PMI End Use Verificatin (EUV) Survey Uganda 31 May 2016 Date f cllectin: 25 th -30 th April 2016 # f facilities: 75 Regins: 4 Rainy seasn: (Nt applicable) Intrductin Malaria is the leading cause f mrtality and mrbidity in Uganda, accunting fr 30-5 f utpatient visits and 15- hspital admissins. The cuntry has the sixth highest number f malaria deaths in Africa and ne f the highest malaria transmissin rates wrldwide. Pregnant wmen and children under five years f age are mst affected, althugh the entire ppulatin is at risk. 1 In June 2015, 10 districts in the Nrth f the cuntry were faced with a malaria epidemic suggesting strnger emphasis n mnitring and surveillance f Malaria. The Uganda Malaria Reductin Strategic Plan (UMRSP, 2014-20) calls fr cst effective, evidence-based preventin and treatment methds. It aims t: 1) By 2017, achieve and sustain prtectin f at least 85% f the ppulatin at risk thrugh recmmended malaria preventin measures; 2) By 2018, achieve and sustain prtectin f at least 9 f malaria cases in the public and private sectrs and cmmunity level receive prmpt treatment accrding t natinal guidelines; 3) By 2017, at least 85% f the ppulatin practices crrect malaria preventin and management measures; 4) By 2016, the prgramme is able t manage and crdinate multi-sectral malaria reductin effrts at all levels; 5) By 2017, all health facilities and District Health Offices reprt rutinely and timely n malaria prgramme perfrmance 6) By 2017, all malaria epidemic prne districts have the capacity fr epidemic preparedness and respnse Uganda has in recent years made gains in preventin and cntrl f malaria: the cuntry has imprved prvisin f anti-malarial medicines; intensified surveillance and behaviral change cmmunicatin; and prvided lng-life insecticidal nets (LLINs) and mass fever treatment. An end-use verificatin (EUV) survey the fifth in the series was cnducted t assess malaria case management (MCM) as well as the availability and use f anti-malaria medicines and cmmdities at public health facilities. The survey aimed t infrm the US President's Malaria Initiative (PMI) and key stakehlders at bth natinal and district level f achievements and challenges f current interventins, infrm planning and plicy decisins as well as the health system's delivery f anti-malaria cmmdities. Methdlgy Overall, 75 facilities 60 public, 13 private-nt-fr-prfits and 2 private in 15 districts were surveyed. Health facilities were selected using a tw-stage stratified randm sampling prcess. In the first stage, districts were listed accrding t their malaria case lad and stratified int three strata. Five districts were then randmly selected 1 The Uganda Malaria Reductin Strategic Plan 2014-2020
frm each stratum yielding a ttal f 15 districts: Lamw, Jinja, Rakai, Agag, Gulu, Mityana, Kabarle, Kamwenge, Bugiri, Katakwi, Maracha, Sirnk, Masindi, Kbk and Sembabule. Within each district, five health facilities frm each level f care were randmly selected: 13 hspitals, 15 HC IVs, 29 HC IIIs, and 18 HC IIs. The sample included at least ne private-nt-fr-prfit (PNFP) facility per district. The data cllectin team cnsisted f 24 individuals: five reginal pharmacists, three reginal Perfrmance Mnitring Team (RPMT) members, fur principal dispensers, five pharmacists, three scial wrkers, and fur medicine management supervisrs (MMS). They were divided int eight teams f three members each t assess 10 facilities in six days. T ensure standardizatin f data cllectin, the data cllectrs attended a three-day training that rientated them with the end use verificatin (EUV) tl, defined and interpreted indicatrs, and prvided specific sampling instructins. Data were cllected using paper-based tls and then entered int cmputers using a CSPr data entry applicatin. The data were then exprted t STATA and MS Excel fr analysis. Figure: Map f Uganda shwing selected districts and health facilities fr the survey lking at prevalence and endemicity Key Observatins Availability f RDTs was high (88% n day f visit). The testing Rate has increased t 69% which is within the NMCP annual set target (69%) fr 2016. There is a fur percent pint increase in percentage f OPD cases that are attributed t malaria, frm 23% f EUV4 (2015) t 27% in the current survey. Only f staff is trained in Malaria Case Management (MCM), implying that there is still lw cverage f updated knwledge abut treatment guidelines and the Natinal Malaria Cntrl Plicy. A large prprtin f test negative patients were still treated fr malaria (92% f the Negative under 5 cases were given ACTs). The rate f giving an antibitic tgether with an ACT drpped cnsiderably frm 7% in 2015 t 2% in 2016
The availability f anti-malarial cmmdities, including RDTs, ACTS, and Artesunate, varied cnsiderably. While certain pack sizes f ACTs (AL 6x1, 6x2, 6x3) were cmmnly ut-f-stck, 94.7% f all facilities had at least ne ACT pack size available. Recmmendatins Apprpriate medicines use and adherence t RDT results need t be addressed. T this effect, Apprpriate Medicines Unit has been established at Pharmacy Divisin. The unit will fcus n adherence t RDT s and treatment f malaria The unit will use a cmbined strategy: Perfrmance Assessment - SPARS tl revised t capture specific infrmatin Managerial revisin f guidelines UCG; n antibitic use fr malaria Educatinal in service training Medicines Therapeutic cmmittees Specialized bimnthly reprting SPARS data, HMIS data Use f supprtive supervisin and implementatin f the peer strategy aimed at strengthening the management supprt fr medicines management at facility level Next Steps The findings frm the data cllectin will be disseminated t Uganda s Ministry f Health and relevant stakehlders t guide plicy planning and initiate crrective actins.
SUPPLY CHAIN INDICATORS Cmmdity % f Facilities Stcked-Out fr 3 Days r Mre in the Last 3 Mnths % f Facilities Stcked-Out n the Day f the Visit AL 1x6 59% (49) 33% (63) AL 2x6 6 (45) 23% (60) AL 3x6 43% (37) 44% (55) AL 4x6 39% (62) 14% (74) LLIN 28% (29) 16% (63) SP (51) 17% (72) RDT 22% (51) 12% (67) Artesunate Inj 57% (40) 42% (50) Quinine Inj 56% (16) 39% (23) On average, 5 f all surveyed facilities visited reprted stck ut f sme ACT pack sizes that lasted mre than three days in the last three mnths, while 33%, 23% and 44% reprted stck ut f AL 6-, 12-, and 18- pack sizes respectively, n the day f the visit. Hwever, 86% f all facilities had the 4x6 pack size available n the day f the visit. Similarly, the SPARS data fr the perid Oct 2015 t April 2016 shwed % f facilities n the day f visit that had an ACT available averaged at 89%, RDTs at 93% and SP at 37% respectively. NMS nly prcures and supplies AL 4x6, the ther pack sizes are prvided by the Glbal Fund. The stck status findings were reflective f the Facility Stck Status Reprt f January-March 2016 where 14% f health facilities had a stck ut f an ACT. AVAILABILITY OF ACT PACK SIZES ON THE DAY OF VISIT INDEX Availability f ACTs (April 2016) 5% 31% 15% 21% 28% Nne Only 1 Any 2 Any 3 All 4 3 25% 15% 1 5% % HFs with cmplete stck ut f ACTs 25% 13% 3% 5% EUV 1 2010 EUV 3 2014 EUV 4 2015 EUV 5 2016 Only 5% f the surveyed facilities reprted a cmplete stck ut f ACTs (tw HCIIs and tw HCIIIs) mainly frm the fur districts in the Nrthern Regin (Agag, Gulu, Lamw and Maracha). A tw percent pint increase frm the previus survey. 21% f the facilities had nly ne f the ACTs available. The lwest availability f the ACT 24- pack was at HCIIIs (79%) clsely fllwed by HCII (83%); HCIVs and Hspitals had 10 and 92% availability respectively. These trends illustrate the challenge assciated with the kit supply system (push system) at the lwer levels (HCII and HCIII). It is wrth nting thugh, that availability at HCIIs has kept n imprving frm 71% (2014) t 83% (current survey). This is pssibly attributed t the NMS custmizing kits t district level and wrking clsely with districts t estimate the kit quantities.
Percent Facility stcking level, EUV 2015 Facility stcking level, EUV 2016 under stcked (0.1-1.9MOS) > 2MOS under stcked (0.1-1.9MOS) > 2MOS 7 6 5 3 1 5 61% 62% 68% 7 57% 67% 68% 62% 10 6 76% 65% 7% 12% 77% 52% 48% 62% 49% Health facilities were gruped by their expected average mnths f stck (MOS) based n the recmmended stcking levels f public facilities in Uganda. The data shwed that mre facilities had up t date stck cards fr cmmdities they received mre cnsistently (e.g. AL 4x6 and RDT). On average, abut a quarter f the facilities that had updated stck recrds were apprpriately stcked fr first line malarial medicines while 5 f facilities were stcked ut, 43% with less than tw mnths f stck and 5% were apprpriately stcked with artesunate injectin (2 nd line). Injectable Artesunate is the preferred first line fr severe malaria treatment and is expected frm HCIIIs and abve. The number f facilities stcking quinine injectin has reduced cmpared t previus surveys which is in line with the NMCP plicy change. Natinal Malaria Cntrl Plicy 3 recmmends the use f RDTs at HCII and cmmunity levels and t fill gaps at higher-level health centers whenever micrscpy is nt pssible. f the facilities reprted verstck f RDTs mstly at HCIV (67%), HCII (54%), Hspitals (33%) and HCIII (25%). SPARS data fr the perid Octber 2015 t April 2016 highlighted facilities especially HC2 and HC3 had verstcks f RDTs with average mnths f stck f 8.8 and 8.1 respectively yet nly 69% f the malaria cases had a diagnstic test. *Facilities that reprted t managing the cmmdity and had updated stck cards %age f facilities understcked (<2 MOS) by Level f care 100 100 100 94 100 100 92 83 80 69 67 67 60 45 50 45 40 25 20 0 AL 4x6 Quinine Inj Artesunate Inj RDT Hspitals HCIV HCIII HCII Analysis f the insufficient stck f key cmmdities by level f care shwed that fr AL 4x6: HCIV had the highest percentage with insufficient stck (69%), fllwed by HCII (5), least f all were Hspitals (25%). All the facilities that managed artesunate injectins were largely under stcked; 83% f HCIVs and all hspitals were als under stcked fr artesunate injectins. The lw stck levels result frm the lng stck ut f Artesunate injectin at the central warehuse during the same perid. Larger percentages f HCIIs (92%) and HCIIIs (45%) were under stcked fr RDTs. It is imprtant t nte that there are lwer level facilities that stck Quinine injectin. Mre investigatin needs t be made abut this issue and surce f the items mre s fr gvernment facilities.
Timeliness f Stck Reprting / Ordering Status EUV 2014 EUV4 (2015) EUV5 (2016) On time 82% 79% 72% Nt n 12% Time 1 15% Unknwn 6% 11% 13% Only HC IV, Hspitals, and PNFP facilities make rders. Therefre, 52% (r 39) f the 75 facilities visited were expected t make rders. Trends ver time shw a decline in adherence t rdering schedules frm 82% (2014) t 72% (2016); this decline was similar t that reprted in the latest Annual Pharmaceutical Sectr Perfrmance Reprt (i.e. frm 89% in 2013/14 t 77% in 2014/15). Health Wrker Training % f Staff Trained by Service Area Service Percentage (Number f Staff) MCM Guidelines (1197) IPTp 62% (333) RDT 68% (617) Micrscpy 59% (288) Stck Management 78% (208) 69% 63% Prprtin f health wrkers trained by service area ver time 41% 36% 87% 44% 37% 11% 91% 59% 55% 59% 98% 89% 73% 67% 3 27% 78% 68% 62% 59% EUV1 (2010) EUV2 (2011) EUV3 (2014) EUV4 (2015) EUV4 (2016) MCM IPTp RDTs Micrscpy Stck Management There have been tremendus effrts t train and build health wrker skills and capacity by bth the gvernment and develpment partners. The trainings resulted in imprvements by service area ver time (stck management at 111% and RDT at 518% frm 2011 t 2016). With the plicy change frm use f Quinine t use f Artesunate in management f severe malaria, a number f trainings in MCM have been cnducted mainly supprted by partners. Hwever just like the previus surveys less than half f the health wrkers invlved in case management have had training n the new guidelines; this is an undesirable situatin as far as the quality f malaria case management is cncerned. Thugh training helps build health wrker skills, a number f studies shw that training alne cannt make cnsiderable impact but a mve t a cmbinatin f interventins t address gaps. The Ministry f Health has established an Apprpriate Medicines Unit in Pharmacy Divisin that will apply a cmbined strategy f Perfrmance Assessment - SPARS tl revised t capture specific infrmatin, Managerial revisin f guidelines UCG; n antibitic use fr malaria, Educatinal in service training fr key health wrkers, Medicines Therapeutic cmmittees and Specialized bimnthly reprting using SPARS data, HMIS data.
MALARIA CASE MANAGEMENT INDICATORS Percentage f Malaria Cases as a prprtin f ttal OPD cases Nnmalaria cases 73% Malaria cases 27% 3 Trends shwing percentage f Malaria Cases as a prprtin f ttal OPD cases 31% 36% 36% 23% 27% 1 EUV 1 2010EUV 2 2011EUV 3 2014EUV 4 2015EUV 5 2016 The current survey shwed that 27% f the utpatient department cases are diagnsed as malaria (alne r with c-mrbidities); this represents a 4 percent pint increase frm the 23% f EUV4 (2015). The current result represents a slight increase, fllwing an earlier decline t a recrd lw percentage f 23% malaria cases (which was the lwest ver time as cmpared t 31% f EUV1 (2010), 36% f EUV2 (2011) and 36% f EUV3). This calls fr added effrt t ensure that the earlier gains frm several interventins t eliminate malaria are maintained. Fever cases culd nt be captured frm health facility recrds. Malaria Cases Yunger Than Age Five as a prprtin f ttal OPD cases The lw prprtin f under 5 malaria cases as a percentage f ttal OPD cases was maintained (in 2016); fllwing the earlier reductins ver the curse f the EUV surveys as shwn in the graph. This fllws the trend f few under malaria cases with a test psitivity rate f 23% Under 5 malaria cases as a percentage f ttal 36% OPD cases 29% 25% 7% 8% This trend reflects the gains frm targeted interventins by Natinal Malaria Cntrl Prgram and partners EUV1 (2010) EUV2 (2011) EUV3 (2014) EUV4 (2015) EUV5 (2016) 6 Trends f treated malaria cases that were tested 56% 59% 61% 69% EUV 2 2011 EUV 3 2014 EUV 4 2015 EUV 5 2016
Number f Malaria Cases under Age Five NOT Treated with an ACT vs. Treated with an ACT %age use f ACTs in under 5s 53% 87% 93% 93% 85% 92% 77% 74% 81% 48% N test and given an ACT 93% 26% 2011 2014 2015 2016 2011 2014 2015 2016 2011 2014 2015 2016 11% 2011 17% 7% 2014 2015 2% Under 5 given an ACT Under 5 psitive & given an ACT Under 5 negative & given an ACT Under 5 pstive & given an antibitic The Natinal Malaria Cntrl Plicy recmmends that parasite-based diagnsis with micrscpy r RDT befre treatment is perfrmed fr any suspected malaria cases. Hwever, the survey fund that nly 69% f the treated malaria cases received a diagnstic test (still lwer than the 9 natinal target, but an imprvement frm 2015 survey (61%). Case management still leaves a lt t be desired; 92% f the test negative under five cases were given an ACT. These high rates f giving ACTs t negative cases were cmmn acrss all levels f care i.e. 89%, 96%, 94% and 86% in Hspitals, HCIV, HCIII and HCII respectively. RDTs were intrduced in the supply chain in December 2012. In line with the remarkable increase f nnadherence t the diagnsis, the survey findings shwed that 76% f the diagnsis was dne using RDTs; this represents an 11 pint increase frm the 65% f EUV4 (2015). 27% f the diagnsis was dne using Micrscpy. 94% f the Negative RDT test cases were given ACTs while 9 f the Negative Micrscpy cases were als given ACTs and 93% with a missing test received an ACT.