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2013 ANNUAL PERFORMANCE REPORT
ASANTE-AKYEM PRESBY HEALTH SERVICE
PRESENTED BY
ALEX KESSE NYAMESA (FRSH)
GENERAL MANAGER
PRESENTATION OUTLINE
• Introduction
• Key Priority Objectives
• Highlights
• Implementation of Plans and Budgets
• Main Achievements
• Constraints/Challenges
• Way Forward
• Best Practices/Innovations
2
INTRODUCTION
The Asante-Akyem Presbyterian Health Service operates in Ashanti, Eastern,
Western and Central regions of Ghana.
The institutions under the Asante-Akyem Presbyterian Health Service are:
Agogo Presby Hospital (District Hospital)
Agogo Presby Nurses’ Training College
Agogo Presby Primary Health Care
Kwahu Praso Presby Health Centre
Aowin-Suaman Presby Primary Health Care
Assin Praso Presby Health Centre
Assin Nsuta Presby Health Centre
Kom Clinic, Aburi
3
Services Provided – Agogo Hospital
• Internal Medicine
• General Surgery
• Child Health
• Obstetrics/Gynaecology
• Dentistry
• Pharmacy
• Ophthalmology
• Ultrasonography
• Electrocardiography
• Physiotherapy
• Laboratory Services
• X-Ray Services
• HIV/AIDS:
– VCT
– ART
– PMTCT
• Special Sickle Cell Clinic
• Special Diabetic Clinic
• Special Hypertensive Clinic
• Special TB Clinic
• Special Psychiatry Clinic
• Morgue Services
4
STAFFING POSITION – AGOGO HOSPITAL (AS AT 31-12-2013)
STAFF CATEGORY STAFF AT POST
Medical Officers 21
Medical Assistants 6
General Nurses 101
Midwives 20
Auxiliary Nurses 31
Pharmacists 3
Pharmacy Technicians 10
Biomedical Scientists 5
Physiotherapist 1
Technical Officers (X-Ray) 2
Nurses Anaesthetist 5
Others 218
TOTAL 423
5
STAFFING POSITION – HEALTH CENTRES/POST(AS AT 31-12-2013)
GRADEAGOGO
PHC
ASSIN
PRASO
ASSIN
NSUTA
KWAHU
PRASO
ENCHI
PHC
DDNS/PNO/SNO/NO/SSN/SN - 1 2 - 7
Med. Asst./Rural Nurse
Practitioner- 2 1 1 2
Accounts/Administration 3 1 1 - 1
Midwives/Midwifery Supt. 1 1 1 1 1
Enrolled Nurse 7 5 3 - 10
Lab Technician/Assistant - 2 - 2 3
Community Health Nurse 21 5 7 5 9
Pharmacy Technician/Assistant - 1 1 - 4
Field Technician/Technical
Officer2 6 - - 1
6
GRADEAGOGO
PHC
ASSIN
PRASO
ASSIN
NSUTA
KWAHU
PRASO
ENCHI
PHC
Driver 2 1 1 - 2
Medical Record Assistant - - 2 - 3
Health Aides/Ward Assistant 3 8 12 1 3
Labourer/Orderly - 2 3 5 5
Watchman 2 - 2 1 2
Tradesman - 1 - - -
Storekeeper - - 1 - 1
Others 4 1 7 - 9
TOTAL 45 37 44 16 63
7
KEY PRIORITY OBJECTIVES
1. To increase access to health services and bridge equity gaps
2. To improve quality of care
3. To improve financial and human resource mobilization
4. To increase efficiency in resource utilization
5. To improve maternal and child health care
6. To prevent and control non-communicable diseases
7. To control the incidence of Malaria, HIV/AIDS, STI/TB
Transmission and other Communicable Diseases
8. To spread the gospel through health service delivery
9. To improve collaboration and networking with MOH/GHS and
other stakeholders
8
ASANTE-AKYEM PRESBYTERIAN HEALTH SERVICE
ANNUAL PERFORMANCE REPORT
JANUARY – DECEMBER 2013
HIGHLIGHTS
• 281,435 outpatient attendances were recorded, it was 5.2% above the figure of 267,442 recorded in 2012
• 91.0% of all cases was insured. The total number of insured cases was 219,917 (excluding Agogo PHC and Kwahu Praso) which was 2.2% higher than the percentage figure of 88.8% in 2012
• The total number of Admissions was 12,930 which was 6.9% above the figure of 12,092 recorded in 2012.
• Discharges totalled 12,438 and there were 380 deaths. Discharges and Deaths recorded 6.6% and 5.5% respectively as compared to 2012 figures (i.e. 11,657 discharges and 360 deaths)
• 5,489 Antenatal Registrants were recorded as against 5,782 in 2012, indicating a decrease of 5.1%
9
• Supervised Deliveries totalled 3,142; 5.5% above the figure of 2,978 for 2012
• There were 2,833 Postnatal Registrants as against 3,393 in 2012, indicating a
decrease of 16.5%
• 2,078 General Surgeries, 1,389 Obstetric/Gynaecological Surgeries and 859
Eye Surgeries were performed. The total number of Surgeries performed was
4,326 which recorded 5.1% lower than the 2012 figure of 4,559
• Laboratory Investigations for Agogo Hospital totalled 84,556 which was 2.3%
above the number of investigations recorded in 2012 (i.e. 82,582). Assin Praso
Health Centre and Enchi PHC conducted a total of 16,143 laboratory
investigations indicating 20.3% increased compared to 2012 total recorded
figure of 13,416
• 7,056 X-Ray Investigations were carried out which was higher than the 2012
figure (i.e. 5,790) by 21.8%
10
• Ultrasound Investigations totalled 4,012 which was 7.1% below the recorded
figure of 4,323 for 2012
• There were 7 Maternal Deaths as against 6 in 2012; 65 Stillbirths as against 75
in 2012; 34 Neonatal Deaths as against 36 in 2012. These convert into
Maternal Mortality Ratio of 329 per 100,000 life births as against 298 in 2012;
Stillbirth Ratio of 29.7 per 1,000 births as against 34.9 in 2012 and Neonatal
Mortality Ratio of 16.0 per 1,000 life births as against 17.4 in 2012. Death Rate
of Admissions remained the same as 2012 (3.0%)
• Malaria retained its position as the topmost cause of outpatient attendance and
admission and also the first amongst the top ten communicable diseases in
Agogo Hospital
• As a proportion of all Malaria Deaths, Under-Five Malaria Deaths fell from
87.5% in 2012 to 56.3% in 2013
11
• Recorded EPI coverage was as follows:
BCG 124.0% OPV III 122.7%
Measles 155.1% Yellow Fever 113.0%
Penta III 120.1% TT2 176.6%
• A consolidated Income and Expenditure Account gave total income as
GH¢14,736,206.40 and total expenditure as GH¢13,693,423.54 indicating a
surplus of GH¢1,042,782.86
• Development Expenditure was GH¢774,461.86 giving a ratio of development
expenditure to re-current expenditure of 1.0 : 17.7
• Total Internally Generated Fund (IGF) was GH¢8,205,962.13 which was
55.7% of total income
• Government subvention was GH¢6,472,569.28 which was 43.8% of total
income
12
• Donations from Overseas Partners and Friends totalled GH¢12,300.59 which
was 0.1% of total income. The percentage for 2012 was 0.2%
• Drug Sales Income was GH¢4,421,061.65 which accounted for 53.8% of IGF.
Total cost of drugs sold was GH¢2,499,450.59 giving a gross margin of
GH¢1,921,611.06 or 76.5%
• Total expenditure on Church Salaries and Allowances was GH¢2,096,233.91
which took 25.5% of IGF
• Total revenue from insured clients was GH¢5,531,916.03 which constituted
67.4% of IGF
• Outstanding health insurance reimbursements for all facilities as at 31st
December, 2013 totalled GH¢1,608,266.65
13
IMPLEMENTATION OF PLANS AND BUDGET (JAN – DEC 2013)
PLANNED ACTIVITIES CARRIED OUT, OUTPUTS AND OUTCOMES
OBJECTIVE 1: INCREASE ACCESS TO HEALTH SERVICES AND BRIDGE
EQUITY GAPS
ACTIVITY OUTPUT OUTCOME
STRATEGY (I) Strengthen Hospital’s Capacity to Respond to Challenges of National
Health Insurance Scheme
Strengthen Health
Insurance Claims Office
in the Hospital
A total amount of
GHȼ29,489.00 has been
devoted for the first phase
of the computerization of
the hospital OPD systemHealth insurance claim’s
accurately prepared and
promptly submitted at all timesEngagement of two (2)
permanent staff to assist in
the processing of insurance
claims14
Prepare and Discuss
NHIS Implementation
Report monthly at IMC
meetings – Agogo
Hospital
12 Health Insurance
Operational reports,
including monthly
statement of health
insurance account,
discussed by management
Smooth implementation of the
National Health Insurance
Scheme evidenced by two
Clinical Audits
Provide Training &
Refresher Trainings for
all Staff in the
Implementation of
NHIS – Agogo Hospital
A 5-day in-service training
on E-CLAIMS organized
for staff at the Health
Insurance Unit
Significant improvement in
Health Insurance
documentation
Accuracy in claims submission
enhanced
15
Continue
Implementation
of NHIS
Total No. of Cases: 240,067
Total Insured cases: 219,917
% of Insured Patients: 91.0%
Total IGF: GH¢7,683,662.87
Revenue from Insured: GHȼ5,531,916.03
As a % of IGF: 71.0%
Total Reimbursement: GHȼ3,923,649.38
Outstanding Reimbursement:
GHȼ1,608,266.65
Increase in access to
health services as a
direct result of the
health insurance
scheme; total number of
insured cases rose
marginally by 3.0%
compared to 2012
16
NHIS Accounts exclude Agogo PHC and Kwahu Praso H/C
17
STRATEGY (II) Provide Subsidies to Poor and Sick
Provide Free Treatment
for Uninsured Poor and
Sick
A total of GHȼ2,684.00
(including feeding and
transportation as well as
registration with NHIS) was
spent on Poor and Sick in
all facilities
The poor and sick had access to
health care
STRATEGY (III) Improve on Existing HIV/AIDS Response System
Increase Service Hours
at ART, VCT, PMTCT
Centres
1,083 clients received HIV/
AIDS clinical care at ART
Centre
1,156 clients were
counselled and tested at
VCT Centre (666 females;
490 males)
Increased access to services for
clients at ART, VCT and
PMTCT centres in the hospital
Increase Service Hours
at ART, VCT, PMTCT
Centres
275 tested positive (174
females; 101 males)
1,922 ante-natal registrants
were counselled and tested
29 tested positive
29 Mothers received ARVs
43 Babies received ARVs
Increased access to services for
clients at ART, VCT and
PMTCT centres in the hospital
Organize World AIDS
Day
World AIDS Day organized
on 1st December. Activities
included:
Health talks at Agogo
(APCE & Asempa FM,
Akutuase, Konongo (Kings
FM)
Float on the principal
streets of Agogo
Improved public knowledge on
HIV/AIDS issues
18
STRATEGY (IV) Provide General/Specialized Out-Patient and In-Patient Services
Provide 24-Hour
General/Specialized
Out-Patient Services
134,758 attendances were
recorded at the General
OPD in Agogo Hospital, out
of this;
16,832 were specialized
surgical consultations
11,878 were specialized
obstetric/gynaecological
consultations
30,459 specialized
paediatric attendances were
recorded
22,598 attendances were
recorded at the Eye Clinic
3,049 attendances were
recorded at the
Physiotherapy centre
1,426 attendances were
recorded at the Dental
Clinic
9.7% decrease in OPD services
compared with 2012 figure of
149,230
19
20
Provide 24-Hour
General/Specialized
Out-Patient Services
OPD attendances recorded
at PHC/Health Centres:
Agogo PHC – 4,107
Assin Praso H/C – 30,997
Assin Nsuta H/C – 40,571
Enchi PHC – 33,741
Kom Clinic – 11,342
Kwahu Praso H/C – 25,919
Total: 146,677
24.1% increase in attendances
compared to the total figure of
118,212 recorded in 2012
Provide In-Patient
Services
12,930 admissions; 12,438
discharges; 380 deaths were
recorded in Agogo Hospital
6.9% increase in admissions
compared to 2012 figure of
12,092
Provide Laboratory
Services
84,556 laboratory
investigations were carried
out in Agogo Hospital
8,907 investigations were
recorded at Assin Praso
Health Centre
7,236 investigations carried
out at Enchi PHC
2.4% increased in laboratory
services in Agogo Hospital as
compared to 2012 figure of
82,582
20.3% increased access to
laboratory services at Assin
Praso and Enchi PHC
compared to 2012 total
recorded figure of 13,416
Provide X-Ray Services
A total of 7,056 x-ray
investigations were
recorded
21.9% increased access to x-
ray services compared to 2012
figure of 5,790
Provide Physiotherapy
Services
3,049 attendances were
recorded at the
Physiotherapy Centre
27.2% increase in attendance
over the 2012 figure of 2,397
21
Provide Surgical
Services
Surgeries performed:
642 major General Surgeries
1,569 minor General Surgeries
743 major O&G Surgeries
646 minor O&G Surgeries
746 major Eye Surgeries
113 minor Eye Surgeries
4,459 major and minor surgeries
A decrease of 2.1% in
access to surgical services
compared to 2012 figure
of 4,559
STRATEGY (V) Promote Nutrition Activities
Carry out Health
Education on Exclusive
Breast Feeding,
Complementary Feeding
and Micro Nutrient
Deficiency
Health education talks given
regularly at Antenatal Clinic
days by all facilities
Exclusive breastfeeding is
practised by most nursing
mothers
upgraded knowledge,
attitude and practice on
the part of mothers in the
use of locally available
food items
22
Carry out Cooking
Demonstrations
Cooking demonstrations
carried out on monthly basis
using local food items
Upgraded knowledge, attitude
and practice on the part of
mothers in the use of locally
available food items
STRATEGY (VI) Implement Special Programmes
Provide Eye Care
1,686 attendances at Eye
Clinic recorded at Enchi
PHC
17.2% decreased in eye care
services compared to the 2,037
recorded in 2012
Search for Buruli Ulcer
Cases at the Nodular
Stage – Agogo PHC
Buruli Ulcer cases identified
Nodular stage - 21
Plaque stage - 14
Oedema stage - 0
Ulcer stage – 12
10.5% increased in cases
detected at the nodular stage
(i.e. from 19 in 2012 to 21 in
2013)
Participate in Malaria
Vaccine Trial – Agogo
PHC
The third phase (MAL 055)
has ended with no adverse
effect seen
MAL 063 also begun in May
2012
MAL 055 final result is yet to
be published
MAL 063 is on-going
23
24
OBJECTIVE 2: IMPROVE QUALITY OF CARE
ACTIVITY OUTPUT OUTCOME
STRATEGY (I) Strengthen Existing Quality Assurance Programme Implementation
Draw and Implement
Quality Assurance
Action Plan on
Quarterly Basis
Yearly Quality Assurance action
plan drawn
Four (4) Quality Assurance
Team meetings held in the year
Two (2) Quality Assurance
reports discussed at IMC
meetings
Improved quality of care
Discuss Quality
Assurance Activity
Reports quarterly at
IMC meetings
25
Review Cases at
Accidents and
Emergency Department
every morning
All cases at Accident &
Emergency Department
reviewed by full Clinical Team
every morning from Monday to
Friday except ThursdaysImproved quality of care:
Improvement in
Neonatal Mortality Ratio
from 17.4 per 1,000 Life
Births in 2012 to 16.0 per
1,000 Life Births in 2013
Reduction of stillbirths
from 34.9 per 1,000 Births
in 2012 to 29.7 per 1,000
Births in 2013
Hold Weekly Clinical
Meetings36 clinical meetings held
Hold Monthly Mortality
Conferences/Audits
12 mortality conferences/audits
held
Hold Half-Yearly
Clinical Review
Meetings
2 clinical review meetings held
26
Conduct User
Satisfaction Survey
Twice a Year at all OPD
Units (General, Eye,
Antenatal, etc.) and
Inpatient Departments
and Disseminate Results
Agogo Hospital:
Two (2) surveys were conducted
Assin Praso H/C:
Two (2) surveys were conducted
Assin Nsuta H/C
One (1) survey was conducted
See APPENDIX I (a – f)
Standard level of clients
satisfaction maintained
Conduct Quarterly
Rational Drug Use
Survey
Four (4) Rational Drugs Use
survey were conducted
See APPENDIX II
Significant improvement in
prescription habit
STRATEGY (II) Update Staff Knowledge on Infection Prevention and Control and
Clinical Protocols
Organize In-Service
Training Workshop on
Infection Prevention and
Control
Five (5) members of staff
benefitted from a workshop on
Infection Prevention and
Control in Enchi PHC
Knowledge of staff in
infection prevention and
control improved
27
STRATEGY (III) Ensure Availability of Requisite Medical Equipment and
Logistics
Procure Requisite
Medical Equipment
Various types of medical
equipment purchased:
Agogo Hospital:
GH¢110,766.45
Assin Praso: GH¢21,700.00
Enchi PHC: GH¢9,530.00
Total: GH¢141,996.45
Improved tracer medical
equipment availability for
improved quality of care
Make Quarterly Bulk
Purchase of Basic Inputs
Total expenditure on drugs and
non-drugs medical consumables
as a percentage of total non-
wage expenditure for each
facility was:
Agogo Hospital: 68.9%
All other facilities: 60.2%
Adequate stocks of basic
inputs available in all
facilities almost at all times
28
STRATEGY (IV) Provide Additional Infrastructural Facilities
Construct Identified
Priority Infrastructure
Assin Nsuta
Construction of Nurses
Quarters: GHȼ12,187.00
Project on-going at roofing
level
Assin Praso H/C
Construction and mechanization
of borehole at a total cost of
GHȼ10,558.90
Continuous supply of
water for the facility
ensured
STRATEGY (V) Ensure Availability of Functioning Assets in all Facilities
Identify and Procure
Needed Assets
Agogo Hospital
One (1) Toyota Land Cruiser
Prado, Furniture, Medical
Equipment and Non-Medical
Equipment
Total: GHȼ325,244.40
Availability of needed
assets for improved quality
of care ensured
29
Identify and Procure
Needed Assets
Assin Praso H/C:
Furniture, Medical Equipment
and Non-Medical Equipment
Total: GHȼ22,286.00
Assin Nsuta H/C:
Non-Medial Equipment:
GHȼ2,900.00
Enchi PHC:
Furniture, Medical Equipment
and Non-Medical Equipment
Total: GHȼ14,730.00
Availability of needed
assets for improved quality
of care ensured
30
STRATEGY (VI) Organize In-Service Training
Draw and Organize
Training Plan
Agogo Hospital
327 various categories of staff
participated in six (6) different
in-service training workshops at
a total cost of GHȼ1,421.00
Assin Praso H/C
Exclusive Breast Feeding for
all category of staff
Quality Assurance Refresher
course for the Quality Assurance
Team
Other topics included: Jadelle
Insertion, Malaria in Pregnancy,
Medical Terminology and
Disease Coding, TB, Nutrition &
PMTCT
Improved human resource
capacity building for
improved quality of care
31
Draw and Organize
Training Plan
Enchi PHC
112 various category of staff
benefitted from 13 different
workshops in Tuberculosis,
PMTCT, Laboratory
Techniques, Obstetric and new
born care, Emergency care,
Quality Assurance, Procurement
and stock management, etc.
Improved human resource
capacity
STRATEGY (VII) Improve Infrastructure
Carry out Renovation of
Existing Structures
Agogo Hospital carried out the
following renovation works:
Conversion of Doors and
Windows to Aluminium Glazing
type
Conversion of KVIP into WCs
at the staff quarters
Repair of Underground Water
Tanks
Infrastructure modernized
32
Carry out Renovation of
Existing Structures
Completion of the Front View
Fence Wall
Conversion of the Houseman
Flat into two bungalows
Modernization of the
Pharmacy
Rehabilitation of Residential
Buildings
All at a total cost of
GHȼ225,067.78
Assin Praso H/C
Extension of OPD waiting
Area: GHȼ1,270.00
Enchi PHC
Renovation of Amonie and
Papueso Clinics: GHȼ6,239.00
Face lift of infrastructure
achieved and possible
prolonged useful life of
building
33
STRATEGY (VIII) Ensure Adequate Maintenance of Assets
Continue
Implementation of PPM
Schedules
Expenditure on maintenance of
assets as a percentage of non-
wage recurrent expenditure for
each facility was as follows:
Agogo Hospital: 4.8%
All other facilities: 5.2%
Maintenance of assets
ensured in the region of the
5% threshold of non-wage
recurrent expenditure
STRATEGY (IX) Improve Hospital/Customer/Community Relations
Hold Daily Education/
Interaction with Clients
at the OPD and in the
Wards
Daily education/interaction with
clients at OPD and on wards
held as part of daily morning
devotion
Improved hospital-client
relations
OTHER QUALITY OF CARE INDICATORS
COMPLICATED DELIVERIES
Number of Complicated Deliveries - 641
Caesarean Section - 584
Twin Deliveries - 57
CAUSES OF CAESAREAN SECTIONS
Compound Presentation - 19
Eclampsia - 9
Foetal Distress - 56
Cervical Dystocia - 4
Abruptio Placenta - 23
34
Placenta Praevia - 28
Antepartum Haemorrhage (APH) - 39
Face Presentation - 3
Post Maturity - 2
Cord Prolapse - 18
Elective C/S - 45
Previous C/S - 75
OPP - 10
Cephalopelvic Disproportion (CPD) - 83
Obstructed Labour - 17
Breech Presentation - 13
Pregnancy Induced Hypertension - 15
Foot Presentation - 4
Raptured Uterus - 71
Delayed 2nd Stage - 21
IUFD - 29
35
MATERNAL DEATHS
Number Recorded - 7 (All Audited)
CAUSES
Eclampsia - 3
Irrevesible shock 2° Sev. Haemorrhage
from a raptured uterus - 1
Acute pulmonary Oedeme 2° Sickle Cell
Cardiomyopathy - 1
Pulmonary Ebolism - 1
HIV Encephalopathy - 1
36
NEONATAL DEATHS
Number Recorded - 34
CAUSES
Prematurity - 16
Foetal Distress - 3
Neonatal Sepsis - 4
Severe Asphysia - 10
Broncho Pneumonia - 1
37
STILLBIRTHS
Number Recorded - 65
CAUSES
Preterm - 10
I U F D - 25
Cord Prolapse - 3
Delayed 2nd Stage - 4
Ruptured Uterus - 2
Breech Presentation - 10
Prolonged Labour - 3
Foetal Distress - 6
P I H - 2
38
MEASURES TO REDUCE MATERNAL DEATHS,
NEONATAL DEATHS AND STILLBIRTHS
• Intensify education on the need to refer cases early
• Regular interaction among the Hospital and referring institutions through
their District Directors of Health Services
• Involvement of Medical Superintendents of referring institutions in
Mortality Audits
• Continuous education by the PHC on the essence of antenatal and
postnatal attendances
• Enforce the use of Pathograph to monitor labour
• Increase staff strength (Midwives) and motivate them
39
MEASURES TO REDUCE MATERNAL DEATHS,
NEONATAL DEATHS AND STILLBIRTHS (Cont’d)
• Adequate stocking of the Blood Bank
2009 2010 2011 2012 2013
• No of pints of blood stocked: 1289 1634 1824 1796 1736
• No of pints of blood used: 1271 1633 1741 1640 1639
• Ensure availability at all times of adequate obstetric/gynaecological emergency
packs for:
• Antepartum Haemorrhage
• Pregnancy Induced Hypertension
• Eclampsia
• Retained Placenta
• Postpartum Haemorrhage
40
41
OBJECTIVE 3: IMPROVE FINANCIAL AND HUMAN RESOURCE
MOBILIZATION
ACTIVITY OUTPUT OUTCOME
STRATEGY (I) Strengthen Internal Income Generation System
Continue/Initiate
Income Generation
Activities
Agogo Hospital:
Mortuary Operations:
No. of bodies deposited:614
No. of bodies collected: 594
Total Revenue: GHȼ141,925.00
Total Exp.: GHȼ62,397.70
Gross Margin: GHȼ79,527.70
Hospital’s share of 45%:
GHȼ35,787.29
Agogo PHC:
GHȼ3,750.00 was realized from
the Unit’s Guest House
Additional income of
GHȼ35,787.29 was
available to the hospital for
utilization
42
Intensify Supervisory
Checks on Revenue
Collectors and Health
Insurance Billing
Officers
Institutional IGFs (GHȼ):
Agogo Hospital: 6,040,205.31
Agogo PHC: 241,651.25
Assin Praso H/C: 437,782.74
Assin Nsuta H/C: 606,810.50
Kwahu Praso H/C: 275,113.90
Enchi PHC: 604,398.43
Total: GHȼ8,205,962.13
10.7% increased in IGF
over 2012 total of
GHȼ7,409,983.79
Implement Development
Levy
GHȼ154,885.75 realized from
Development Levy – Agogo
Hospital
Additional income
available to the hospital for
developmental projects
STRATEGY (II) Provide Residential Accommodation for Staff
Rent Additional
Accommodation for
Staff
Agogo Hospital:
Accommodation was rented for
senior staff and other newly
posted staff at GHȼ33,986.39
Morale of beneficiary staff
boosted
43
STRATEGY (III) Recruit Needed Technical and Professional Staff and Ensure
Retention
Recruit Needed Staff to
fill vacancies
Staff recruited - Agogo Hospital:
1 Stenographer
2 Technical Officers
1 Physiotherapy/Orthotics
Assistant
10 Staff Nurses
1 Accounts Officer
1 Finance Officer
5 Midwives
1 Gynaecologist/Obstetrician
6 Community Health Nurses
14 Enrolled Nurses
1 Dental Technician
1 Driver
Improved technical/
professional staff strength
44
Identify and Recruit
Needed Staff
Assin Praso H/C
1 Physician Assistant
3 Comm. Health Nurses
2 Enrolled Nurses
1 Health Assistant
1 Laboratory Assistant
Enchi PHC
3 Health Extension Workers
2 Community Health Nurses
1 Biostatistics Records
Assistants
1 Physician Assistant
1 Enrolled Nurse
Improved staff strength
Reduced workload
45
Promote Deserving Staff
Staff promotions – Agogo
Hospital:
1 Prin. Nursing Officer
1 Senior Physiotherapist
1 Principal Accountant
2 Snr. Nursing Officers
21 Senior Staff Nurse
5 Senior Staff Midwife
1 Snr. Physician Assistant
(Anaesthesia)
2 Snr. Medical Assistant
(Medical)
2 Snr. Medical Officers
2 Snr. Pharmacy Technicians
Improved staff morale
46
Implement Existing
Incentive Packages for
Staff and Introduce
Feasible new ones
Expenditures on staff Internal
Allowances (GHȼ):
Agogo Hospital:
Rural Allow: 704,957.22
Locum Allow: 9,998.48
Call/Night Allow: 27,543.70
Snack Allow: 24,630.94
Parting Gift: 10,430.12
End of Year Bonus: 10,430.00
Total: GHȼ805,510.46
Improved staff morale
Staff shortage contained
47
Provide Uniform and
Protective Clothing to
Staff
Uniform provided at a total cost of
GHȼ6,615 for all category of staff in
Agogo Hospital
Staff morale boosted
Promote Staff
Development and
Growth through
Sponsorship with
Bonding
Agogo Hospital:
Training sponsorship or study leave
with pay provided for:
1 Snr. Lab Technician for BSc.
Medical Lab Technician (Sandwich)
2 Snr. Staff Nurse for Advanced
Diploma in Ophthalmic Nursing
1 Snr. Staff Nurse for Advanced
Diploma in Nurse Anaesthesia
1 Snr. Staff Nurse for Advanced
Diploma in Public Health
1 Snr. Health Aide for Diploma in
Dental Surgery Assistant (Sandwich)
Critical human resource
capacity building
embarked on
48
Promote Staff
Development and
Growth through
Sponsorship with
Bonding
Agogo Hospital:
Training sponsorship or study leave
with pay provided for:
1 Snr. Staff Nurse for Certificate in
Paediatric Nursing
1 Kitchen Supervisor for HND in
Hotel Catering and Institutional
Management
Enchi PHC:
Registered General Nurse – 3
Midwifery - 1
Critical human resource
capacity building
embarked on
49
OBJECTIVE 4: INCREASE EFFICIENCY IN RESOURCE UTILIZATION
ACTIVITY OUTPUT OUTCOME
STRATEGY (I) Prepare and Implement Plans and Budget
Prepare and Implement
Annual/Quarterly
Programme of Work
Based on Three Year
Strategic Plan
Annual and quarterly budgets
prepared
Performance of quarterly
budgets monitored on quarterly
basis by Income and
Expenditure Account to track
and analyse variances
Annual Income and Expenditure
Accounts prepared
Budget overruns checked
Income surplus of
GHȼ1,042,782.86 recorded
in 2013
50
Participate in Annual
Ministry of Health/
CHAG/GoG Plans and
Budget Preparation
Seminars
Two (2) seminars on Plan and
Budget preparation organized
by CHAG and MOH attended
by core budget team
Hospital budget captured
in CHAG and MOH
budgets
STRATEGY (II) Intensify Supervision, Monitoring and Evaluation
Prepare Activity
Reports Quarterly and
Discuss at all Heads of
Departments/IMC
Meeting
Three (3) out of four (4)
Quarterly Activity Reports
prepared and discussed at IMC
meetings
Improved supervision,
monitoring and evaluation
of hospital’s activities
Prepare Quarterly
Activity Reports for
Discussion by Area
Board
The first three quarters activity
reports prepared by all facilities
and discussed at Area Board
meetings
Improved supervision,
monitoring and evaluation
51
Participate Actively in
MOH/GHS Half-Year
and Annual
Performance Reviews
Regional GHS Half-Year and
Annual Performance Review
meetings attended by Hospital
DHMT Half-Year and Annual
Performance meetings attended
by each Health Centre and PHC
programme
Stewardship accounted to
MOH/GHS
52
STRATEGY (III) Improve the Existing Health Management Information System
Develop/Update Staff
Data Base on
Continuous Basis
Staff database updated on
continuous basis
Easy referencing, retrieval
and reporting on staff
Easy manpower budgeting
STRATEGY (IV) Strengthen Internal Communication
Hold Monthly IMC
Meetings
Agogo Hospital/PHC:
14 IMC meetings held to
discuss general management and
administrative issues
Three (3) out of fourteen (14)
IMC meetings held to discuss
Quarterly Activity Reports
Number of IMC meetings
attended by:
Assin Praso H/C: 6
Enchi PHC: 10
Team spirit enhanced
Emerging challenges
identified and dealt with
promptly
53
Hold Monthly General
Manager, Medical
Administrator and
Clinical in-charges
Meeting – Agogo
Hospital
Eight (8) out of twelve (12)
meetings held
Clinical Heads have
opportunity to contribute
to management decision
making processes
Inter-departmental
relationship and
complementation enhanced
Hold Quarterly Staff
Durbars/Meetings
Three (3) staff durbars were
held in Agogo Hospital
Assin Praso H/C: Five (5) staff
meeting held
Assin Nsuta H/C: Two (2) staff
meetings held
Enchi PHC: Two (2) staff
meetings held
Management/staff
interaction and mutual
trust promoted
Industrial harmony
maintained throughout the
year
54
Install Public Address
System (PAS) Linked to
all Departments/Units of
the Hospital
Public Address System installed
at the Medical Records
Ease of communication
between staff and patients
STRATEGY (V) Improve on Existing Procurement System
Make Available Policy
Guidelines and
Procedure for
Procurement
Policy Guidelines and Procedure
for procurement made availableProcurement streamlined
Hold Quarterly
Procurement Meeting
Three (3) procurement meetings
held at Agogo Hospital
Procurement Act adhered
for efficiency and
transparency
55
OBJECTIVE 5: IMPROVE MATERNAL AND CHILD HEALTH CARE
ACTIVITY OUTPUT OUTCOME
STRATEGY (I) Intensify Reproductive Health Care
Provide Focus Antenatal
Services
5,489 antenatal registrants
recorded in all facilities
5.1% decrease in antenatal
registrants compared to 2012
figure of 5,782
Conduct Supervised
Deliveries
A total of 3,142 supervised
deliveries conducted in all
facilities
5.5% decrease in supervised
deliveries compared to 2012
total of 2,978
Provide Postnatal
Services
2,833 postnatal registrants
recorded in all facilities
16.5% decrease in postnatal
registrants compared to 2012
total of 3,393
56
Run Child Welfare
Clinic (0 – 23 months)
7,878 registrants were
recorded in all facilities
15.5% increase in child welfare
services compare to 2012 total
of 6,820
Carry out School Health
Services
Agogo PHC: 4,181 pupils
examined
Assin Praso: No – 2,266
Assin Nsuta: No – 1,124
Minor illnesses were detected
and treated
Major illnesses referred to
hospital
Distribute Insecticide
Treated (Bed) Nets
(ITNs)
ITNs supplied and
distributed
Agogo PHC – 3,412
Beneficiaries had protection
against malaria
57
Distribute Vitamin “A”
Capsules to Postnatal
Mothers and Children
(6 – 59 months)
Vitamin “A” capsules
administered to children
Agogo PHC – 5,786
Assin Nsuta – 972
Assin Praso - 634
Prevention of morbidity and
mortality
Carry out Maternal
Mortality Audits and
give Feedback
Seven (7) Maternal deaths
recorded in Agogo Hospital,
all audited
Causes of the maternal deaths
were:
Eclampsia – 3, Irrevesible shock
2° Sev. Haemorrhage from a
raptured uterus – 1, Acute
pulmonary Oedeme 2° Sickle
Cell Cardiomyopathy – 1,
Pulmonary Ebolism – 1, HIV
Encephalopathy – 1
Provide Family
Planning Services
7,879 acceptors were
recorded in all facilities
50.8% increase in family
planning acceptor rate
compared to 2012 figure of
5,224
58
STRATEGY (II) Intensify Child Health Services
Provide Immunization
Services
Coverages recorded for the
various antigens were as
follows (2012 coverages in
brackets):
BCG: 124.0% (103.7%)
Measles: 140.6% (84.8%)
Penta III: 120.0% (90.0%)
OPV III: 122.7% (92.4%)
Y F: 113.0% (108.4%)
TT2++: 176.6% (128.0%)
Significant improvement over
2012 coverage
No vaccine preventable
disease was recorded in any of
the facilities
Feed Children on
Admission
All children on admission are
fed once a day at a total cost
of GHȼ10,578.00 – Agogo
Hospital Improved child health
services
Screening of the New-
Born within 48 Hours
All new-born babies screened
with 48 hours – Agogo
Hospital
59
STRATEGY (IV) Prepare for Obstetric Emergencies
Provide Obstetrics
Emergency Packs
Emergency packs available at
all times in adequate
quantities for:
Ante Partum Haemorrhage
Post Partum Haemorrhage
Pregnancy Induced
Hypertension
Eclampsia
Retained Placenta
Improved management of
obstetric emergencies
STRATEGY (V) Ensure Community Participation
Organize Community
Durbars
Three community durbars
were organized in three
different communities in
Assin Praso
Community participation in
RCH activities secured for
improved service delivery
60
OBJECTIVE 6: PREVENT AND CONTROL NON-COMMUNICABLE DISEASES
ACTIVITY OUTPUT OUTCOME
STRATEGY (I) Promote Non-Communicable Disease Control and Prevention
Establish/Run Non-
Communicable Disease
Clinics
23,808 attendances
recorded at Hypertensive
Clinic,
4,918 at Diabetic Clinic,
417 at Sickle Cell Clinic,
making a total of 29,143
attendances at non-
communicable disease
clinics at Agogo Hospital
6.1% decrease in attendances at
non-communicable disease
clinics compared to 2012 figure
of 31,042
61
OBJECTIVE 7: TO CONTROL THE INCIDENCE OF MALARIA, HIV/AIDS,
STI/TB TRANSMISSION AND OTHER COMMUNICABLE DISEASE
ACTIVITY OUTPUT OUTCOME
STRATEGY (I) Improve Disease Control and Prevention
Provide Health
Education
Assin Praso H/C:
Health education given:
Expired Products
Regenerative Health
Signs and Symptoms of
TB
Malaria Prevention
The Use of ITN
Child Survival
NID &
HIV Prevention
Increased awareness of disease
transmission, prevention and
control
Reduced disease burden
62
Provide Health
Education
Assin Nsuta H/C
Health education given:
Misconception about
family planning
Prevention of Cholera/
diarrhoea and management
Personal hygiene
Prevention of home
accident
Care of new born baby
Importance of
breastfeeding
Hand washing with soap
and clean water
Import of family planning
Benefit of facility delivery
Increased awareness of disease
transmission, prevention and
control
Reduced disease burden
63
Treat and Manage
Infected and Affected
People
Assin Nsuta H/C: 8 TB
Clients were referred from
Fosu Hospital for
supervision
Reduction in morbidity
Train CBSV on Current
Health Issues
Refresher course on Buruli
Ulcer for 40 CBSV and 30
Health Staff of Agogo PHS
Reduced disease burden
STRATEGY (II) Ensure Universal Precautionary Measures
Train Staff on Infection
Prevention and Control
Assin Praso H/C: All newly
engaged staff trained on
Infection Prevention and
Control
Enchi PHC: 5 staff trained
on infection prevention and
control
Reduced disease burden
64
STRATEGY (III) Promote Malaria and TB Control Programme
Follow Established
Treatment Guidelines on
Malaria and TB Control
Malaria:
Total number of lab confirmed
malaria cases at OPD: 15,656
Total number of admissions
due to lab confirmed malaria
cases (all ages): 1,855
Total number of deaths due to
lab confirmed malaria cases (all
ages): 16
Total number of admissions
due to malaria (<5 years): 1,200
Total number of deaths due to
malaria (<5 years): 9
Increased in laboratory
confirmed malaria
admissions (all ages) from
9.1% of total admissions in
2012 to 14.3% in 2013
65
Follow Established
Treatment Guidelines on
Malaria and TB Control
TB:
Total number of cases: 186
Cases under treatment: 75
Defaulters: 21
Deaths: 11
Treatment failure: 0
Transfer Out: 3
16.3% increase in
number of TB cases
compared to 160 in 2012
4.5% reduction in
defaulters rate compared
to 22 in 2012
Provide ITNs for All
Hospital Beds
All 223 beds in use in Agogo
Hospital have ITNs
All inpatients protected
against ward-acquired
malaria
Educate Clients on Daily
Basis at the OPD on
Malaria and TB
Prevention and Control
Daily morning devotion at OPD is
followed by health education of
clients on various topics including
malaria and TB prevention and
control
Clients knowledge on
malaria and TB
prevention and control
improved
66
OBJECTIVE 8: TO SPREAD THE GOSPEL THROUGH HEALTH SERVICE
DELIVERY
ACTIVITY OUTPUT OUTCOME
STRATEGY (I) Intensify Chaplaincy Activities
Make the Chaplain a
Member of the Clinical
Team – Agogo Hospital
Chaplain is an active
member of the clinical
team; takes part in daily
review of cases in the
Accident and Emergency
Department
Presence of the Chaplaincy
Department much felt in the
hospital through counselling of
clients
Draw and Implement a
Devotional Plan for
Clients and Staff
Yearly devotional plan
drawn for clients and staff,
Agogo Hospital
Number of Lay Preachers
enlisted: 16
Good News preached to
Patients/clients and staff on a
continuous basis to increase
their faith in the Lord
67
Draw and Implement a
Devotional Plan for
Clients and Staff
Number of devotional
services held for clients per
week:
Medical Ward: 5
Main OPD: 5
Eye OPD: 5
Antenatal Clinic: 2
Two (2) devotional services
held for staff per week in
the Hospital Chapel
Good News preached to
Patients/clients and staff on a
continuous basis to increase
their faith in the Lord
Carry out Daily Bedside
Visitations
Average number of Bedside
visitations per month by
Chaplain: 27
Theatre visitations by
Chaplain in the year: 2
Patients’ hope of recovery
boosted
Patients apprehension allayed
to undergo surgery
68
Organize Counselling
for Clients and Staff –
Agogo Hospital
Number of patients/clients
counselled during year: 8
Number of staff counselled
during year: 5
Alcoholic patients counselled
stopped drinking
Patients with suicidal
tendencies were helped to cope
with the difficulties they were
going through
Patients who declined surgery
initially were emboldened to
undergo the procedure
successfully
Organize End of Year
Carols Night Events
Carols night was
successfully organized on
20th December, 2013, at
Agogo Hospital
Impressive attendance by staff/
relatives and patients
The significance of Christmas
made real
69
Organize Social Support
for Needy Clients, Agogo
Hospital
Number of Needy Clients
supported: 5
Nature of support:
Free Treatment
Feeding
Transportation
Expenditure involved:
GHȼ2,684.00
Improved health of needy
clients
70
OBJECTIVE 9: IMPROVE COLLABORATION AND NETWORKING WITH
MOH/GHS/CHAG AND OTHER STAKEHOLDERS
ACTIVITY OUTPUT OUTCOME
STRATEGY (I) Deepen Existing Relations
Attend Quarterly
DHMT Meetings
DHMT meetings attended:
Agogo PHC: 4
Assin Nsuta H/C: 4
Sustained collaboration
Institutions kept up-to-date on
information from MOH/GHS
and vice-versa
Attend CHAG Annual
Delegates Meetings
CHAG Annual Delegates
conference attended by:
Agogo Hospital
Agogo PHC
Assin Praso H/C
Assin Nsuta H/C
Enchi PHC
Sustained collaboration
Institutions kept up-to-date on
information from CHAG
71
Attend Quarterly
General Manager’s
Meetings
Two (2) meetings were
attended by the General
Manager
Common challenges
discussed by all General
Managers for better service
delivery
Attend Association
Meetings for the various
Professional Groups
Annual meetings of the
following professional
groups/associations attended:
Pharmaceutical Society of
Ghana
Nurse Anaesthetist Group
Association of
Physiotherapists
Medical Assistants
Association
Paediatric Society of Ghana
Public Health Nurses Group
Staff updated on current
issues affecting their
respective professional
bodies for enhanced service
delivery
72
Collaborate with
Traditional Councils for
Quality Health Delivery
Traditional council still
represented on Area BoardSustained collaboration
Collaborate with
Malaria Vaccine Trial
Group
The third phase (MAL 055)
Has ended with no adverse
effect seen
MAL 063 also begun in May
2012
MAL 055 final result is yet
to be published
MAL 063 is on-going
30% of generator fuel cost
borne by Malaria Vaccine Trial
Group
Fuel cost burden lessened
73
Collaborate with
Foreign Partners for
Quality Health Delivery
The sixth seconded Doctor
(Dermatologist) from the
German Army started her six-
month tour of duty in July
Dermatological care
enhanced
Placement of eleven (11)
students from Medical Schools
in the Netherlands, Germany,
Australia, Switzerland,
England, for clinical elective
training
GHȼ4,090.00 realized from
clinical elective fee payments
Training successfully
completed
International recognition of
Agogo Hospital as
accredited centre for clinical
electives
74
Collaborate with
Foreign Partners for
Quality Health Delivery
Installation of donated
Transformer and Electrical
materials by Volketswil
Congregation, Switzerland,
through the collaborative
effort of the Ghana-Swiss
Technician Group completed
February 2013
Stable power supply ensured
Life span of Hospital
Equipment prolonged
Collaborate with
Training Institutions to
offer Practical Training
to Students
35 trainees from 25 training
institutions were given training
attachment/orientation by
Agogo Hospital
Contribution of hospital to
human resource
development of the country
OBJECTIVE: TO IMPROVE QUALITY OF CARE
Build Modern Toilet
for the OPD to replace
an old KVIP
Agogo HospitalLack of reliable source of water for the
project
Establish Assets
Replacement FundsAll Facilities
Cash flow problems throughout the
year as consequence of delayed
payment of health insurance claims
made this impossible
Build Staff
AccommodationAll Facilities Lack of funds
75
PLANNED ACTIVITIES NOT EXECUTED AND REASONS FOR NON-
PERFORMANCE
76
Complete the
Construction of the
new site to vacate the
current rented
premises
Assin Nsuta
Lack of funds
Agencies contacted did not respond
favourably to the request for financial
assistance
OBJECTIVE: INCREASE EFFICIENCY IN RESOURCE UTILIZATION
Establish LAN for
Clinical and Other
Relevant Departments
Agogo Hospital Project will commence early next year
Computerize Stores All Facilities Lack of funds
77
Carry out Yearly Peer
Review of PHS Sister
Institutions
Agogo Hospital
Exercise was not accorded priority
attention for 2013
Carry out Field Trips
to Facilities Acclaimed
as Centres of
Excellence
Undertake Annual
Management RetreatLack of funds
BIOSTATISTICS
SERVICE OUTPUTS
SERVICE
2013 TARGET 2013 ACTUAL
HOSP.
PHCs/
Health
Centres
TOTAL HOSP.
PHCs/
Health
Centres
TOTAL
OPD Attendance 155506 127348 282854 134758 146677 281435
Admissions 11208 - 11208 12930 - 12930
Surgical Op (Gen) 3500 - 3500 3366 - 3366
Surgical Op (Eye) 900 - 900 859 - 859
Sup. Deliveries 2080 829 2,909 2144 998 3142
Lab. Invest. 97592 21347 118939 84556 13855 98411
X-Ray Invest. 6800 - 6800 7056 - 7056
Ultrasound Inv. 3500 300 3800 4012 - 401278
SERVICE
2013 TARGET 2013 ACTUAL
HOSP.
PHCs/
Health
Centres
TOTAL HOSP.
PHCs/
Health
Centres
TOTAL
Antenatal Visits 13930 12000 25930 2092 3397 5489
Postnatal Visits 2130 1271 2520 1429 1404 2833
Neonatal Deaths - - - 34 - 34
Maternal Deaths - - - 8 - 8
Stillbirths - - - 65 - 65
Total Deaths - - - 380 - 380
HIV SCREENING: - - - -
Patients - - - 1038 - 1038
No. Positive - - - 226(21.8%) - 226(21.8%)
Donors - - - 2983 - 2983
No. Positive - - - 192(6.4%) - 192(6.4%)
Buruli Ulcer - - - 47 - 47
SERVICE OUTPUTS
79
OUTPATIENT ATTENDANCE - TREND
INSTITUTION 2009 (%) 2010 (%) 2011 (%) 2012 (%) 2013 (%)
Agogo Hospital
Assin Praso
Assin Nsuta
Kwahu Praso
Agogo PHC
Enchi PHC
Kom Clinic
125668 (60.2)
12544 (6.0)
18262 (8.8)
12693 (6.1)
4982 (2.4)
34467 (16.5)
-
167739 (58.4)
18733 (6.5)
42741 (14.9)
11706 (4.1)
4484 (1.6)
41944 (14.6)
-
144068 (52.7)
25250 (9.2)
51141 (18.7)
-
3225 (1.2)
49763 (18.2)
-
149230 (55.8)
24609 (9.2)
45007 (16.8)
-
3930 (1.5)
44666 (16.7)
-
134758(47.9)
30997 (11.0)
40571(14.4)
25919(9.2)
4107(1.5)
33741(12.0)
11342 (4.0)
TOTAL 208616 287347 273447 267442 28143580
OUTPATIENT ATTENDANCE - TREND
208616
287347273447 267442
281435
0
50000
100000
150000
200000
250000
300000
350000
2009 2010 2011 2012 2013
81
ADMISSIONS - TREND
INSTITUTION 2009 2010 2011 2012 2013
Agogo Hospital 9719 11449 11748 12092 12930
82
ADMISSIONS - TREND
0
2000
4000
6000
8000
10000
12000
14000
2009 2010 2011 2012 2013
9719
11449 11748 1209212930
83
ANTENATAL REGISTRANTS - TREND
INSTITUTION 2009 (%) 2010 (%) 2011 (%) 2012 (%) 2013 (%)
Agogo Hospital
Assin Praso
Assin Nsuta
Kwahu Praso
Agogo PHC
Enchi PHC
Kom Clinic
1784 (32.9)
844 (15.5)
559 (10.3)
383 (7.1)
727 (13.4)
1131 (20.8)
-
1985 (34.0)
680 (11.6)
803 (13.7)
384 (6.6)
423 (7.2)
1568 (26.8)
-
2067 (39.9)
747 (14.4)
835 (16.1)
-
443 (8.5)
1094 (21.1)
-
2216 (38.3)
616(10.7)
713(12.3)
-
596 (10.3)
1641 (28.4)
-
2092 (38.1)
604 (11.0)
726 (13.2)
-
594 (10.8)
1124 (20.5)
349 (6.4)
TOTAL 5428 5843 5186 5782 5489
84
ANTENATAL REGISTRANTS - TREND
4800
4900
5000
5100
5200
5300
5400
5500
5600
5700
5800
5900
2009 2010 2011 2012 2013
5428
5843
5186
5782
5489
85
SUPERVISED DELIVERIES - TREND
INSTITUTION 2009 (%) 2010 (%) 2011 (%) 2012 (%) 2013 (%)
Agogo Hospital
Assin Praso
Assin Nsuta
Kwahu Praso
Agogo PHC
Enchi PHC
Kom Clinic
1713 (62.7)
300 (11.0)
297 (10.9)
167 (6.1)
181 (6.6)
75 (2.7)
-
1906 (64.7)
324 (11.0)
303 (10.3)
138 (4.7)
156 (5.3)
118 (4.0)
-
2085 (64.9)
442 (13.8)
366 (11.4)
-
178 (5.5)
140 (4.4)
-
2099 (70.5)
286 (9.6)
246 (8.3)
-
234 (7.9)
113 (3.8)
-
2144 (68.2)
281 (8.9)
383 (12.2)
-
140 (4.5)
70 (2.2)
124 (3.9)
TOTAL 2733 2945 3211 2978 3142
86
SUPERVISED DELIVERIES - TREND
2400
2500
2600
2700
2800
2900
3000
3100
3200
3300
2009 2010 2011 2012 2013
2733
2945
3211
2978
3142
87
POSTNATAL REGISTRANTS - TREND
INSTITUTION 2009 (%) 2010 (%) 2011 (%) 2012 (%) 2013 (%)
Agogo Hospital
Assin Praso
Assin Nsuta
Kwahu Praso
Agogo PHC
Enchi PHC
Kom Clinic
1387 (43.5)
338 (10.6)
297 (9.3)
167 (5.2)
727 (22.8)
276 (8.6)
-
1420 (45.5)
345 (11.0)
358 (11.5)
338 (10.8)
180 (5.8)
482 (15.4)
-
1622 (50.0)
441 (13.6)
606 (18.7)
-
175 (5.4)
399 (12.3)
-
1521 (44.8)
307 (9.1)
345 (10.2)
-
687 (20.3)
533 (15.7)
-
1429 (50.4)
337 (11.9)
396 (14.0)
-
194 (6.8)
353 (12.5)
124 (4.4)
TOTAL 3192 3123 3243 3393 2833
88
POSTNATAL REGISTRANTS - TREND
2500
2600
2700
2800
2900
3000
3100
3200
3300
3400
2009 2010 2011 2012 2013
31923123
3243
3393
2833
89
REPRODUCTIVE AND CHILD HEALTH ACTIVITIES
(FAMILY PLANNING)
INSTITUTION 2009 (%) 2010 (%) 2011 (%) 2012 (%) 2013 (%)
Agogo PHC
Assin Praso
Assin Nsuta
Kwahu Praso
Enchi PHC
Kom Clinic
3238 (47.8)
818 (12.1)
883 (13.0)
1158 (17.1)
678 (10.0)
-
2074 (40.0)
342 (6.6)
912 (17.6)
1103 (21.3)
749 (14.5)
-
2334 (53.8)
450 (10.4)
1398 (32.2)
-
154 (3.6)
-
2630 (50.3)
1278 (24.5)
1044 (20.0)
-
272 (5.2)
-
2900 (35.8)
1535 (19.5)
829 (10.5)
-
541 (6.9)
2074 (26.3)
TOTAL 6775 5180 4336 5224 7879
90
REPRODUCTIVE AND CHILD HEALTH ACTIVITIES
(FAMILY PLANNING)
0
1000
2000
3000
4000
5000
6000
7000
8000
2009 2010 2011 2012 2013
6775
51804336
5224
7879
91
REPRODUCTIVE AND CHILD HEALTH ACTIVITIES
(CWC 0 – 23 MONTHS)
INSTITUTION 2009 (%) 2010 (%) 2011 (%) 2012 (%) 2013 (%)
Agogo PHC
Assin Praso
Assin Nsuta
Kwahu Praso
Enchi PHC
Kom Clinic
3238 (53.7)
729 (12.1)
657 (10.9)
976 (16.2)
434 (7.2)
-
3525 (55.8)
586 (9.3)
583 (9.2)
1060 (16.8)
565 (8.9)
-
3297 (71.2)
513 (11.1)
365 (7.9)
-
458 (9.9)
-
4528 (66.4)
542 (8.0)
776 (11.4)
-
974 (14.3)
-
4759 (60.4)
526 (6. 7)
379 (4.8)
-
1413 (17.9)
801 (10.2)
TOTAL 6034 6319 4633 6820 7878
92
REPRODUCTIVE AND CHILD HEALTH ACTIVITIES
(CWC 0 – 23 MONTHS)
0
2000
4000
6000
8000
2009 2010 2011 2012 2013
6034 6319
4633
6820
7878
93
SURGERIES – AGOGO HOSPITAL
TYPE 2009 2010 2011 2012 2013
General:
Major
Minor
821
1213
816
1297
628
1375
621
1375
642
1569
Sub-Total 2034 2113 2003 1996 2078
O & G:
Major
Minor
535
399
528
351
720
511
887
728
743
646
Sub-Total 934 879 1231 1615 1389
Eye:
Major
Minor
869
241
853
254
843
178
785
163
746
113
Sub-Total 1110 1107 1021 948 8 59
Grand Total 4078 4099 4255 4559 4326
94
SURGERIES - TREND
3800
3900
4000
4100
4200
4300
4400
4500
4600
2009 2010 2011 2012 2013
4078 4099
4255
4559
4326
95
LABORATORY INVESTIGATIONS - TREND
TYPE 2009 2010 2011 2012 2013
Serology
Biochemistry
Parasitology
Bacteriology
Haemotology
Others
18472
18700
23805
1595
30255
1424
22291
15274
28159
1182
31934
1821
20830
13897
21668
952
25666
2063
18768
16383
22423
788
22408
1812
19792
23742
21534
899
16667
1922
TOTAL 94251 100661 85076 82582 84556
96
LABORATORY INVESTIGATIONS - TREND
0
20000
40000
60000
80000
100000
120000
2009 2010 2011 2012 2013
94251100661
85076 82582 84556
97
X-RAY INVESTIGATIONS - TREND
TYPE 2009 2010 2011 2012 2013
Skull/Mandible/Sinuses
Chest
Upper Extremities
Lower Extremities
Abdomen
Hip & Pelvis
Spinal Column
Histerosalpingogram
222
3513
610
852
314
259
407
189
315
3579
708
769
345
424
539
188
242
3316
665
999
244
360
444
191
284
3018
670
718
240
261
433
166
283
3953
712
905
262
312
485
144
TOTAL 6366 6867 6461 5790 7056
98
X-RAY INVESTIGATIONS - TREND
0
1000
2000
3000
4000
5000
6000
7000
8000
2009 2010 2011 2012 2013
63666867
6461
5790
7056
99
ULTRASOUND INVESTIGATIONS - TREND
INSTITUTION 2009 2010 2011 2012 2013
Agogo Hospital 1531 1618 2380 4323 4012
100
ULTRASOUND INVESTIGATIONS - TREND
0
500
1000
1500
2000
2500
3000
3500
4000
4500
2009 2010 2011 2012 2013
1531 1618
2380
4323
4012
101
MORTALITY - TREND
TYPE 2009 2010 2011 2012 2013
Maternal Deaths
Stillbirths
Neonatal Deaths
All other Deaths
6
60
54
204
5
71
49
215
8
62
86
225
6
75
36
243
7
65
34
274
TOTAL 324 340 381 360 380
102
MORTALITY - TREND
290
300
310
320
330
340
350
360
370
380
390
2009 2010 2011 2012 2013
324
340
382
360
380
103
DEATHS BY CLINICAL DEPARTMENT
DEP’T 2009 (%) 2010 (%) 2011 (%) 2012 (%) 2013 (%)
A &E
Surgical
Medical
Obst./Gynae
Paediatrics
89 (27.5)
22 (6.8)
109 (33.6)
7 (2.2)
97 (29.9)
96 (28.2)
25 (7.4)
112 (32.9)
5 (1.5)
102 (30.0)
106 (27.8)
9 (2.4)
120 (31.5)
9 (2.4)
137 (36.0)
84 (23.3)
41 (11.4)
118 (32.8)
8 (2.2)
109 (30.3)
94 (24.7)
15 (3.9)
166 (43.7)
9 (2.4)
96 (25.3)
TOTAL 324 340 381 360 380
104
MALARIA CASES - AGOGO HOSPITAL
OUT-PATIENT DEPARTMENT
2009 2010 2011 2012 2013
Total No. of Cases
Total No. of Cases < 5 yrs
% of Cases < 5 yrs
15423
3632
23.6
17117
4245
24.8
15475
3745
24.2
13165
3525
26.8
15656
4058
25.9
105
MALARIA CASES - AGOGO HOSPITAL
IN-PATIENT DEPARTMENT (ADMISSIONS)
2009 2010 2011 2012 2013
Total No. of Cases
Total No. of Cases < 5 yrs
% of Cases < 5 yrs
2441
1229
50.4
2304
1247
54.1
1639
941
57.4
1099
629
57.2
1855
1200
64.7
106
MALARIA CASES - AGOGO HOSPITAL
DEATHS
2009 2010 2011 2012 2013
Total No. of Deaths
Total No. of Deaths < 5 yrs
% of Deaths < 5 yrs
18
13
72.2
7
4
57.1
12
8
66.7
8
7
87.5
16
9
56.3
107
TUBERCULOSIS - AGOGO HOSPITAL
2009 2010 2011 2012 2013
Total No. of Cases
Cases Under Treatment
Defaulters
Deaths
Treatment Failure
Relapses
Transfer Out
Cure
Completed
119
62
12
6
-
9
3
-
-
156
51
37
9
1
-
2
-
-
154
51
32
12
2
12
2
16
41
160
95
22
4
1
-
1
9
28
186
75
21
11
-
-
3
22
54
108
EXPANDED PROGRAMME ON IMMUNIZATION (EPI) COVERAGE
B C G
TARGET
POP
NO.
IMM.
%
COV.
AGOGO PHC 2164 2574 118.95
ASSIN PRASO 339 319 94.10
ASSIN NSUTA 477 470 98.53
KOM CLINIC 112 177 158.04
ENCHI357
536 150.14
109
-
20.0
40.0
60.0
80.0
100.0
120.0
140.0
160.0
PERCENTAGE IMMUNIZED
150.6
82.2
101.1
158.0
81.0
AGOGO PHC
ASSIN PRASO
ASSIN NSUTA
KOM CLINIC
ENCHI
110
EXPANDED PROGRAMME ON IMMUNIZATION (EPI) COVERAGE
MEASLES
TARGET
POP
NO.
IMM.
%
COV.
AGOGO PHC 2164 1991 92.9
ASSIN PRASO 339 246 72.57
ASSIN NSUTA 477 344 72.12
KOM CLINIC 112 347 309.82
ENCHI 357 556 155.74
111
-
50.0
100.0
150.0
200.0
250.0
300.0
350.0
PERCENTAGE IMMUNIZED
103.9
58.3
97.4
309.8
87.4
AGOGO PHC
ASSIN PRASO
ASSIN NSUTA
KOM CLINIC
ENCHI
112
EXPANDED PROGRAMME ON IMMUNIZATION (EPI) COVERAGE
PENTA III
TARGET
POP
NO.
IMM.
%
COV.
AGOGO PHC 2164 2062 95.29
ASSIN PRASO 339 226 66.67
ASSIN NSUTA 477 406 85.12
KOM CLINIC 112 234 208.93
ENCHI 357 515 144.26
113
-
50.0
100.0
150.0
200.0
250.0
PERCENTAGE IMMUNIZED
100.3
74.3
92.5
208.9
92.8
AGOGO PHC
ASSIN PRASO
ASSIN NSUTA
KOM CLINIC
ENCHI
114
EXPANDED PROGRAMME ON IMMUNIZATION (EPI) COVERAGE
OPV 3
TARGET
POP
NO.
IMM.
%
COV.
AGOGO PHC 2164 2062 95.29
ASSIN PRASO 339 234 69.03
ASSIN NSUTA 477 406 85.12
KOM CLINIC 112 234 208.93
ENCHI 357 554 155.18
115
-
50.0
100.0
150.0
200.0
250.0
PERCENTAGE IMMUNIZED
100.3
75.0
101.3
208.9
92.8
AGOGO PHC
ASSIN PRASO
ASSIN NSUTA
KOM CLINIC
ENCHI
116
EXPANDED PROGRAMME ON IMMUNIZATION (EPI) COVERAGE
YELLOW FEVER
TARGET
POP
NO.
IMM.
%
COV.
AGOGO PHC 2164 1991 92.01
ASSIN PRASO 339 247 72.86
ASSIN NSUTA 477 344 72.12
KOM CLINIC 112 193 172.32
ENCHI 357 556 155.74
117
-
20.0
40.0
60.0
80.0
100.0
120.0
140.0
160.0
180.0
PERCENTAGE IMMUNIZED
103.9
144.8
97.4
172.3
87.4
AGOGO PHC
ASSIN PRASO
ASSIN NSUTA
KOM CLINIC
ENCHI
118
EXPANDED PROGRAMME ON IMMUNIZATION (EPI) COVERAGE
T T 2
TARGET
POP
NO.
IMM.
%
COV.
AGOGO PHC 2164 3159 145.98
ASSIN PRASO 339 684 201.77
ASSIN NSUTA 477 762 159.75
KOM CLINIC 112 - -
ENCHI 357 710 198.88
119
-
20.0
40.0
60.0
80.0
100.0
120.0
140.0
160.0
180.0
PERCENTAGE IMMUNIZED
167.6
55.0
163.9
-
125.6
AGOGO PHC
ASSIN PRASO
ASSIN NSUTA
KOM CLINIC
ENCHI
120
BED UTILIZATION INDICES - AGOGO HOSPITAL
INDEX 2009 2010 2011 2012 2013
Average Daily Bed
Occupancy164 163 167 165 164
Occupancy Rate 73.4% 73.1% 75.1% 74.0% 73.4
Average Length of Stay 6 Days 5 Days 5 Days 5 Days 5 Days
Turnover Per Bed 43 Pts 51 Pts 52 Pts 54 Pts 58 Pts
Turnover Interval 2 Days 2 Days 2 Days 2 Days 2 Days
Death Rate 3.4% 3.0% 3.3% 3.0% 3.0%
121
MORBIDITY AND MORTALITY STATISTICS
TOP TEN (10) OPD CASES – AGOGO HOSPITAL
NO.
2012 2013
DISEASENO. OF
CASES
% OF
ALL
CASES
DISEASENO. OF
CASES
% OF
ALL
CASES
1 Malaria 13165 9.15 Malaria 15491 13.90
2 Acute Eye Infection 12129 8.43 Cough/Cold (URTI) 9535 8.56
3 Cough & Cold (URTI) 10415 7.24 Acute Eye Infections 6312 5.66
4 Gynae. Conditions 4291 2.98 Gynecological Conditions 4146 3.72
5 U. T. I. 4130 2.87 Acute Urinary Tract Inf. 4028 3.61
6 P. U. D. 3670 2.55 PUD 3662 3.29
7 Skin Diseases & Ulcer 2752 1.91 Skin Diseases & Ulcers 2801 2.51
8 Preg. & Related 2486 1.73 Acute Ear Infection 1566 1.41
9 Lower Abdominal Pain 2052 1.43 Anaemia 1456 1.31
10 Road Traffic 1489 1.03 Lower Abdominal Pain 1452 1.30
122
TOP TEN (10) CAUSES OF ADMISSION – AGOGO HOSPITAL
NO.
2012 2013
DISEASENO. OF
CASES
% OF
ALL
CASES
DISEASENO. OF
CASES
% OF
ALL
CASES
1 Malaria 1397 10.78 Malaria 1977 15.77
2 Skin Diseases & Ulcer 919 7.09 Gynecological Cond. 720 5.74
3 Hypertension 777 6.00 Hypertension 701 5.59
4 Gynae. Conditions 604 4.66 Skin Diseases & Ulcers 642 5.12
5 Cataract 586 4.52 Cataract 630 5.03
6 Septicaemia 502 3.87 Septicaemia 554 4.42
7 Pneumonia 502 3.87 Preg. Related Compl. 527 4.20
8 Preg. & Related 492 3.80 Severe Pneumonia 489 3.90
9 Prematurity 442 3.41 Anaemia 358 2.86
10 Anaemia 388 2.99 Malnutrition 303 2.42
123
TOP TEN (10) COMMUNICABLE – AGOGO HOSPITAL
NO.
2012 2013
DISEASENO. OF
CASES
% OF
ALL
CASES
DISEASENO. OF
CASES
% OF
ALL
CASES
1 Malaria 13165 93.64 Malaria 15491 94.28
2 HIV/AIDS 439 3.12 HIV/AIDS 355 2.16
3 Viral Hepatitis 187 1.33 Tuberculosis 240 1.46
4 Chicken Pox 122 0.87 Viral Hepatitis 162 0.99
5 Buruli Ulcer 52 0.37 Chicken Pox 89 0.54
6 Tuberculosis 31 0.22 Buruli Ulcer 36 0.22
7 Schistosomiasis 26 0.18 Typhoid Fever/Perf. 26 0.16
8 Typhoid Fever/Perf. 16 0.11 Measles 10 0.06
9 Intestinal Worm 16 0.11 Schistosomiasis 9 0.05
10 Other Meningitis 5 0.04 Intestinal Worm 9 0.05
124
TOP TEN (10) CAUSES OF DEATH – AGOGO HOSPITAL
NO.
2012 2013
DISEASENO. OF
CASES
% OF
ALL
CASES
DISEASENO. OF
CASES
% OF
ALL
CASES
1 Pneumonia 54 15.00 Sev. Pneumonia 45 11.84
2 Anaemia 23 6.39 Septicaemia 35 9.21
3 Liver Cirrhosis 23 6.39 Anaemia 29 7.63
4 Tuberculosis 20 5.56 Tuberculosis 27 7.11
5 C V A 19 5.28 Liver Cirrhosis 22 5.79
6 Cardiac Diseases 17 4.72 HIV/AIDS 20 5.26
7 Prematurity 15 4.17 Cardiac Diseases 17 4.47
8 HIV/AIDS 14 3.89 Severe Malaria 16 4.21
9 Malaria 12 3.33 C V A 16 4.21
10 Hypertension 9 2.50 Prematurity 15 3.95
125
CASE FATALITY RATE – AGOGO HOSPITAL
NO
2012 2013
DISEASE RATE DISEASE RATE
1 Pneumonia 10.76 Sev. Pneumonia 56.25
2 Anaemia 5.93 Septicaemia 6.32
3 Liver Cirrhosis 40.35 Anaemia 8.10
4 Tuberculosis 14.18 Tuberculosis 14.10
5 C V A 8.48 Liver Cirrhosis 28.95
6 Cardiac Diseases 24.64 Hiv/Aids 10.58
7 Prematurity 3.39 Cardiac Diseases 45.95
8 HIV/AIDS 8.05 Severe Malaria 0.81
9 Malaria 0.86 C V A 6.72
10 Hypertension 1.16 Prematurity 15.15
126
MORTALITY RATIOS – AGOGO HOSPITAL
2009 2010 2011 2012 2013
Maternal Mortality (per 100,000
Life Births)414 264 381 290 329
Neonatal Mortality (per 1,000 Life
Births)32.0 25.9 40.9 17.4 16.0
Stillbirths (per 1,000 Births) 34.3 36.2 28.7 34.9 29.7
Death Rate (% of all Admissions) 3.4 3.0 3.3 3.0 3.0
127
OTHER PERFORMANCE INDICATORS
UTILIZATION INDICATORS – AGOGO HOSPITAL
INDICATOR 2009 2010 2011 2012 2013
OPD COVERAGE: OPD
visits per capita0.74 0.94 0.78 0.79 1.72
INPATIENT COVERAGE:
Hospital Admissions per
1000 – coverage population
56.88 64.80 64.30 63.64 165.37
PROPORTION of Hospital
Deliveries as a % of
Expected Deliveries in
Catchment Population
25.08 27.02 28.50 27.62 11.82
128
INDICATOR 2009 2010 2011 2012 2013
Average Monthly
Admissions per Doctor43 50 52 53 49
Average Patient-Day
Equivalents per Nurse per
Day
2.61 2.93 1.70 1.68 1.90
Average Patient-Day
Equivalents per Staff
Member per Day
0.72 0.82 0.58 0.57 0.33
WORKLOAD INDICATORS – AGOGO HOSPITAL
129
QUALITY INDICATORS – AGOGO HOSPITAL
INDICATOR 2009 2010 2011 2012 2013
CAESARIAN COVERAGE:
Caesarian Sections as a % of
total expected deliveries in
catchment area
5.6 6.4 6.2 8.1 3.2
LABORATORY TEST:
Per Admission
Per 3 OPD Visits9.7
2.3
8.8
1.8
7.2
1.8
6.8
1.7
6.5
1.9
X-RAYS:
Per Admission
Per 3 OPD Visits
0.7
0.2
0.6
0.1
0.5
0.1
0.48
0.12
0.55
0.16
Ratio of Surgical Cases per
Admission0.4 0.4 0.4 0.38 0.34
130
FINANCE
INCOME & EXPENDITURE ACCOUNT
INCOME ITEMS
2013 BUDGET (GH¢) 2013 ACTUAL (GH¢)
HOSPITAL
PHCS/
HEALTH
CENTRES
TOTAL HOSPITAL
PHCS/
HEALTH
CENTRES
TOTAL
Govt. Subvention:
Salaries/Allow. 6,000,000.00 494,113.00 6,494,113.00 5,939,123.40 529,636.28 6,468,759.68
Service/Adm - 9,975.60 9,975.60 - 3,809.60 3,809.60
Electricity 80,0000.00 - 80,0000.00 - - -
Water 15,000.00 - 15,000.00 - - -
Fees/Other Charges 2,295,725.00 644,141.85 2,939,866.85 2,550,802.49 759,180.00 3,309,982.59
Sale of Drugs 3,050,000.000 1,008,400.00 4,058,400.63 3,261,848.39 1,159,213.26 4,421,061.65
Local Donations 22,000.00 23,600.00 45,600.00 15,624.40 29,750.59 45,374.40
Part/Fri. Overseas 10,000.00 29,004.64 39,004.64 600.00 11,700.59 12,300.59
Miscellaneous 211,500.00 12,666.65 224,166.65 227,554.43 247,363.46 474,917.89
TOTAL 11,684,225.00 2,221,902.37 13,906,127.37 11,995,553.11 2,740,653.29 14,736,206.40
131
Salaries/Allow.
43.90%
Service/Adm
0.03%
Fees/Other
Charges
22.46%
Sale of Drugs
30.00%
Local Donations
0.31%
Part/Fri.
Overseas
0.08%
Miscellaneous
3.22%
INCOME
132
EXPENDITURE
ITEMS
2013 BUDGET (GH¢) 2013 ACTUAL (GH¢)
HOSPITAL
PHCS/
HEALTH
CENTRES
TOTAL HOSPITAL
PHCS/
HEALTH
CENTRES
TOTAL
Govt. Sal./Allow. 6,000,000.00 494,113.00 6,494,113.00 5,939,123.40 529,636.28 6,468,759.68
Church Sal./Allow. 1,541,849.50 440,147.86 1,981,997.36 1,690,673.82 405,560.09 2,096,233.91
Staff Med. Subsidy 11,600.00 8,573.08 20,173.08 20,278.58 1,057.20 21,335.78
P & S Subsidy 9,060.00 4,772.48 13,832.48 10,578.00 3,183.90 13,761.90
Drugs 1,823,000.00 887,083.52 2,710,083.52 1,827,474.97 671,975.62 2,499,450.59
Med. Consumables 872,625.00 172,584.44 1,045,209.44 780,159.85 135,633.69 915,793.54
Maint. (Assets) 211,300.00 18,781.49 230,081.49 180,559.51 69,186.80 249,746.31
Fuel & Lubricants 86,000.00 44,025.20 130,025.20 93,016.60 44,721.70 137,738.30
Staff Trg. & Dev. 43,400.00 27,889.55 71,289.55 58,972.50 10,975.00 69,947.50
Utilities 63,175.00 20,108.15 83,283.15 29,329.06 5,947.22 35,276.28
Miscellaneous 538,096.50 262,071.02 800,167.52 517,670.88 201,237.85 718,908.73
Depreciation of Assets - - - 268,056.09 198,414.93 466,471.02
TOTAL 11,200,106.00 2,380,149.79 13,580,255.79 11,415,893.26 2,277,530.28 13,693,423.54
SURPLUS/DEFICIT 484,119.00 -158,247.42 325,871.58 579,659.85 463,123.01 1,042,782.86
133
Govt. Sal./Allow. 47.24%
Church Sal./Allow.
15.31%
Staff Med. Subsidy 0.16%
P & S Subsidy 0.10%
Drugs 18.25%
Med. Consumables
6.69%
Maint. (Assets) 1.82%
Fuel & Lubricants
1.01%
Staff Trg. & Dev. 0.51%
Utilities 0.26% Miscellaneous
5.25%Depreciation of
Assets 3.41%
EXPENDITURE
134
INCOME ITEM BUDGET ACTUAL
VARIANCE
AMOUNT %
Govt. Subvention:
Salaries/Allow. 6,494,113.00 6,468,759.00 -25,353.32 -0.39
Service/Adm 9,975.60 3,809.60 -6,166.00 -61.81
Electricity 80,000.00 - -80,000.00 -100.00
Water 15,000.00 - -15,000.00 -100.00
Fees/Other Charges 2,939,866.85 3,309,982.59 370,115.74 12.59
Sale of Drugs 4,058,400.63 4,421,061.65 362,661.02 8.94
Local Donations 45,600.00 45,374.40 -225.60 -0.49
Part/Fri. Overseas 39,004.64 12,300.59 -26,704.05 -68.46
Miscellaneous 224,166.65 474,917.89 250,751.24 111.86
TOTAL 13,906,127.37 14,736,206.40 830,079.03 5.97
135
EXPENDITURE ITEM BUDGET ACTUALVARIANCE
AMOUNT %
Govt. Sal./Allow. 6,494,113.00 6,468,759.68 25,353.32 0.39
Church Sal./Allow. 1,981,997.36 2,096,233.91 -114,236.55 -5.76
Staff Med. Subsidy 20,173.08 21,335.78 -1,162.70 -5.76
P & S Subsidy 13,832.48 13,761.90 70.58 0.51
Drugs 2,710,083.52 2,499,450.59 210,632.93 7.77
Med. Consumables 1,045,209.44 915,793.54 129,415.90 12.38
Maint. (Assets) 230,081.49 249,746.31 -19,664.82 -8.55
Fuel & Lubricants 130,025.20 137,738.30 -7,713.10 -5.93
Staff Trg. & Dev. 71,289.55 69,947.50 1,342.05 1.88
Utilities 83,283.15 35,276.28 48,006.87 57.64
Miscellaneous 800,167.52 718,908.73 81,258.79 10.16
Depreciation - 466,471.02 -466,471.02
TOTAL 13,580,255.79 13,693,423.54 -113,167.75 -0.83
SURPLUS/DEFICIT 325,871.58 1,042,782.86 716,911.28 219.9
136
DESCRIPTION INSTITUTIONAMOUNT
(GH¢)
SOURCE OF
FUNDING
Constructional Works
(Rehabilitation)
Agogo Hospital
Assin Praso H/C
Enchi PHC
225,067.78
1,270.00
6,239.00
IGF
IGF
IGF
SUB-TOTAL 232,576.78
Constructional Works
(New Projects)
Assin Nsuta H/C
Assin Praso H/C
12,187.00
10,558.90
IGF
IGF
SUB-TOTAL 22,745.90
SUMMARY OF DEVELOPMENT EXPENDITURE
137
Acquisition of New
Medical Equipment
Agogo Hospital
Assin Praso H/C
Enchi PHC
110,766.45
21,700.00
9,530.00
IGF
IGF
IGF
SUB-TOTAL 141,996.45
Acquisition of Non-
Medical Equipment/
Plant
Agogo Hospital
Assin Praso H/C
Assin Nsuta H/C
Enchi PHC
77,358.45
230.00
2,900.00
5,000.00
IGF
IGF
IGF
IGF
SUB-TOTAL 85,488.45
138
Major Rehabilitation of
Equipment, Plants,
Vehicles
Agogo Hospital 153,978.81 IGF
SUB-TOTAL 153,978.81
Acquisition of New
VehiclesAgogo Hospital 121,920.00 IGF
SUB-TOTAL 121,920.00
Acquisition of Furniture
Agogo Hospital
Assin Praso H/C
Enchi PHC
15,199.50
356.00
200.00
IGF
IGF
IGF
SUB-TOTAL 15,755.50
GRAND TOTAL 774,461.86
139
OPERATIONAL EFFICIENCY INDICATORS
AGOGO HOSPITAL2009
(GH¢)
2010
(GH¢)
2011
(GH¢)
2012
(GH¢)
2013
(GH¢)
Average Revenue per
OPD Attendance
Average Expenditure
per OPD Attendance
Margin
Average Revenue per
In-Patient Day
Average Expenditure
per In-Patient Day
Margin
10.65
9.74
0.91 (9.3%)
31.94
29.21
2.73 (9.3%)
9.82
8.55
1.27 (14.9%)
29.46
25.66
3.80 (14.8%)
23.82
20.14
3.68 (15.5%)
71.45
60.41
11.03 (15.4%)
50.62
48.20
2.42 (5.0%)
151.87
144.60
7.27 (5.0%)
69.12
65.78
3.34 (5.1%)
207.36
197.34
10.02(5.1%)
140
OPERATIONAL EFFICIENCY INDICATORS
141
ASSIN PRASO H/C2009
(GH¢)
2010
(GH¢)
2011
(GH¢)
2012
(GH¢)
2013
(GH¢)
Average Revenue per OPD
Attendance
Average Expenditure per
OPD Attendance
Margin
9.34
4.88
4.46
(91.4%)
9.94
7.43
2.51
(33.8%)
11.83
3.99
7.84
(66.2%)
18.81
10.57
8.24
(78.0%)
22.57
18.79
3.78
(20.1%)
OPERATIONAL EFFICIENCY INDICATORS
142
ASSIN NSUTA H/C2009
(GH¢)
2010
(GH¢)
2011
(GH¢)
2012
(GH¢)
2013
(GH¢)
Average Revenue per OPD
Attendance
Average Expenditure per
OPD Attendance
Margin
9.28
8.44
0.84
(47.5%)
8.50
6.30
2.20
(34.9%)
9.92
7.64
2.26
(22.8%)
16.60
14.47
2.13
(14.7%)
19.54
16.43
3.11
(18.9%)
OPERATIONAL EFFICIENCY INDICATORS
143
KWAHU PRASO H/C2009
(GH¢)
2010
(GH¢)
2011
(GH¢)
2012
(GH¢)
2013
(GH¢)
Average Revenue per
OPD Attendance
Average Expenditure per
OPD Attendance
Margin
-
-
-
4.16
5.78
(1.62)
-
-
-
-
-
-
10.61
7.61
3.0
(39.4%)
144
OPERATIONAL EFFICIENCY INDICATORS
ENCHI PHC2009
(GH¢)
2010
(GH¢)
2011
(GH¢)
2012
(GH¢)
2013
(GH¢)
Average Revenue per
OPD Attendance
Average Expenditure per
OPD Attendance
Margin
9.81
8.99
0.82
(9.1%)
8.28
13.94
-5.66
(-41.6)
20.46
13.40
7.06
(34.5%)
17.25
13.38
3.87
(28.9%)
18.02
20.01
-1.99
(-9.9%)
IMPLEMENTATION OF NATIONAL HEALTH INSURANCE
SCHEME
AGOGO HOSPITAL/EYE
Total No. of Cases
No. of Insured Cases
% of Insured Patients
Total IGF
Revenue from Insured
As a % of IGF
Total Reimbursement
Outstanding Reimbursement
134,758
123,136
91.4
GHȼ6,040,205.31
GHȼ4,291,702.23
71.1
GHȼ3,203,190.20
GHȼ1,088,512.03
145
IMPLEMENTATION OF NATIONAL HEALTH INSURANCE
SCHEME
146
ASSIN PRASO HEALTH CENTRE
Total No. of Cases
No. of Insured Cases
% of Insured Patients
Total IGF
Revenue from Insured
As a % of IGF
Total Reimbursement
Outstanding Reimbursement
30,997
27,274
88.0
GHȼ437,782.74
GHȼ380,184.79
86.8
GHȼ252,721.48
GHȼ127,463.31
IMPLEMENTATION OF NATIONAL HEALTH INSURANCE
SCHEME
147
ASSIN NSUTA HEALTH CENTRE
Total No. of Cases
No. of Insured Cases
% of Insured Patients
Total IGF
Revenue from Insured
As a % of IGF
Total Reimbursement
Outstanding Reimbursement
40,571
37,750
93.0
GHȼ606,810.50
GHȼ454,766.12
74.9
GHȼ271,459.71
GHȼ183,306.41
IMPLEMENTATION OF NATIONAL HEALTH INSURANCE
SCHEME
148
ENCHI PHC
Total No. of Cases
No. of Insured Cases
% of Insured Patients
Total IGF
Revenue from Insured
As a % of IGF
Total Reimbursement
Outstanding Reimbursement
33,741
31,757
94.1
GHȼ604,398.43
GHȼ405,262.89
67.1
GHȼ196,277.99
GHȼ208,984.90
AGOGO HOSPITAL
Acquisition of a Brand new Land Cruiser Prado
Establishment of a Dental Clinic
Renovation and extension of the Houseman flat to convert into a twin
bungalow to house two families
Repair works at the children’s ward which included roof leakages,
replacement of locks, louvre blades and frames, mosquito nets and
repair of cabinets
Renovation of Eye Theatre & Eye Ward by installation of glazing
windows and glass swing doors
149
MAIN ACHIEVEMENTS
150
AGOGO HOSPITAL
• On-going massive renovation of the Pharmacy block into an ultra-
modern facility (about 70% complete)
• Changing of Laboratory windows and doors to a glazing type and
swing door to meet international standards
• Donation of a mobile ultrasound machine worth €3,500.00 by Dr.
Lutz
• Donation of assorted medical equipment through the MoH
Equipment Replacement Programme
151
AGOGO PHC
• Staff actively participating in the malaria vaccine trial
• Buruli Ulcer cases reduced by 30%
• A new outreach point has been opened at Hwidiem to increase CWC
coverage
• Community Health Officers have been assigned to each electoral
area in Agogo. This has intensified School Health Activities and
Home Visits to trace defaulters
152
ASSIN PRASO HEALTH CENTRE
• Posting of Physician Assistant from CHAG to improve staffing
and to reduce workload on the sole Retired Physician assistant.
• Drilling and Mechanization of Borehole offering the facility self
sufficiency in water supply
• Acquisition of ultrasound machine to improve service delivery
• Major maintenance works on facility buildings
• Donation of medical equipment from USAid worth GH¢3,885.00
153
KWAHU PRASO HEALTH CENTRE
• Completion of Staff Bungalow for the Physician Assistants
• Acquisition of a Generator for the Centre
• Running of Eye Outreach Program with Agogo Presby Hospital
• Completion of staff bungalow and acquisition of laboratory
equipment through the support of Agogo Hospital
• Creation of a male ward and furnished with new hospital beds,
side lockers, etc
• Painting of all buildings of the facility
• Purchase of a new modern delivery bed for the maternity
154
ASSIN NSUTA HEALTH CENTRE
• Construction of nurses’ quarter in progress
• Construction of a pavilion to reduce congestion at the CWC
• Improved staff strength as two Health Assistants have been
posted to the facility
155
ENCHI PHC
• Posting of a Disease Control Officer and an Enrolled Nurse
• Purchase of a slit lamp for the eye unit
• Renovation of Amonie Presby Clinic completed and ready for
use
156
KOM CLINIC
• Average daily OPD attendance improved from 30 to 100 due to
the posting of a Physician Assistant to the clinic
• Kom Clinic in collaboration with Agogo Hospital Eye Unit
undertook 50 eye surgeries and 547 eye OPD attendances under
the outreach programme
• Payment of electricity bill by government as a financial relief
• Few nurses now posted to the clinic through Health Co-
ordination office
• Extension of water supply system to all staff quarters through
the support of the Health Co-ordination office
MAIN CONSTRAINTS/CHALLENGES
COMMON CHALLENGES/CONSTRAINTS
• Cash flow problem as a result of health insurance scheme delayed
claims payment
• Shortage of professional staff especially Nurses and Midwives
• Difficulty in obtaining financial clearance for mechanization of staff
to free IGF for development
• Shortage of staff accommodation compounded by increasing
numbers of Rotation Nurses and newly posted staff
157
158
AGOGO HOSPITAL
• Single spine salary imposing high financial burden of
unmechanised salaries/wages
• Lack of accommodation for doctors and other critical staff
159
AGOGO PHC
• Inadequate funds to run all activities
• Over aged vehicles especially the Toyota Land Cruiser
• Unmotorable roads in the sub-municipality contributing to
frequent breakdown of the vehicles
• Lack of CHPS compounds
160
ASSIN NSUTA HEALTH CENTRE
• General accommodation problem as the facility faces ejection
• Congestion of clients at the OPD
161
ENCHI PHC
• Lack of Staff Nurses/Midwives for Papueso and Amonie CHPS
compounds
• Both vehicles for the programme have broken down
• Inadequate accommodation leading to high expenditure on rent
162
KOM CLINIC
• Lack of accommodation for critical staff
• Majority of staff unmechanized draining the IGF
• Lack of equipment, office accommodation and wards
• Laboratory not accredited by NHIA affecting quality of service
delivery
163
WAY FORWARD
DEALING WITH CROSS-CUTTING CHALLENGES FROM
GENERAL MANAGER’S OFFICE
• Work through Health Co-ordination office and CHAG to get staff
on unmechanized payroll mechanized for financial relief
• Apply for national service personnel with health (nursing and
midwifery in particular) background
164
AGOGO HOSPITAL
• Computerization of the OPD system (including Medical
Records Department), principally to reduce waiting time
• Collaborate with Asante-Akim North and Central Assemblies
to assist in the construction of staff accommodation
• Possibly construct accommodation units from own resources
165
166
167
AGOGO PHC
• Liaise with the Presby Health Coordinator’s office, the Hospital
and the District Assembly to establish CHPS compounds in all
CHPS zones (especially Bebome)
• Intensify progress on all PHC activities
• Organize an EPI mop up in our hard to reach communities during
the dry season
ASSIN PRASO HEALTH CENTRE
• Expand facility to accommodate the increasing level of clients
168
ASSIN NSUTA HEALTH CENTRE
Seek funds to construct permanent buildings for the centre at new
site as a long-term solution to the problem of inadequate space at
current location
KWAHU PRASO HEALTH CENTRE
• Collaborate with stakeholders and NGOs to assist in acquisition of
vehicle or possibly contract a loan to acquire one.
• To empower staff in communication skill through workshops to
enhance staff patient relationship to improve OPD attendance
169
ENCHI PHC
• Computerize pharmacy operations
• Commence construction of a Doctors bungalow
• Start process of upgrading the Enchi Health Centre to a Polyclinic
status
KOM CLINIC
• Run 24-hour emergency services
• Construct male and female wards for detention of critically ill
patients
• Migration of un-mechanized staff to single spine salary structure
• Seek posting of more professional staff (eg Nurses and Midwives)
170
BEST PRACTICES/INNOVATIONS
Review of all cases at Accident and Emergency Department
by entire Clinical Team first thing every morning
Holding of clinical meeting every Thursday throughout the
year
Display of printed Clinical and Infection Prevention
Protocols in all departments of the hospital
Provision of insecticide treated nets for all beds in the
hospital
171
Availability at all times of adequate obstetric emergency
packs for:
Ante-Partum Haemorrhage
Pregnancy Induced Hypertension
Eclampsia
Retained Placenta
Post-Partum Haemorrhage
24-hour theatre services every day
Use of improvised incubators in the Nursery manufactured
by the Hospital’s Maintenance department
Provision of oxygen concentrator in Accident and Emergency
Department, Children’s Ward and Medical Ward
Screening all new-borns within 48 hours
ACKNOWLEDGEMENT
The contributions and support in various forms of the following institutions,
bodies, organizations and individuals are hereby thankfully acknowledged.
• Government of Ghana through MOH/GHS
• The Moderator and General Assembly Council of the Presbyterian
Church of Ghana
• The Director of Development and Social Services, PCG
• The Chairman and Members, Committee on Health and Environment
of the PCG
• The Health Coordinator, PCG
• Chairman and Members of the Area Board, Asante-Akyem Presby
Health Services
• CHAG National Secretariat
• Rev. Ernst Peyer Memorial Foundation, Switzerland
• World Vision Ghana
• Asante Akim North Municipal Assembly
172
APPENDIX I (a)
USER SATISFACTION SURVEY AT OPD (AGOGO HOSPITAL)
INDICATOR2011 2012
2013
Proportion of patients: JUN DEC
1 Seen promptly within 2 hours 57 30 57 68
2 Seen without unnecessary delay 78 90 62 100
3 Examined by Doctor 76 97 97 100
4 Told their diagnosis 69 59 90 72
5 Given instructions about illness by Doctor 53 56 90 90
6 Told whether to return 80 82 72 74
7 Having privacy during consultation 99 100 98 100
8 Receiving all drugs prescribed 93 98 78 98
9 Understanding instruction from the Pharmacy 100 100 98 100
10 Perceiving staff attitude to be very good 84 95 89 100
11 Perceiving hospital to be clean 80 99 92 96
12Seeking emergency treatment in previous 6
months who were seen promptly100 67 42 71
13 Feeling very satisfied with their visit 92 100 96 100173
0
20
40
60
80
100
120
1 2 3 4 5 6 7 8 9 10 11 12 13
Jun-11
Jun-12
Jun-13
Dec-13
174
APPENDIX I (b)
INPATIENTS DEPT. USER SATISFACTION SURVEY
(AGOGO HOSPITAL)
INDICATORS 2011 20122013
JUN DEC
1 Proportion of patients given bed within 30 mins. 93 100 85 84
2Proportion of patients given bed without
unnecessary delay45 99 100 94
3 Proportion of patients visited by a Doctor daily 94 100 80 100
4Proportion of patients examined by Doctor on
each visit83 100 80 100
5Proportion of patients receiving all prescribed
drugs in the hospital75 96 90 67
6Proportion of patients served regularly their
medication97 100 100 100
7Proportion of patients receiving privacy while on
admission42 100 90 98
175
8aProportion of patients admitted with
emergency condition34 12 65 42
8b Proportion of patients given prompt attention 71 67 77 90
9Proportion of patients perceiving staff attitude
to be very good84 100 100 96
10aProportion of patients needing other services
(e.g. x-ray, lab etc)82 89 80 86
10bProportion of patients given prompt attention
at the lab, x-ray etc.94 59 81 91
11Proportion of patients receiving receipt for
each payment100 96 100 100
12Proportion of patients perceiving ward to be
clean90 98 95 98
13Proportion of patients able to pay for all
services95 100 100 96
14 Proportion of patients told to return for review 86 97 90 100
15Proportion of patients feeling very satisfied
with services95 100 80 100
176
0
20
40
60
80
100
120
1 2 3 4 5 6 7 8a 8b 9 10a 10b 11 12 13 14 15
Jun-11
Jun-12
Jun-13
Dec-13
177
APPENDIX I (c)
USER SATISFACTION SURVEY AT OPD
(ASSIN PRASO HEALTH CENTRE)
INDICATOR 2012 2013
Proportion of patients: JUN DEC JUN DEC
1 Seen promptly within 1 hours or less 80 90 100 95
2 Seen without unnecessary delay 85 89 100 99
3 Examined by Doctor 95 99 75 100
4 Told their diagnosis 90 100 60 100
5 Told how to take treatment 100 100 50 100
6 Told whether to return 99 100 80 100
7 Having privacy during consultation 100 100 90 75
8 Receiving all drugs prescribed 100 100 100 100
9 Understanding instruction from the Pharmacy 90 85 90 85
10 Perceiving staff attitude to be very good 99 100 98 90
11 Perceiving clinic to be clean 99 98 100 95
12Seeking emergency treatment in previous 6
months who were seen promptly100 100 100 100
13 Feeling very satisfied with their visit 99 99 95 98178
0
20
40
60
80
100
120
1 2 3 4 5 6 7 8 9 10 11 12 13
Jun-12
Dec-12
Jun-13
Dec-13
179
APPENDIX I (d)
USER SATISFACTION SURVEY AT OPD
(ASSIN NSUTA HEALTH CENTRE)
INDICATOR2011 2012 2013
Proportion of patients:
1 Seen promptly within 1 hours or less 90 86 86
2 Seen without unnecessary delay 90 88 88
3 Examined by Doctor 94 98 74
4 Told their diagnosis 100 100 100
5 Told how to take treatment 100 100 100
6 Told whether to return 100 100 100
7 Having privacy during consultation 74 80 76
8 Receiving all drugs prescribed 100 100 100
9 Understanding instruction from the Pharmacy 100 100 100
10 Perceiving staff attitude to be very good 84 98 98
11 Perceiving clinic to be clean 96 100 100
12Seeking emergency treatment in previous 6
months who were seen promptly100 100 100
13 Feeling very satisfied with their visit 100 98 90180
0
20
40
60
80
100
120
1 2 3 4 5 6 7 8 9 10 11 12 13
2011
2012
2013
181
APPENDIX I (e)
USER SATISFACTION SURVEY AT OPD
(KWAHU PRASO HEALTH CENTRE)
INDICATOR2009 2010
Proportion of patients:
1 Seen promptly within 1 hours or less 100 100
2 Seen without unnecessary delay 100 100
3 Examined by Doctor 100 80
4 Told their diagnosis 100 80
5 Told how to take treatment 100 100
6 Told whether to return 100 32
7 Having privacy during consultation 100 100
8 Receiving all drugs prescribed 100 100
9 Understanding instruction from the Pharmacy 100 100
10 Perceiving staff attitude to be very good 100 100
11 Perceiving clinic to be clean 96 100
12Seeking emergency treatment in previous 6 months
who were seen promptly100 34
13 Feeling very satisfied with their visit 100 100 182
0
20
40
60
80
100
120
1 2 3 4 5 6 7 8 9 10 11 12 13
2009
2010
183
APPENDIX I (f)
USER SATISFACTION SURVEY AT OPD
(ENCHI PRIMARY HEALTH CARE)
INDICATOR2012 2013
Proportion of patients:
1 Seen promptly within 1 hours or less 50 60
2 Seen without unnecessary delay 58 81
3 Examined by Doctor 87 90
4 Told their diagnosis 47 51
5 Told how to take treatment 64 60
6 Told whether to return 74 62
7 Having privacy during consultation 89 95
8 Receiving all drugs prescribed 80 94
9 Understanding instruction from the Pharmacy 80 99
10 Perceiving staff attitude to be very good 95 95
11 Perceiving clinic to be clean 87 88
12Seeking emergency treatment in previous 6 months
who were seen promptly71 100
13 Feeling very satisfied with their visit 89 100 184
0
20
40
60
80
100
120
1 2 3 4 5 6 7 8 9 10 11 12 13
2012
2013
185
APPENDIX II
RATIONAL DRUG PRESCRIPTION INDICATORS (AGOGO HOSPITAL)
INDICATOR
AGOGO HOSPITAL STANDARD
1ST QTR
2013
2ND QTR
2013
3RD QTR
2013
4TH QTR
2013
ASH.
REGIONWHO
Diagnosis
No. of Drugs per
Prescription
Prescription
Generic Drugs
Antibiotics
Injections
Prescriptions
within EDL
96.0%
3.3
65.3%
23.1%
8.0%
89.7%
98.0%
3.7
68.4%
22.8%
5.3
87.2%
100.0%
3.1
70.2
31.2%
3.7%
75.5%
100%
3.4
54.9%
34.5%
2.0%
80%
100%
4
84%
40%
40%
100%
100%
2
100%
20%
20%
100%
186
APPENDIX III
PURCHASE OF MEDICAL EQUIPMENT (AGOGO HOSPITAL)
187
DESCRIPTION QUANTITYTOTAL COST
GHȼ
Delivery Bed
Digital Thermometer
Litman Stethoscope
PB Apparatus
Electric Boiler
Electrical Suction Machine
Drum (Sterilizing)
SUB-TOTAL
1
320
21
45
1
1
1
2,200.00
2,968.00
1,680.00
11,050.00
800.00
2,200.00
120.00
21,018.00
188
DESCRIPTION QUANTITYTOTAL COST
GHȼ
Oxygen Flometers
ORISCOPE
Selecta Flow meter
Weighing Scales
Dental Unit Assorted Medical Items
SUB TOTAL
GRAND TOTAL
15
10
5
8
5,585.00
5,000.00
4891.25
3,500.00
70,772.20
89,748.45
110,766.45
189
NAME OF INSTITUTION/ORGANIZATIONNO. OF
TRAINEES
Christian Service University College
Catholic University College
Grace Baptist University College
Kwame Nkrumah University of Science & Technology
Presby University College, Abetifi-Kwahu
University of Professional Studies
University of Cape Coast
University of Development Studies
All Nations University College, Koforidua
University of Ghana
1
2
1
2
2
1
3
3
1
2
APPENDIX IV
TRAINING ATTACHMENT OFFERED TO STUDENTS
190
NAME OF INSTITUTION/ORGANIZATIONNO. OF
TRAINEES
University of Education, Winneba-Kumasi Campus
Koforidua Polytechnic
Takoradi Polytechnic
Kumasi Polytechnic
Allied Health Professional Council, Korle-Bu
Medicare College of Applied Sciences, Kumasi
Ramseyer Vocational/Technical Institute
Physiotherapy Assistant Training School, Duayaw-Nkwanta
Bright College, Kukurantumi
Opoku Ware Girls’ Vocational/Technical Institute, Nkawie
Kwara State Polytechnic, Nigeria
Nerebehi ICCES of Vocational Institute
GIMPA
1
3
1
2
1
1
1
1
1
1
1
1
1
191
TOYOTA LAND
CRUISER PRADO
192
DISPENSING COUNTER
PHARMACY DEPARTMENT
193
INSIDE THE PHARMACY
DEPARTMENT
194
INSIDE THE PHARMACY
DEPARTMENT
195
RENOVATED PHARMACY
DEPARTMENT
196
INSIDE THE DENTAL UNIT
197
INSIDE THE DENTAL UNIT
198
FRONT VIEW FENCE WALL
THANK YOU
199