Inside cracks in Shs600b for maternal healthcare

The Auditor General has uncovered irregularities in financial management, slow and poor coordination in the implementation of the $159.5 million (Shs609 billion) health improvement project, the shortfalls affecting access to and quality of care.

The project dubbed Uganda Reproductive, Maternal and Child Health Services Improvement Project (URMCHIP), was implemented by the Ministry of Health (MoH) between 2017 and 2023 in health facilities across the country. The project’s specific objectives were to “improve utilisation of essential health services with a focus on reproductive, maternal, newborn, child, and adolescent health services in target districts” and “scale up birth and death registration services” for better planning.

The project was jointly financed by the government, the World Bank, the Swedish International Development Agency (SIDA), and the Global Financing Facility, according to information from the Health ministry. The project comprised components such as Results Based Financing (RBF) for primary health care services – with the objective to scale up and institutionalize RBF focusing on Reproductive, Maternal, Neonatal, Child and Adolescent Health (RMNCAH) services. 

In the November 2023 value-for-money audit report, the Auditor General said some health facilities failed to account for Shs1.2 billion for improving service delivery, and that some equipment such as the ultrasound machine, operating table and baby warmer machine, which were bought through the project were either lying idle or non-functional. The Auditor General also noted that the National Medical Stores (NMS) did not procure medicines worth Shs3.4 billion that were budgeted for to save mothers with pregnancy-related complications, and newborn babies, among other anomalies.

The Auditor General (AG), Mr John Muwanga, indicated in the report that although “MoH registered a number of notable achievements through implementation of URMCHIP,” lack of accountability, failure to implement some essential activities and slow implementation were major hindrances to maximising the achievements.

Mr Muwanga said the new audit report covered an assessment of MoH management’s remedial actions on the previous recommendations of the interim audit report of 2021. The interim audit was done for the three financial years starting 2017/2018 when the project became effective to 2019/2020. 

In the November 2023 report, the AG stated that out of the 10 key audit recommendations made in the Auditor General’s report of 2021, only 40 percent were fully implemented. And the rest, 40 were partially implemented and 20 percent were not implemented at all. The recommendations were in the expediting procurement of equipment, construction of maternity units and improving financial records keeping. Others regarded absorbing personnel trained in handling pregnant women and babies, registering births and deaths and also improving budgeting and monitoring of facilities.

“There is significant improvement in maternal and child health indicators such as: mothers delivering under skilled care at a health facility, pregnant mothers seeking antenatal care, uptake of post-natal family planning, immunisation of children under age five, and the registration of births and deaths by National Identification and Registration Authority (Nira),” the AG said in the report.

“However, between January 2022 – June 2023 (1 ½) years, no interventions were made thereby impairing any progress earlier registered on the indicators above. With exhaustion of the RBF funding component, sustainability of the attained success has remained a challenge within the implementing districts,” the AG added.

Irregularities 
The Auditor General said some health facilities failed to account for some of the money they received to improve service delivery through the project and some essential activities were not implemented.

“Out of a total of 367 planned activities as per the Health Facility Performance Improvement Plans of the sampled 47 facilities, only 191 (52 percent) were actually implemented. Furthermore, the 47 facilities visited received RBF funds worth Shs3.8 billion in total out of which Shs2.3 billion (68 percent) was appropriately accounted for,” the report reads.

“However, due to insufficient accountabilities (such as vouchers, requisitions, invoices or receipts) for the RBF expenditures, it was not possible to confirm whether the RBF performance improvement grants worth Shs1.2 billion (32 percent) were actually being spent on activities to improve service delivery in line with their Performance Improvement plans, which plans were in part and poorly developed,” the report reads further.

The AG, in the report, recommended that the Ministry of Health should liaise with the District Health Management Teams (DHMTs) to improve the capacity of health facility in-charges in basic financial record keeping to ensure proper management and accountability of the RBF funds receive by their health facilities.

However, the MoH management in their official response, told AG they have conducted targeted training in districts that experienced challenges in record keeping, accountability and reporting.

The AG’s report also doesn’t state whether there would be more investigations regarding the accountability for the Shs1.2 billion. But these irregularities in financial management have also been reported in the past, signaling a need to hold responsible officials accountable.

A probe on hospitals by the Parliamentary Public Accounts Committee (PAC) for Central Government last year showed that in all 16 major health facilities and specialised health votes investigated, monies were irregularly diverted in the 2021/2022 financial year. This, the MPs said was happening amid issues of over-budgeting and concealing “funds under statutory items yet they were over and above the actual requirement.” 

“Most of the diversions were effected on statutory expenditure lines of salary, pension and gratuity. For instance; Lira, Kawempe, Jinja Hospitals registered mischarges amounting to Shs105 million, Shs47 million and Shs75 million respectively,” the report reads in part.

Uganda is one of the countries racing to attain Sustainable Development Goals (SDGs), one of them being the goal to reduce maternal death and death of children. A project like URMCHIP is an essential avenue to hit the goal.

Ms Margaret Muhanga, the State minister for Primary Health Care, said the government is expediting plans to reduce the general maternal death rates. 

“The current rate of decline in maternal and neonatal deaths has been slow for Uganda to attain her sector development goals and the longer-term sustainable development goals (SDG) of 2030. The SDG target for maternal mortality rate as 70 per 100,000 live births and the perinatal mortality is 12 per 1,000 live births,” she said.

The Uganda Demographic and Health Survey (UDHS) 2022 report shows that the number of mothers who died during pregnancy, delivery or forty-two days after delivery is at 189 deaths per 100,000 live births, a figure which is very high when compared to countries like the United Kingdom where only 10 mothers die out of 100,000 live births.  It means 2,800 mothers die every year from pregnancy and birth related complications in Uganda.

For infant mortality, the UDHS report shows that there are 36 deaths per 1000 live births, a figure which is very high when compared to four deaths per 1000 live births reported in Europe. Around 1.5 million live births are registered in Uganda annually.

Ms Muhanga said there is a need for “all stakeholders to join hands and implement aggressive strategies to accelerate the progress towards improving maternal and new-born health.”
She said they have already started seeing a decline with numbers being reported by hospitals declining from 16 maternal deaths per day to five maternal deaths daily.

Dr Richard Mugahi, the assistant commissioner in charge of Reproductive and Infant Health, attributed the decline they are seeing to improvement in quality of care. 

“Uganda is making progress in maternal and new-born health because of the investment that the government has put into upgrading of health center IIs to health center IIIs (HCIIIs) with over 500 upgraded in the last three years. This has made deliveries in the lower health facilities to increase,” he said. 

Dr Mugahi  said the government has also increased investment in establishing neonatal intensive care units to address death of newborns. 

The Auditor General said in the new report when their inspectors visited health facilities, they found some procured equipment either missing or not being used.

This means patients may not access certain services despite the equipment being procured. But many equipment had been installed and were functioning well when the inspectors visited, the report states.

At Mbale Rregional Referral Hospital, the report states, the patient operating table delivered under the project was non-functional because the adjusting lever was faulty after three months of use for theatre surgeries at the Obstetrics and Gynecology theatre.

Still at the same facility, the generator is fully functional but is currently not in use because “the oxygen plant has been non-functional for the last eight months.”

The story was not very different from that of Walukuba HC IV in Jinja, according to the inspectors. “The ultrasound machine was delivered but it was not in use and was still in its original package. The in-charge explained that they did not have expertise to use it,” part of the report reads.
At the same facility, the baby warmer was delivered and installed, however the facility health workers were not trained in the use of the machine. Also, the incubator was delivered and installed, however the temperature regulator was faulty, according to the AG’s report.

At Kojja HC IV in Mukono, a laptop for birth and death registration being done to support government’s planning, was not there. “Although a delivery note was provided indicating delivery of a laptop (serial no. MP2BFPZJ) to the facility, there was no laptop at the health facility. The facility has a desktop that is being used for notifications,” the report reads.

Drugs not procured
In the November 2023 report, AG explained that some essential medicines for pregnant mothers and newborns were either not procured or delivered late to health facilities.

“Although the National Medical Stores (NMS), through URMCHIP procured and distributed medicines such Misoprostol, Amoxicillin and Co-packaged ORS and Zinc to various HC IIIs and HC IVs, it was noted that essential RMNCAH medicines such as chlorohexidine (an anti-bacterial), magnesium sulphate and oxytocin, which were originally planned for in the project budget were not procured,” the report reads.

Magnesium sulphate is used to treat convulsions during pregnancy, especially women with raised blood pressure –a common problem. Oxytocin is used to manage postpartum haemorrhage, which is the leading cause of maternal deaths –accounting for more than 40 percent of deaths in Uganda, according to government statistics.

Budget for commodities not procured were as follows: Magnesium sulphate 50 percent 5Ml Injection worth $376,081 (Shs1.4 billion), Chlorhexidine 7% Gel Tubes worth $500,000 (Shs1.9billion), one million Oxytocin Injections, and one million Depo-Provera –contraceptive injection.

“It is worth noting that these three medicines are part of basket of essential RMNCAH commodities. By procuring these medicines as planned, the ministry would have optimised service delivery to mothers and children within health facilities as illustrated by the purpose of these commodities,” the report reads.

But even those that were procured, heath facilities received late.
“Review of distribution lists from NMS indicated that RMNCAH medicines procured during FY 2021/22 such as Misoprostol, Amoxicillin and Co-packaged ORS and Zinc were distributed to various HC IIIs and HC IVs over the months of February 2023 to June 2023,” the report reads further.
It added: “This delay to make the above RMNCAH medicines available to the health facilities had rendered them partly incapable of handling certain complications arising in mothers during delivery.

The AG’s report doesn’t state whether the unspent money was recovered and NMS had not yet given comments by press time.

However, the Ministry of Health in their official response to AG, said all the outstanding deliveries were made by the end of December 2022.

“NMS has been distributing the supplies to the respective facilities. Ministry is in the process of verifying the distributions made by NMS to beneficiary facilities across the country,” the Health ministry said.

Issues of shortage of medicines in health facilities are common with some legislators and hospital leaders attributing to delayed delivery and stealing of the commodities in the facilities.

Drugs not procured

In the November 2023 report, AG explained that some essential medicines for pregnant mothers and newborns were either not procured or delivered late to health facilities.

“Although the National Medical Stores (NMS), through URMCHIP procured and distributed medicines such misoprostol, amoxicillin and Co-packaged ORS and zinc to various HC IIIs and HC IVs, it was noted that essential RMNCAH medicines such as chlorohexidine (an anti-bacterial), magnesium sulphate and oxytocin, which were originally planned for in the project budget were not procured,” the report reads.

Magnesium sulphate is used to treat convulsions during pregnancy, especially women with raised blood pressure –a common problem. 

Oxytocin is used to manage postpartum haemorrhage, which is the leading cause of maternal deaths –accounting for more than 40 percent of deaths in Uganda, according to government statistics.

But even those that were procured, heath facilities received late.