 2 8 21 4 35 MITYANA 5 13 2 20 MPIGI 2 6 17 5 30 MUBENDE 9 8 17 MUKONO 2 7 19 1 29 NAKASEKE 3 8 11 NAKASONGOLA 1 7 1 9 RAKAI 4 18 1 23 SSEMBABULE 2 1 20 23 10 43 145 23 221



Did the health facility conduct self assessment?


KAYUNGA 1 5 4 10 KIBOGA 5 4 5 14 MASAKA 5 23 7 35 MITYANA 3 5 12 20 MPIGI 13 13 4 30 MUBENDE 7 9 1 17 MUKONO 3 12 13 1 29 NAKASEKE 4 7 11 NAKASONGOLA 5 4 9 RAKAI 4 5 14 23 SSEMBABULE 1 16 6 23 22 99 94 6 221

Was there any support Supervision carried out to lower Health facilities?


Total

KAYUNGA 1 8 1 10 KIBOGA 2 3 5 4 14 MASAKA 5 16 5 9 35 MITYANA 9 5 6 20 MPIGI 1 10 9 10 30 MUBENDE 2 9 6 17 MUKONO 1 19 7 2 29 NAKASEKE 1 6 1 3 11 NAKASONGOLA 1 4 4 9 RAKAI 13 8 2 23 SSEMBABULE 5 8 7 3 23 Total 17 98 61 45 221



Does the Health unit Management Committee meet once a quarter?


KAYUNGA 10 10 KIBOGA 2 7 3 2 14 MASAKA 1 28 6 35 MITYANA 1 11 8 20 MPIGI 28 2 30 MUBENDE 1 12 4 17 MUKONO 2 19 7 28 NAKASEKE 8 3 11 NAKASONGOLA 2 6 1 9 RAKAI 1 10 12 23 SSEMBABULE 1 16 6 23 Total 9 151 57 3 220

Is staff trained in Management of malaria cases


KAYUNGA 10 10 KIBOGA 3 9 2 14 MASAKA 2 32 1 1 36 MITYANA 5 10 5 20 MPIGI 30 30 MUBENDE 1 14 1 16 MUKONO 2 23 3 28 NAKASEKE 1 10 11 NAKASONGOLA 1 8 9 RAKAI 1 20 2 23 SSEMBABULE 20 3 23 16 186 17 1 220



Are Providers giving technically appropriate treatment of malaria cases?


KAYUNGA 10 10 KIBOGA 4 7 2 1 14 MASAKA 6 28 2 36 MITYANA 4 13 1 1 19 MPIGI 27 3 30 MUBENDE 1 15 16 MUKONO 1 26 2 29 NAKASEKE 10 1 11 NAKASONGOLA 1 8 9 RAKAI 1 22 23 SSEMBABULE 5 18 23 23 184 11 2 220

Is Malaria treatment based on Lab diagnosis


KAYUNGA 9 1 10 KIBOGA 2 9 3 14 MASAKA 3 13 18 2 36 MITYANA 2 13 4 19 MPIGI 15 15 30 MUBENDE 1 9 6 16 MUKONO 4 20 5 29 NAKASEKE 6 5 11 NAKASONGOLA 4 5 9 RAKAI 2 17 4 23 SSEMBABULE 1 8 13 1 23 Total 15 123 79 3 220



Is there a health provider available all the time?


Total

KAYUNGA 8 1 1 10 KIBOGA 2 9 2 1 14 MASAKA 4 26 5 1 36 MITYANA 4 16 20 MPIGI 29 1 30 MUBENDE 15 1 16 MUKONO 2 26 1 29 NAKASEKE 10 1 11 NAKASONGOLA 8 1 9 RAKAI 3 19 1 23 SSEMBABULE 3 17 2 1 23 Total 18 183 16 4 221

Does facility have guidelines and standards?


KAYUNGA 9 1 10 KIBOGA 4 6 3 1 14 MASAKA 3 30 3 36 MITYANA 5 12 3 20 MPIGI 28 2 30 MUBENDE 2 13 1 16 MUKONO 2 27 29 NAKASEKE 2 8 1 11 NAKASONGOLA 9 9 RAKAI 1 21 1 23 SSEMBABULE 1 21 1 23 Total 20 184 16 1 221



Are providers giving technically appropriate services?


KAYUNGA 10 10 KIBOGA 2 8 3 1 14 MASAKA 5 27 3 1 36 MITYANA 8 10 1 19 MPIGI 27 3 30 MUBENDE 4 12 16 MUKONO 3 23 3 29 NAKASEKE 1 10 11 NAKASONGOLA 3 3 3 9 RAKAI 2 15 6 23 SSEMBABULE 2 17 4 23 Total 30 162 26 2 220

Does facility have a referral system for emergency cases?


KAYUNGA 1 7 2 10 KIBOGA 4 2 8 14 MASAKA 3 16 16 1 36 MITYANA 5 9 6 20 MPIGI 7 23 30 MUBENDE 2 11 3 16 MUKONO 3 21 5 29 NAKASEKE 1 6 4 11 NAKASONGOLA 1 3 5 9 RAKAI 3 8 11 1 23 SSEMBABULE 4 3 16 23 Total 27 93 99 2 221



Does facility have Malaria IEC Displayed


KAYUNGA 1 6 3 10 KIBOGA 3 7 4 14 MASAKA 9 24 3 36 MITYANA 4 15 1 20 MPIGI 29 1 30 MUBENDE 1 15 16 MUKONO 3 26 29 NAKASEKE 2 9 11 NAKASONGOLA 1 7 1 9 RAKAI 22 1 23 SSEMBABULE 22 1 23 Total 24 182 15 221

Does the facility have a functional Lab Space?


KAYUNGA 9 1 10 KIBOGA 3 8 2 1 14 MASAKA 4 16 11 5 36 MITYANA 5 15 20 MPIGI 21 8 1 30 MUBENDE 10 5 2 17 MUKONO 26 3 29 NAKASEKE 1 6 4 11 NAKASONGOLA 8 1 9 RAKAI 3 18 1 1 23 SSEMBABULE 3 6 11 3 23 Total 19 143 47 13 222



Is there Skilled Human Resource?


KAYUNGA 8 1 1 10 KIBOGA 3 10 1 14 MASAKA 5 15 2 14 36 MITYANA 4 13 3 20 MPIGI 21 9 30 MUBENDE 9 4 4 17 MUKONO 26 3 29 NAKASEKE 7 4 11 NAKASONGOLA 9 9 RAKAI 1 19 3 23 SSEMBABULE 4 7 4 8 23 17 144 21 40 222

Is there a Lab Personnel Available at all times?


KAYUNGA 9 1 10 KIBOGA 4 7 2 1 14 MASAKA 4 13 5 14 36 MITYANA 6 12 1 1 20 MPIGI 18 3 9 30 MUBENDE 9 2 6 17 MUKONO 17 12 29 NAKASEKE 6 5 11 NAKASONGOLA 5 4 9 RAKAI 1 16 3 3 23 SSEMBABULE 4 9 10 23 Total 19 121 37 45 222



Do Lab staff have job aids?


KAYUNGA 7 2 1 10 KIBOGA 3 8 2 1 14 MASAKA 7 10 3 16 36 MITYANA 6 8 6 20 MPIGI 1 14 7 8 30 MUBENDE 1 9 1 6 17 MUKONO 26 3 29 NAKASEKE 1 6 2 2 11 NAKASONGOLA 7 1 1 9 RAKAI 1 16 3 3 23 SSEMBABULE 3 7 2 11 23 Total 23 118 32 49 222

Is there a system for quality assurance?


KAYUNGA 1 7 1 1 10 KIBOGA 6 6 1 1 14 MASAKA 6 7 5 18 36 MITYANA 12 5 3 20 MPIGI 12 6 12 30 MUBENDE 3 7 7 17 MUKONO 2 12 13 2 29 NAKASEKE 1 3 4 3 11 NAKASONGOLA 4 4 1 9 RAKAI 1 13 6 3 23 SSEMBABULE 3 4 4 12 23 Total 35 80 47 60 222



Is there a Lab register?


KAYUNGA 9 1 10 KIBOGA 2 11 1 14 MASAKA 6 16 14 36 MITYANA 4 15 1 20 MPIGI 19 11 30 MUBENDE 10 7 17 MUKONO 1 26 2 29 NAKASEKE 7 2 2 11 NAKASONGOLA 8 1 9 RAKAI 2 18 3 23 SSEMBABULE 3 9 11 23 Total 18 148 6 50 222

Is Lab data analyzed and reports submitted


KAYUNGA 8 1 1 10 KIBOGA 2 12 14 MASAKA 6 13 2 15 36 MITYANA 5 14 1 20 MPIGI 16 2 12 30 MUBENDE 1 9 1 6 17 MUKONO 28 1 29 NAKASEKE 7 2 2 11 NAKASONGOLA 1 7 1 9 RAKAI 1 18 1 3 23 SSEMBABULE 4 7 1 11 23 Total 20 139 12 51 222



Any Stock out of Lab supply?


KAYUNGA 1 5 3 1 10 KIBOGA 8 4 2 14 MASAKA 8 3 9 16 36 MITYANA 5 3 11 1 20 MPIGI 11 7 12 30 MUBENDE 1 9 7 17 MUKONO 5 10 14 29 NAKASEKE 1 4 4 2 11 NAKASONGOLA 1 4 3 1 9 RAKAI 2 16 2 3 23 SSEMBABULE 5 6 2 10 23 Total 36 67 66 53 222

Are there updated stock cards?


KAYUNGA 3 7 10 KIBOGA 7 7 14 MASAKA 7 18 9 1 35 MITYANA 6 14 20 MPIGI 3 24 1 2 30 MUBENDE 4 13 17 MUKONO 3 25 1 29 NAKASEKE 1 10 11 NAKASONGOLA 7 7 RAKAI 4 17 2 23 SSEMBABULE 5 14 2 21 43 156 14 4 217



Any regular stock outs of essential Malaria Drugs?

NR Yes NO Total

KAYUNGA 2 4 4 10 KIBOGA 5 6 3 14 MASAKA 12 8 15 35 MITYANA 11 2 7 20 MPIGI 3 12 14 29 MUBENDE 5 3 9 17 MUKONO 6 12 11 29 NAKASEKE 1 6 4 11 NAKASONGOLA 2 5 7 RAKAI 7 12 4 23 SSEMBABULE 11 3 8 22 Total 63 70 84 217

Are Health Education Talks given to clients?


KAYUNGA 10 10 KIBOGA 3 9 2 14 MASAKA 1 34 1 36 MITYANA 4 12 4 20 MPIGI 29 1 30 MUBENDE 16 16 MUKONO 28 1 29 NAKASEKE 8 3 11 NAKASONGOLA 2 3 4 9 RAKAI 22 1 23 SSEMBABULE 1 21 22 Total 11 192 16 1 220



Supervision received from higher level health facility

No Response Yes No

Total

KAYUNGA 10 10 KIBOGA 2 11 1 14 MASAKA 1 32 2 35 MITYANA 1 17 2 20 MPIGI 29 1 30 MUBENDE 1 14 2 17 MUKONO 1 26 2 29 NAKASEKE 1 9 1 11 NAKASONGOLA 8 8 RAKAI 1 20 2 23 SSEMBABULE 21 21 Total 8 197 13 218

Supervision carried out to lower health facilities


KAYUNGA 8 2 10 KIBOGA 2 6 6 14 MASAKA 2 14 9 9 34 MITYANA 1 2 10 6 19 MPIGI 6 15 9 30 MUBENDE 1 4 6 6 17 MUKONO 1 16 10 1 28 NAKASEKE 1 6 1 3 11 NAKASONGOLA 4 4 8 RAKAI 2 11 9 1 23 SSEMBABULE 1 7 7 6 21 Total 11 78 77 49 215

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