Nkozi Strategic Plan

OUR LADY HEALTH OF THE SICK
NKOZI HOSPITAL
STRATEGIC PLAN
2015/16 - 2019/20
October 2015
NKOZI HOSPITAL Strategic plan: 2015/16 - 2019/20
OUR LADY HEALTH OF THE SICK

NKOZI HOSPITAL
STRATEGIC PLAN
2015/16 TO 2019/20
October 2015
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Our Lady Health Of The Sick

Nkozi Hospital
Contact:
Tel.: +256 (0) 392842207;
Fax: +256(0) 38 410100
Email: nkozi@ucmb.co.ug
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Contents
FOREWORD 4
PREFACE 6
ACKNOWLEDGEMENTS 8
EXECUTIVE SUMMARY 10
Section one: BACKGROUND 13
1.1 History 13
1.2 General Overview 13
1.3 Morbidity and mortality trends 14
1.4 National context: 14
1.5 Development process 14
Section two: ORGANISATIONAL ARRANGEMENT 16
2.1 Hospital organisation 16
2.2 Hospital functions/services 17
Section three: REVIEW OF THE PREVIOUS STRATEGIC PLAN (2009/10-2014/15) 19
Goal 1: Improving human resources in Nkozi hospital through effective
utilization of the employment manual 19
Goal 2: Ensure a sustainable financial base 20
Goal 3: Increase utilization of services offered at Nkozi hospital 21
Goal 4: Improve hospital governance and management 22
Goal 5: Contribute to improved health for people living in
Mawokota South HSD 22
Section four: SITUATIONAL ANALYSIS: 24
4.1 Strength and opportunities and proposed strategies for improvement 25
4.2 Weaknesses and threats and proposed strategies for mitigation 31
4.3 Performance review analysis 35
Section five: STRATEGIC DIRECTION 36
5.1 VISION 36
5.2 MISSION 36
5.3 GOAL 36
5.4 MOTTO 36
5.5 GUIDING PRINCIPLES 36
5.6 CORE VALUES 37
5.7 STRATEGIC OBJECTIVES: 37
Section six: MONITORING AND EVALUATION OF THE STRATEGIC PLAN 50
MONITORING AND EVALUATION FRAMEWORK FOR NKOZI HOSPITAL
STRATEGIC PLAN FOR 2015/16 – 2019/20 50
BUDGET FOR NKOZI HOSPITAL STRATEGIC PLAN FOR 2015 /16– 2019/20 106
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FOREWORD
Our lady Health of the sick, Nkozi Hospital, is one of the longest serving catholic
founded hospitals in Uganda. Having been started by the Missionary of the White
Sisters of Our Lady of Africa in as far back as 1942, it gives me a lot of joy to make
my contribution to the effort started almost seventy three years ago but is now
being carried on with the development of this new five year strategic plan. This
relates very well with the goal of the hospital which emphasises provision of high
quality services that are accessible and sustainable.
For all human beings living on earth, life is the most valuable gift received from
God and we always work hard to keep it in the best desirable condition possible.
It is therefore important to note that all those people called up on to serve in the
field of healthcare are privileged and honoured to contribute to this noble cause.
The leadership of Kampala Archdiocese wishes to acknowledge the tremendous
work done by the staff of Nkozi Hospital in serving and caring for the sick. I wish
to thank you very much for the commitment and excellent service offered to
the community in the surrounding area and beyond. Similarly, I would also like
to thank the management and the Board of Governors for successfully steering
Nkozi Hospital forward and having it prepared for the next phase of implementing
the new strategic plan.
As many of you could know, the health sector continues to face a growing number
of challenges more especially the increase in non-communicable diseases. The
changing lifestyles, the improving infrastructure as well as increasing number
of the advanced age group in our society have all translated to increased
morbidity and mortality from conditions such as hypertension, diabetes mellitus
and road traffic accidents to take place. That aside the battle against HIV/AIDS,
tuberculosis, malaria, chest infections, and other diseases is still a thorn in flesh
to our community. I have confidence that this strategic plan has been developed
with a lot of consideration for these changes in the community. I wish to urge
all health service providers to continue with a lot of enthusiasm the drive for
health promotion and prevention campaigns to prevent further spread of these
conditions. The plan to have an emergence unit is a timely innovation which
should be pursued to the end so that those suffering more especially from
accidents and other injuries can be attended to in time and give them new hope
to regain their normal lives.
I am aware that a number of stakeholders have supported Nkozi Hospital to make

it shine and reach out to those suffering with various illnesses. Let me use this
opportunity to thank the Uganda Catholic Medical Bureau, the Government of
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Uganda, Mpigi district Local Government and the donors for their support and
commitment to work with Nkozi Hospital. Your contribution has always made a
difference in the way the hospital has continued to function over the past period.
It is my prayer that this support shall continue and even increase to come in the
coming years of operationalising the new strategic plan to make our dream for
Nkozi Hospital to excel become a reality.
As I conclude, allow me to thank the team that has participated in the development
of this strategic plan. We are all very proud of your dedicated effort and love for
Nkozi Hospital. I wish you God’s blessings and prosperity in your work. I also wish
the management and staff for Nkozi Hospital a successful period of implementing
the new strategic plan 2015/16 to 2019/20. May God be with you and guide you
all the time.
+Cyprian Kizito Lwanga

ARCHBISHOP OF KAMPALA ARCHDIOCESE
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PREFACE
This strategic plan is the third version to be developed by Nkozi Hospital in recent
history. I would like to congratulate the Hospital Management Team for building a
culture of setting priorities right and planning for long term improvement to take
place for the Hospital. The Board of Governors, which was inaugurated early this
year, takes pride to be associated with this spirited effort and shall give full support
towards successful implementation of the strategic plan for Nkozi Hospital.
The Health Sector Development Plan (HSDP 2015/16 to 2019/20) by the Ministry
of health has been finalised this year 2015. This coincided with development
process for Nkozi Hospital strategic plan 2015/16 to 2019/20. The HSDP goal is “To
accelerate movement towards Universal Health Coverage with essential health and
related services needed for promotion of a healthy and productive life”. The goal
for Nkozi Hospital is, “To provide sustainable, accessible and high quality services to
uplift health standards of the community”. Universal Health Coverage emphasises
improving access, equity and high quality of services for the community served.
The hospital strategic plan has been aligned with the HSDP to keep the hospital
focused with the Government programmes on health services.
The Board of Governors shall take keen interest in the implementation process of
the strategic plan for Nkozi Hospital. The monitoring process should be carried out
regularly to make sure that the strategic objectives are followed to meet the set
targets. The Hospital management shall be expected to provide regular updates
to the Board of Governors and also plan ahead for the mid-term and end of term
review of the strategic plan.
I would like to point out, that the hospital highly appreciates the valuable
contribution received from the different stakeholders who have continued to work
and support Nkozi hospital. These include the hospital staff, the local community in
the catchment area, Kampala Archdiocese through the Sisters of the Immaculate
Heart of Mary Reparatrix Ggogonya, the Ministry of health, the Local Government
of Mpigi and District Health Officer’s office, the Uganda Catholic Medical Bureau,
the donors and all the rest. The Board of Governors wishes to commend all of them
for the support they have extended to Nkozi Hospital up to now. Thank you very
much for this effort and may we look forward to more collaboration and success
during the coming period of implementation of new hospital strategic plan.
Finally I allow me to thank wholeheartedly all those that worked tirelessly to

produce this strategic plan. Special thanks go to the staff, the management and
Board of Governors for Nkozi Hospital, the consultant who spearheaded the
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process, Prof. John Mugisha and the Uganda Catholic Medical Bureau for the
guidance. Thank you very much for your support.
Dr. Ssendyona Martin (MD, MPH)

Chairman Nkozi Hospital Board of Governors
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ACKNOWLEDGEMENTS
There has been a lot of effort put into the production of this strategic plan; many
individuals have spent a lot of their energy and time to do this work. On behalf of
the hospital’s management team, I would like to express our heartfelt gratitude
for each contribution from all people who were involved in generating this plan.
I will now thank only a few in a special way.
Let me start with Associate Professor Dr. John Mugisha who has been the
consultant facilitator during the development of this plan. He has been committed
to interacting with all the stake holders in order to generate a realistic and
achievable strategic plan. He has also made drafts for the hospital management
and Board of Governors to work with during this exercise.
Allow me then to thank the Village Health Teams of Mawokota South Health Sub-
District for their contributions during the workshops organized for SWOT analysis.
This information made this strategic plan focused on the needs of the catchment
population.
The Nkozi Hospital staff especially those in charge of departments were also very
helpful during the SWOT analysis, giving their input in order to make a realistic
plan.
My fellow management team members, as a whole, cannot be forgotten for their

tireless efforts to ensure that the strategic plan is made with involvement of all
stake holders.
The Board of Governors has been very helpful in giving their advice, moral
support and guidance to the management team. They were also involved in the
SWOT analysis.
I also like to thank the Uganda Catholic Medical Bureau which has been reminding
us to make and follow a strategic plan in order to put forward organized
development in this hospital.
The hospital partners who have been always there for Nkozi Hospital cannot
be forgotten because their support indirectly helps management to fulfill its
obligations, for example, Mpigi District Local Government, Ministry of Health,
Manos Unidas, Stitching Porticus, MIVA, UEC-ACT Program, MildMay, Lilian
Foundation, Uganda Martyrs University, PACE, Insurance Institute of Uganda,
AFA, etc.
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To all of those who have contributed towards this achievement thank you very
much.
Alfred Lumala
Medical Director
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EXECUTIVE SUMMARY
Nkozi Hospital has engaged all its stakeholders in a participatory planning process
to come up with this second strategic plan 2015/16- 2019/20. This plan has also
been based on the achievements of the previous strategic plan 2009/10-2014/15
with knowledge of the local, regional and global challenges. The strategic plan
is intended to guide the effectiveness and efficiency of service delivery of Nkozi
Hospital while remaining faithful to the mission of providing high quality health
services to the people of God.. It explains our vision, mission, objectives, core
values and partnership principles. Nkozi hospital aims to deliver by; increasing
utilisation of services at Nkozi hospital, contributing to improved health for the
people living in Mawokota South Health Sub-District (HSD), ensuring sustainable
financial base for the hospital, improving human resource capacity, expanding
and furnishing hospital infrastructure and improving hospital governance and
management.
The process for developing this plan commenced with the strategic planning
workshop held at the Hospital for two days 22nd and 23rd November 2014 facilitated
by Dr. John F. Mugisha of Uganda Martyrs University with full participation of all
staff members, the Hospital management and at a later date by Board Members.
The strategic plan articulates the vision, mission, core values and objectives; and
also provides the strategies which require to be implemented in order to give
Nkozi Hospital considerable service delivery capacity in the next five years. The
five strategic objectives include:
1. To Increase utilisation of services in Nkozi hospital
This is the raison d’etre of the hospital, which therefore constitutes the main
hospital function. To achieve this goal the hospital will improve on the range of
clinical and nursing services, expand the ancillary services, expand Clinical Pastoral
Care and Counseling, improve on medical records management (patient data
collection, recording, analysis, storage, retrieval and reporting), and expand and
furnish the facilitating hospital infrastructure as the main strategic objectives.
2. Improve Human Resources in Nkozi Hospital
The hospital has been losing staff at a fairly high rate. In the next 5 years of the
plan, it is hoped that this trend will be stopped, reversed and the human resource
situation of the hospital stabilized. To realise this goal, a number of strategies
will be undertaken: (i) ensure competitive and equitable salaries for the staff, (ii)
put in place attractive and welfare terms and conditions, (iii) establish a trans-
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generational bond between the hospital and the staff, (iv) develop differential
skills among staff through specific professional training and development
programs, (v) determine the actual workload-based requirements for staffing and
improve staff retention within the hospital.
3. Ensure sustainable financial base for the Hospital
In the next 5 year period of the plan, efforts will be made to stabilize the financial
situation of the hospital because it is one factor that will improve general hospital
functioning and service delivery. This strategic goal will be pursued through
several strategic objectives: reduce non-critical expenditure in the hospital,
improve financial management, Increase local revenues from different sources
for hospital activities and mobilize resources for continued income generation
and sustainability.
4. Improving Governance, Management And Operational Systems of the

Hospital
This plan seeks to consolidate the existing governance and management structures
of the hospital and to establish and institutionalize a quality management systems
for the routine operations of the hospital, in order to reduce over-reliance on
specific individuals. This will be achieved through increasing the effectiveness of
the Board of Governors (BOG), strengthening the role of the Managing institute
(through an official agreement e.g. the establishment and implementation
of a Memorandum of understanding (MoU)) in supporting the hospital, the
performance of the Management Team and the general management systems
including management of equipment, space, infrastructure and the human
resources.
5. Contribute to improved health for the people living in Mawokota South

Health sub-district (HSD)
In the next 5 years, the hospital will continue to make its contribution by focusing
on 5 strategies of: (i) strengthening PHC department, (ii) preventing the spread of
communicable diseases, (iii) contributing to reduction of maternal and neonatal
mortality, (iv) improving hospital ambulatory services and (iv) improving infection
control.
Some indicators of quality of care have been declining e.g. annual number of
normal deliveries has been declining from 1342 to 1260 in the last five years;
Annual live births have been declining from 1671 to 1522 in the last five years.
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Activities to be accomplished in the next five years have been identified and
elaborated in a logical framework with clear and understandable indicators. To
realize the intentions of this strategic plan, stakeholders have to consider the
following: will need constant networking, participatory planning, learning and
commitment, to provide an excellent opportunity to build a sense of teamwork.
This strategic plan will be communicated to all its users to make a case for the
prioritized strategic choices to avoid over ambitiousness of the plan.
This plan will provide an excellent opportunity to build community consensus,

promote learning and build commitment of staff and other social sectors.
However the hospital is mindful of its limits both internally and externally.
The plan will progressively be monitored and reviewed in the mid-term in order
to make strategic adjustments and bring on board new development as staff
continue to heed the core values and mission that are key in the implementation
of the plan.
The Plan will be financed by both public and private resources, with about
25% being Government contribution, 50% User fee contribution, 7% Income
generating projects and 12% from donations and fund raising.
The common disease cases reported at the hospital during the past strategic plan
period are Malaria, upper respiratory tract infections(URTI), Anemia, malnutrition,
pneumonia, Diarrhea, HIV/AIDS, trauma following Road traffic accident (RTA),
Urinary tract Infection (UTI), Typhoid, Hypertension, Hernia .
Most of the diseases are infectious diseases than life style, malaria contributes
most 37%, URTI 13%,
Trauma following road accidents (RTA) contributing 6%.
Our main focus will be Trauma following RTA and other non- communication
diseases like Diabetes, Hypertension, eye diseases, gynecology because the
Government already supports infectious diseases.
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Section one: BACKGROUND

1.1 History
Nkozi hospital was founded by the White Sisters of Our Lady of Africa from the
Netherlands in 1942. The Management of the hospital was transferred in 1994
to the local Institute of the Sisters of the Immaculate Heart of Mary Reparatrix –
Ggogonya, Headquartered in Kisubi. These Sisters are still serving as the managing
Institute under the guidance of the Board of Governors, which is appointed by
the Archbishop of Kampala Archdiocese.
Currently the legal and registered owner of the Hospital is the Roman Catholic
Archdiocese of Kampala in the person of the Registered Trustees of the
Archdiocese.
The hospital is affiliated to and is accredited by the Uganda Catholic Medical

Bureau (UCMB), which is responsible for coordination of services for several
other health facilities and training schools owned and operated by the Roman
Catholic Church in Uganda.
1.2 General Overview

Nkozi hospital is a Catholic founded Private-Not-For-Profit (PNFP) hospital
which operates within Kampala Archdiocese. The hospital is located adjacent
to Uganda Martyrs University main Campus, in Nkozi sub-county, Mpigi
district. The distance from Kampala, Uganda capital city along Kampala –
Masaka highway is about 83 kms and then you turn on the right hand-side at
Kayabwe trading center for 2.5 kms before reaching the hospital.
Nkozi hospital enjoys good collaboration with Government of Uganda (GoU)

and is the referral health facility for Mawokota South Health Sub-District (HSD),
in Mpigi district. The hospital hence functions as a referral health facility for
the HSD which has an estimated population of 109,984 occupying the three
sub-counties of Nkozi (37,079), Buwama (48,643) and Kituntu (24,262). The
hospital serves as the most accessible health unit for the population of about
30,000 people in the surrounding community of Nkozi Sub-county.
The hospital is located in a rural community where majority of the people being
served are peasant farmers, mainly carrying out subsistence agriculture, small
scale fishing and poultry keeping. This has implications on setting of user fees
and clients’ ability to pay as majority of the catchment population comprises
low income groups that can only pay a very small proportion of the real cost
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of treatment and care. In fact, majority of the people in the catchment area
live below the poverty line.
1.3 Morbidity and mortality trends
malaria and HIV/AIDS are the leading causes of death in the hospital although
there are several efforts to contain them. Children below 5 years of age are the
worst hit by malaria. There is a high number of reported trauma cases due to
road traffic accidents because of the busy Kampala Masaka high way that links
to neighboring countries of Rwanda, Tanzania and the Democratic Republic of
Congo (DRC). On many occasions, the demand for services exceeds the hospital’s
capacity and depletes the limited resources available in the hospital. There are
also maternal deaths due to delay of mothers in the community many times
under the care and support of the Traditional Birth Attendants (TBAs). Most
of these mothers who deliver with TBAs cannot access basic services such as
elimination of Mother To Child Transmission (e-MTCT) services, which exposes
their new born babies to HIV infection.
1.4 National context:

Nkozi hospital operates under the regulations governing hospital management
in the Ministry of Health. The hospital strategic plan has been developed within
the broad context of the Uganda National Development Plan (NDP 2015/16 to
2019/20); The Second National Health Policy (NHP II 2010/11-2019/20) and
The Health Sector Development Plan (HSDP 2015/16 to 2019/20). The theme of
this 2nd NDP is to see “Strengthening Uganda’s Competitiveness for Sustainable
Wealth Creation, inclusive Growth and Employment.” The Hospital being part of
the national health system roots deeply into this theme. The catholic network has
been part of the national effort to support the implantation of the NHP and will
form part and parcel of the HSDP whose period of operation rhymes with that of
Nkozi Hospital Strategic plan.
1.5 Development process

This process has been participatory to involve the key stakeholders before
coming up with the key priorities for the next five year. A consultant was hired
from Uganda Martyrs’ University and a workshop was organised in July 2014
for representatives from Heads of Department, the Management Team, the
community (Village Health Teams) and Board of Governors. Participants worked
in teams on different Vision, Mission, Core values, Goals, strategic objectives
and interventions to needed to be carried out and reported back in the plenary.
Some of the issues discussed in the team and later in the plenary included scope
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of services that the hospital should provide, funding sources and expenditure
patterns, physical infrastructure, primary health care activities, communication
within the hospital and internal management systems, just to mention a few.
Further to the workshop, the process of making this strategic plan involved a
thorough analysis of major hospital documents such as annual analytical reports,
strategic plan for 2009-2014, long term master plan of the hospital, hospital charter,
procurement and disposal of hospital assets manual, employment manual, job
descriptions handbook, financial and material resources manual, among others.
The analysis of these documents focused on identifying major hospital functions
and activities, staffing, infrastructure and other resources, community out-
reaches, sources of funding and main areas of expenditure, burden of disease
in the community being served by the hospital and collaborations between the
hospital and different partners.
Finally, the writing team conducted a physical tour of the hospital and its various
units to acquaint itself with the state of hospital infrastructure, equipment, scope
of services, safety of assets, in-service pathways, patient flow area, water
resources, electricity, compound, incinerator, vehicles, staff houses, land and
other issues that required observation. This strategic plan was a result of analysis
of data from all these activities.
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Section two: ORGANISATIONAL ARRANGEMENT
2.1 Hospital organisation
this has the hierarchal set up at Nkozi hospital as summarised in the

organogram below:
NKOZI HOSPITAL ORGANOGRAM
BOARD OF TRUSTEES:
Delegation of powers
Managing Ministry of
Organization Board of Governors Health
IHMR - Sisters Nkozi Hospital
UCMB
Advisory Assembly
Nkozi Hospital
Management Team
Headed by a Medical Director and Local Government/
consisting of the heads of the Office of the District
main departments Health Officer
(DHO)
Head of the Head of the Head of the Head of Public

Medical Nursing Administration Health
Department Department - Department- Department or
-Medical Senior Nursing Administrator. Public Health
Director Officer Director
Medical and Nursing Accounts / Community

paramedical departments; Administration, Health/ HSD
departments / Nurses and Cleaning/ services and
staff; Diagnostic Nursing Maintenance activities.
departments Assistants. infrastructure,
Pharmacy equipment and
grounds;
Transport; Support
Staff.
Nkozi Hospital is owned by the Board of Trustees which chaired by the Arch-bishop
of Kampala Archdiocese. The Sister of the Immaculate Heart of Mary Reparatrix
(IHMR) Ggogonya, Kisubi were given the mandate to manage the Hospital on behalf
of Kampala Archdiocese. The Board of Governors is the supreme body responsible
for governance and advising on managerial and policy-making issues related to the
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Hospital. The Hospital Management Committee (HMT) is headed by the Hospital

Director and reports to the Board of Governors. The Team is charged with the day
to day running of the hospital, implementing the policies set up by the BOG, and
the national programmes for health service delivery in the catchment area. Other
key stakeholders in the running of the Hospital are the Local Government through
the office of the DHO, Uganda Catholic Medical Bureau (UCMB) and the Hospital
Advisory Assembly as summarized in the organogram above.
2.2 Hospital functions/services

The hospital operates 24 hours and offers preventive, curative and promotive
health services both on site and through outreach activities. The core functions
of the hospital are the following:
• Outpatient Services
o General Outpatient Clinic

o HIV/AIDS Clinic
o Dental Clinic
o Immunization Clinic
o Antenatal and Postnatal Clinic.
o Physiotherapy & Occupational therapy
o Psychiatry
Inpatient/Admission services
o General medical, Paediatric and Surgery sections (Female, Male

and Children)
o Delivery/maternity services ( beds capacity)
o Private ward
• Support Services
o Diagnostic services
Laboratory

X-ray services

Dental x-ray

Ultra sound scan services

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o Pharmaceutical services
o Theater services
o Blood Transfusion services
• Community Health
o Expanded Programme for Immunisation EPI) services

o Antenatal services
o Village Health Teams (VHTs)
• Administration services
o Human Resource Management section

o Finance and Administration
o Health Management Information System (HMIS/Records)
o Pastoral care (clinical and holistic)
o Maintenance services
• Health Sub-district (HSD) services
o Planning, budgeting and coordination PHC services for the HC

IIIS and HC IIs.
o Support supervision, monitoring and technical support services
to the lower level health services
o Support for community services
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Section three: REVIEW OF THE PREVIOUS

STRATEGIC PLAN (2009/10-2014/15)
Review of Nkozi Hospital Strategic Plan for 2009/10-2014/15 was conducted to
appreciate the achievements and challenges met in the implementation process.
The Strategic plan had four goals to accomplish as outlined below:
1) Improved the human resource in Nkozi hospital

2) Ensuring financial sustainability base
3) Increasing utilization of services offered at Nkozi hospital
4) Improving hospital governance, management and operational
systems
5) Contributing to improved health for the people living in Mawokota
South Health Sub-District
During the period of the previous strategic plan, a number of achievements were
made by the hospital in areas the management had set out to accomplish. The
following review highlights the summary of the hospital performance in respect
of achieving the just concluded strategic plan. After each set of achievements is a
brief commentary on each strategic goal in respect of what the key achievements
were supposed to be:
Goal 1: Improving human resources in Nkozi hospital through effective

utilization of the employment manual
1) The hospital was able to recruit more staff that included 1 extra
Doctor, 1 radiographer, clinical officers, nurses, midwives. In this way,
the hospital was able to fill the key human resource gaps which was a
key objective
2) The hospital was able to develop a staff career development plan

although it is now due for revision
3) The hospital managed to conduct Continuing Professional Development

(CPD) sessions for staff, which are well institutionalized and are still on-
going.
4) A staff revolving fund worth UGX 10 million was set up as planned and
some staff are benefiting from the fund.
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Commentary
Although the hospital managed to make some important achievements towards
realizing the goal of improving the human resource, a number of activities
remained undone, rendering some objectives to remain unachieved.
• There was increase in staff salaries during the previous planning period
mainly for nurses, midwives and nursing assistants. However, there was
no increase of salaries for Doctors some of whom are also seconded by
government. Work of constructing staff hostels, which were targeted to
improve staff welfare, began in August 2014 but is not yet completed.
• The number of government seconded staff increased to six, although by
the time of making this plan, one was on study leave and another one
was not active.
• A staff revolving fund was set up as planned and some staff are benefiting
from the fund.
Goal 2: Ensure a sustainable financial base

On this strategic goal, the hospital was able to register a number of achievements,
viz:
1) Management wrote funding proposals and was able to receive some

resources e.g.:
a. Construction of private ward (by the Stiching Porticus)
b. Equipment from Brothers of Brothers – USA, Computers from
Dr. Kabuye, Autoclave from Mirembe Foundation, UEC/ACT
programme
c. Brand new Double Cabin pick-up (MIVA)
d. Staff – 2 midwives (Mildmay – Uganda)
2) Producing financial statements
3) Auditing financial books of accounts
4) Procured the tipper but it was later disposed off due to the increasing
expenses on it with very little income. Instead, Management bought a small
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pick-up for the small duties and such as transporting the tents.
5) Procured tents and chairs for rent
6) Planted eucalyptus trees
Commentary
It is recognized that the hospital managed to make very important achievements
towards realizing this goal for which management should be commended.
However, there are few activities that remained unaccomplished during this
period, namely:
• A hospital restaurant was not constructed as planned

• A hospital hostel was not constructed for renting out to get money
Goal 3: Increase utilization of services offered at Nkozi hospital

On this 3rd strategic goal, the hospital was able to achieve a number of targeted
objectives, where the following were most outstanding:
1) Stock-outs of essential medicines was reduced significantly in the hospital

2) A number of laboratory reagents were procured as and when needed
3) 50 percent of the computers needed for data management were procured
4) The general ward and the private ward were expanded and furnished
5) Fire extinguishers were procured and installed within the key points
6) Health Sub District meetings were held quarterly
Commentary
It is also recognized that the hospital managed to make some vital achievements
towards realizing this goal for increasing utilization of hospital services at Nkozi.
However, the areas that remained unsatisfied include the following:
• Patients did not access medicines at reduced user fees

• An automatic liver and renal function machine was not procured
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• An ECG machine was also not procured

• Filling cabins were not procured as planned
• Maternity ward was not expanded and a theatre was not put
• The HIV/AIDS clinic was not renovated
• A kitchen and a shelter for patients’ attendants were not constructed
• The 4 Television sets and Radio for patients were not bought
Goal 4: Improve hospital governance and management

As far as this strategic goal was concerned, the hospital was able to realize a
number of achievements, which included the following:
1) Some members of the Health Management Team were trained in

Health Services Management
2) Quarterly Board of Governors’ Meetings were held
3) Weekly Management meetings were held
4) One annual stakeholders meeting was held in 2012
5) Quarterly Health Sub District meetings were held
Commentary:
All activities for this goal were achieved, except 1 annual stakeholders meeting
was held instead of 5.
Goal 5: Contribute to improved health for people living in Mawokota

South HSD
The hospital supported the HSD services as indicated below
1) Quarterly planning and budgeting functions

2) Regular performance review meetings
3) Regular support supervision functions
4) Coordinated HSD Child Days activities which are planned at the national
level.
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5) Coordination of HSD Village Health Team (VHT) services

6) Supported health services delivery in the HSD including HIV/AIDS, TB and
Malaria services.
7) Distributed mosquito nets to some members of the community
Commentary
The hospital did a lot to achieve several targets within this strategic goal. Only
a few things such as procurement of an ambulance for improved referral and
movement of the patients was not done. On the whole, the hospital did a
commendable job in achieving the goals and objectives set out in the previous
strategic plan.
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Section four: SITUATIONAL ANALYSIS:
This section provides e situational -analysis of Nkozi Hospital in form of Strengths,

Weaknesses, Opportunities, Threats (SWOT) and the key priority areas for the
five – year period of the Plan. The purpose of the SWOT analysis is to clearly
identify the internal strengths that can be built upon, the weaknesses that need
to be addressed and the external threats that require mitigation as well as the
opportunities that the hospital should take advantage of.
The table below summaries for each service area the strength, opportunities and
focus for improvement; weaknesses and threats with the proposed mitigation
actions:
24
4.1 Strength and opportunities and proposed strategies for improvement
Table 1: Strength and opportunities and proposed strategies for improvement
Service Area Strength Opportunities Strategies for Improvement

1. Human Resources for • Dedicated staff at various • Some staff are • Training needs
Health: levels seconded by MoH assessment and plan
This is the foundation and partners to address the gaps for
for performance and • Accommodation, utility bills capacity building (involve
and security provided for most • Training scholarships
includes both the support by UCMB the UMU).
and technical staff in the staff.
Hospital • Technical support • Reduce on utility bills by
• Regular Continuing Medical from Uganda considering solar power
Education (CME) is provided to Martyrs University source and rain water
staff. (UMU) harvesting.
NKOZI HOSPITAL
Strategic plan: 2015/16 - 2019/20
25
26
2. Service Delivery. • Nkozi is the referral health • Increasing demand • Improve referral system.
NKOZI HOSPITAL
Refers to all interventions facility for the HSD with a for services. Strengthen general
that transform inputs to catchment population. service delivery for Nkozi
• Easy access for hospital.
outputs in the hospital • Expanding capacity for patient with injuries
(including infrastructure specialised care for General following road traffic • Improve management
and equipment available). Surgery and Obstetrics and accidents for emergency/causality
Gynecology. services
• Association with
Strategic plan: 2015/16 - 2019/20
• Availability of diagnostic sister hospitals with • Consider establishing a

services in from of X-ray and greater capacity Comprehensive Nurses’
Ultra-sound scan service. such as Nsambya Training School.
,Lubaga and Kitovu
• Extra space (land) for further Hospitals. • Widen scope for
expansion and development. specialised services with
• Lack of a nurses’ focus of Paediatric and
6. training school internal medicines.
within the district
• Building and equipment for 8.
and beyond.
basic service delivery
7. • Build strong associations
• Vehicles including ambulance with sister hospitals
and a four wheel vehicles used • Master plan for technical support
for service delivery. developed to (Consider monthly or
guide future weekly visits as capacity is
developments for built).
the land
3. Governance and • Catholic foundation • Political support from • Build capacity for
Leadership background for the hospital opinion leaders the Governance and
Management teams.
• Functional board of Governors • Close collaboration
and other management and support from • Strengthen community
structure. the MoH and Local participation in health
Government. service delivery
• Established governance and
management structures that • Support from the • Explore available support
are functional. coordination body from UCMB and other
UCMB agencies
• Availability of tested and key
management tools in form of • Support from the
the Hospital Charter, a Manual Local Government
on Financial and Material through the DHO
Resources Management,
Employment Manual,
Procurement and Disposal of
NKOZI HOSPITAL
Hospital Assets Manual etc.

Strategic plan: 2015/16 - 2019/20
27
28
NKOZI HOSPITAL
4. Finance management • Established finance • Presence of external • Improve efficient

management system with the audit system utilisation of available
required manpower and tools. (quarterly) for the funds
hospital
• Regular funding from user- • Strengthen the financial
fees. • Donor support for base for the hospital.
HIV/AIDs services and More focus on the
• Additional sources of revenue
Strategic plan: 2015/16 - 2019/20
external support for additional sources of

which include: Banks savings; capital investments. revenue.
Banana plantations; Tents
and chairs; eucalyptus tree • Funding support • Harmonise utilization of
plantation, etc. from GoU for donor support especially
delegated funds. for HIV
5. Health Information • Presence of a trained records • Irregular performance • Strengthen knowledge
Management officer. review meetings management and data
• Availability of hard ware (CMEs and HSD) utilisation in the hospital
computer and software for • Availability and • Expand on the electronic
HIV/AIDS programmes having access to data management:
• Establishes capacity for data the electronic HMIS Private ward, Finance
management in the hospital (District Health management etc.
and HSD. Information System- • Continuous capacity
• Availability of tools for data DHIS-2) building on data
management • Probable support from management.
• Presence of Nkozi Hospital stakeholders MoH,
website. UCMB etc. on data
management
NKOZI HOSPITAL
Strategic plan: 2015/16 - 2019/20
29
30
NKOZI HOSPITAL
6. Medicines vaccines • Established dispensary and • Reliable supply • Have regular supply for
and other related store for medicines and health for medicines and medicines and supply
supplies supplies. supplies from Joint • Explore possibility to stock
• Availability of the essential Medical Store. branded medical supplies
medicines and health supplies. • Occasional support for • Improve stock
• Control system for medicines medical supplies from management
and supplies management MoH
Strategic plan: 2015/16 - 2019/20
• Availability guidelines on use of • Middle class clients

medicines and supplies (insurance and UMU)
who can benefit from
branded medical
supplies
4.2 Weaknesses and threats and proposed strategies for mitigation
Table 2: Weaknesses and threats and proposed strategies for mitigation
Service area Weaknesses Threats Strategies for mitigation

1. Human Resources • Inadequate staff • Attractive salary from • Strengthen human
for Health: Government and other resource management
• Noncompetitive health institutions system
remuneration
• Strong job security for staff • Introduce income
• High turnover of staff in public health facilities generating staff
associations (SACCO)
• Restrictive career path
• Assess staffing needs
• Few staff leading to work
basing on work load.
over load
• Lack of incentives to attract

health workers
NKOZI HOSPITAL
Strategic plan: 2015/16 - 2019/20
31
32
NKOZI HOSPITAL
2. Service Delivery • Weak quality improvement • Improving health service • Operationalise quality
system delivery within the improvement framework
9. catchment area for Nkozi
• Common conditions for hospital • Strengthen and focus
health centres managed at more on specialised care
the HSD referral hospital • Increasing number of drug
shops. • Improve the infrastructure
• Specialised care not (old buildings, fencing,
Strategic plan: 2015/16 - 2019/20
streamlined to meet demand • Introduction of service diagnostic services and

in the catchment area provider in the UMU other equipment)
• Old infrastructure(old • Programme (ART clinic) • Increase efficiency with

buildings, diagnostic services specific support for service ambulance and power
and other equipment) delivery supply
• High operation costs for

some services such as
ambulance and power
supply
3. Governance and • Insufficient capacity for • Too many commitments for • Build capacity for
Leadership governance leadership and Board members. the Governance and
management for the hospital Management teams.
establishment • Inadequate facilitation for
HSD services. • Strengthen community
• Inadequate co-ordination of participation in health
the Management structures • Low community service delivery
hospital. participation in service
delivery. • Explore available support
• Weak system for the HSD from UCMB and other
coordination. agencies.
4. Finance • High operation costs for • Low household income for • Strengthen financial
management service delivery clients in the catchment systems in the hospital to
area minimize debtors etc.
• Weak financial base for the
hospital • Increasing donor • Streamline donor
dependence and donor funding into the
NKOZI HOSPITAL
• Ineffective system for debt fatigue hospital system (plan for

collection sustainability)
• Irregular GoU funding and
releases
• Increasing debtors to the

hospitals
Strategic plan: 2015/16 - 2019/20
33
34
NKOZI HOSPITAL
5. Health Information • Inadequate capacity on data • Parallel systems for data • Harmonise reporting in the
Management management for staff collection by projects in the hospital and HSD
• Lack of equipment for hospital/HSD • Prioritise availability of
knowledge management • Irregular supply of medical medical stationery
• Weak systems for stationery and other
communication including the logistics from MoH
website
Strategic plan: 2015/16 - 2019/20
6. Medicines vaccines • Increasing cost for medicines • Improved availability free • Review and streamline
and other related and health supplies medicines (ACTs, antibiotics medicines and health
supplies • Limited range of medicines etc.) and services in the HSD supplies to the hospital
provided at the hospital • Build capacity for
• Uncoordinated prescription medicines and health
practice. supplies management
4.3 Performance review analysis

Nkozi hospital has registered improved outputs for in all the service delivery
areas of outpatients, inpatients, deliveries, surgical operations, immunisation
and antenatal and postnatal services. There has been steady increase in common
disease conditions like malaria and Respiratory Tract Infections (RTI) and even
trauma and injury cases. The majority of the surgical operations during the period
under review were caesarian sections. Surgical cases for chronic conditions have
been also increased when the services of a surgeon became available from 2012.
The General ward was expanded which improved space for management of
admissions for private patient services. There is need for more reorganization of
the ward to have distinct male and female sections and also to improve sanitation
services available.
Support services expanded with the refurbishment of the laboratory services

where more informative tests can now be conducted to guide advanced
management of patients. There is still room for improvement especially regarding
diagnostic services with ultrasound and X-ray services. Having one theater
has been a limitation for emergence obstetric and gynecological cases in the
maternity wing.
The Hospital has been supporting HSD services in collaboration with the DHO’s
office. There has been steady improvement with increased patient load in all
health facilities in the HSD. This has been coupled with improved infrastructure
and staffing in these facilities enabling more access to free services to the
community.
35
Section 5: STRATEGIC DIRECTION

The strategic focus for the next five year shall focus on improving service delivery
for Nkozi hospital and ensure high quality and sustainability of the different
interventions as outlined below.
5.1 VISION
A Centre of Excellence for Holistic and Quality Health Care Service Delivery with
Christian Values, so that they may have life and have it more abundantly.
5.2 MISSION
To uplift the health standards of the community with preference to the most
vulnerable ones through a sustainable comprehensive model of high quality
health service delivery.
5.3 GOAL
To provide sustainable, accessible and high quality services to uplift health
standards of the community.
5.4 MOTTO
In God, We Serve and Care
5.5 GUIDING PRINCIPLES

• Christian focus: Working to emulate the work of Christ in order to meet
the needs of the patients particularly the most vulnerable.
• Team work: Working as a dependable one family. Networking and relying
on one another.
• Quality of Care: Serving as a model for comprehensive health service
delivery through ethical and professional conduct with mutual esteem at
all time.
• Results oriented: Focusing on activities that yield the desirable outputs
• Social obligation: To contribute to community development through
improved health by networking with all the stakeholders to ensure
accessible services
36
5.6 CORE VALUES
• Graciousness: God is able in all we do

• Compassion: Have feelings for those we serve and work with.
• Ethical conduct of conduct: Respect our clients and work professionally.
• Quality Assurance: Striving for excellence in all we do with adherence to
the required standards.
• Transparency: Be accountable and trustworthy.
• Self-motivation: Interest with ambition to progress on and on.
• Team work: Working as a dependable one family. Networking and
relying on one another
• Results oriented: Focusing on activities that yield the desirable outputs
5.7 STRATEGIC OBJECTIVES:
The four strategic objectives to be pursued during this period are the following:
1) Increase utilization of services at Nkozi hospital.

2) Improve the human resource management in Nkozi hospital.
3) Strengthen the financial system of the hospital.
4) Improve hospital governance, leadership and management.
5) Improve health standards for the community living in Mawokota South
Health Sub-District (HSD)
The strategic objectives have been based on both the current needs and what
was not achieved during the previous planning period. More emphasis is put on
what needs to be done to improve than on the routine activities that need to be
done in any hospital setting.
5.7.1 Strategic objective1: Increase utilisation of services at Nkozi Hospital
This is the raison d’etre of the hospital, which therefore constitutes the main
hospital function. To achieve this goal the hospital will improve on the range
of clinical and nursing services, expand the ancillary services, expand Clinical
Pastoral Care and Counseling, improve on medical records management (patient
data collection, recording, analysis, storage, retrieval and reporting), and expand
and furnish the facilitating hospital infrastructure as the main strategic objectives.
37
Strategy 1: Improve on the existing range of clinical and nursing services

provided:
Interventions:
• Plan for steady supply of medicines and health supplies
• Improving patient clinical and nursing care
• Ensure availability of adequate blood supply in the hospital.
• Introduce specialised clinics progressively during the implementation
period (Obstetrics and Gynecology; Surgical clinic, Diabetes,
Hypertension,).
• Expand dental care services
Recruit one dental assistant

Install modern dental equipment

• Improve and expand on diagnostic services
Procure Electrocardiogram (ECG); Automated Liver and Renal

function machines
Introduce culture and sensitivity testing and hematology

investigations
Strategy 2: To improve the quality of care offered in the Hospital

Interventions
• Operationalise quality improvement committees
• Training staff in customer care
• Developing or adapting and adopting technical quality of care protocols
and standards (e.g. Standard Operating Procedures for the laboratory)
• Carry out quality of care performance assessment and awards
• Conduct patient satisfaction survey
38
Strategy 3: To improve patient safety in the Hospital

Interventions
• Training staff on patient safety
• Develop /adopt and implementing patient safety protocols for the
Hospital (e.g. for surgical procedures, for vaginal delivery, for prescription
practices etc.)
• Beginning / strengthening error reporting mechanisms in various
hospital departments
• Establishing an Infection Control Committee
• Establishing an isolation unit within the hospital
Strategy 4: Expand on the Clinical Pastoral Care (CPC) and Counseling

Interventions:
• Training staff in CPC (target: at least 2 staff trained per year)
• Training staff in counseling services (the other option is to recruit
qualified counselors)
• Recruiting a qualified counsellor
• Recruit a medical social worker
Strategy 5: Improve health information management

Interventions:
• Capacity building in data management
• Plan to increase data utilisation in the hospital and HSD
• Computerize the data management system in all departments
• Create new office space for records.
• Provide logistical support for data management
• Improve and maintain Nkozi Hospital website
39
Strategy 6: Expand and furnish hospital infrastructure

Interventions:
• Expanding the Maternity ward and construct a theatre.
• Constructing a kitchen and a shelter for patients’ attendants
• Provide more recreation facilities (Television and radios for patients)
• Renovating the HIV/AIDS clinic
• Shelter the pathways connecting wards and theatre
• Provide a shade at the pharmacy
• Improve the hospital parking yard
• Procure more tents and chairs for hire
• Construct an accident & emergency unit
• Reduce on utility bills by introducing water harvesting tanks and solar
power supply
• Construct a new chapel
• Construct a wall fence and CCTV Cameras
• Improve the quality of buildings in the hospital (replace asbestos sheets
with iron sheets)
5.7.2 Strategic objective 2: Improve human resources management in Nkozi

Hospital
Human resources for health play an important part in service delivery. The next
five years shall focus on improving the number and quality of cadres for the
hospital. It is also important to address the challenges of attraction and retention
of staff during this period:
Strategy 1: To improve the working and welfare terms and conditions for
staff
Interventions
• Establishing a Space Management and Utilisation Policy for the hospital
(which governs eligibility and entitlement for accommodation and office
space, duration of tenancy, sharing of space etc.)
• Conducting regular salary reviews and adjustment to improve on the
remuneration for staff and make them competitive.
• Provide accommodation for all key staff of the hospital who should be
40
housed on site.
• Introduce medical insurance cover for the hospital staff.
• Computing and communicating the monetary value of all benefits
currently provided by the hospital to the staff
• Reviewing the package of fringe benefits provided to staff every two
years with a view to increase them and keep them attractive (e.g. funeral
expenses, medical care etc.)
Strategy 2: To establish a “Trans-generational” bond between the hospital

and the staff
Interventions:
• Establishing a policy on “Trans-generational” relationship between the
hospital and staff (to ensure that staff are committed for a long term,
and to reward staff who have been committed to the hospital for a very
long time)
• Identifying and supporting children of long-serving staff in their education
(e.g. with recommendation for scholarship by donors, offering them
hospital scholarships in the NTS, preference in recruitment as hospital
staff etc.)
• Assisting long serving staff to acquire loans for personal development
e.g. house construction, motor-vehicle purchase etc.
Strategy 3: To develop different skills among staff through specific

professional training and development programmes
Interventions
• Conducting Training Needs Assessment (TNA) annually
• Establishing a Staff Development Policy for the hospital (which covers
issues like eligibility for sponsorship/recommendation for sponsorship,
conditions for recommendation for further studies, which courses will
be sponsored etc.)
• Preparing a Staff Development Plan for the hospital (which covers issues
like what skills, knowledge or expertise are currently required for the
hospital, which people will be sponsored over the next 5 years and in
what order etc.)
• Developing an internal Continuous Professional Development (CDP)
41
plan (including exchange visits)

• Conducting training to develop specific knowledge, attitudes and skills
among the staff
• Searching for and identifying short courses for which staff of the
hospital can be sent, in order to develop local capacity (NB: In some
cases, there are some short courses which have a scholarship already
attached – e.g. UCMB courses, Stichting Porticus, a Dutch Organisation,
which offers scholarships mainly for religious people for bachelors and
masters degrees. The hospital could tap into this to develop a number
of Ggogonya sisters into health professionals who can carry more
responsibilities in the hospital.
• Providing staff with opportunities for sharing information especially on
return from courses in which they represented the hospital (including
exchange visits)
• Developing a policy on mentoring for the hospital (NB: This may need
training of staff in mentoring)
Strategy 4: To improve staff requirement for the hospital basing on actual

workload status
Interventions
• Determining the actual staffing requirements basing on the workload
levels using a suitable approach (e.g. WISN method)
• Reorganize and distribute available staff equitably on the basis of
workload e.g. during roster of nurses
Strategy 5: To improve staff retention within Nkozi hospital

Interventions:
• Determine and analyze regularly reasons for staff exist and retention.
This will involve conducting exit interviews with all departing staff to
determine their causes of departure to make strategies for improved
retention of the existing staff. Post-exit interviews shall be conducted
with staff who left the hospital earlier, to obtain their views on how the
work environment of the hospital can be improved
• Increasing the channels for conflict prevention and resolution within
the hospital
• Establishing staff incentive schemes (e.g. salary advance, hospital loans,
42
security for loans, staff SACCO, awards for long service, extra privileges
for long service etc.)
• Conducting staff expectations surveys/frontline provider assessment to
determine staff expectations and how they can be met by the hospital
annually
• Refining the staff appraisal system of the hospital, with the participation
of the staff
• Introducing a system of public acknowledgement of staff (e.g. on end-
of-year parties, on notice boards etc.)
Strategy 6: Strengthening the human resources management systems

Interventions:
• Implementing fully the Human Resource Management Manual
• Establishing a Staff Performance Review Board to advise the Management
Team on staff performance
• Establishing a Workplace Policy on HIV/AIDS and other chronic illnesses
• Establishing a Staff and Patient Safety Policy for the hospital (covering
issues such as hospital-acquired infection, violence, sexual assault etc.)
5.7.3 Strategic objective 3: IMPROVE FINANCIAL MANAGEMENT FOR THE

HOSPITAL
The hospital has three main sources of funding which are the user fees; PHC
delegated funds and donor support through various programmes such as CRS,
World Vision, Friends from abroad etc.
The following strategies shall aim at enabling better mechanisms for mobilizing
resources and ensure efficient and effective utilisation in order to achieve the
expected goal of the hospital.
Strategy 1: To reduce non-critical expenditure in the hospital

Interventions
• Establishment of a Hospital Efficiency Committee (whose role is to
identify, monitor and help to plug areas of wastage in the different
aspects of the hospital including utilities, personnel costs, medicines
and supplies)
43
• Strengthen the medicines and Therapeutics Committee (MTC)

• Conducting regular (e.g.bi-annual) pharmaceutical audits
• Conducting cost-consciousness/awareness training sessions for all
hospital staff
Strategy 2: To improve financial management for the hospital

Interventions:
• Training accounting and finance staff in the use and maintenance of the
installed accounting package
• Implementing fully the hospital’s Financial Management Manual
• Networking finance and accounting computers for easy sharing of
information
• Appointment of a substantive Internal Auditor for the hospital
• Opening and depositing funds on reserve fund accounts for all key
capital items
• Investing annual surpluses in high-return ventures (e.g. treasury bills
and fixed deposit accounts)
Strategy 3: Increasing local revenues from different sources for hospital

activities
Interventions
• Appointing a full-time focal person for fundraising activities for specific
hospital projects (feasibility to be further explored)
• Increasing the Bed Occupancy Rate in the private ward through
improved client care both clinical and non-clinical care (which bring in
more revenue)
• Regularly review user fees in the hospital to ensure proper costing and
revenue collection.
• Ensuring full time availability of a medical officer for private ward
patients on weekends.
• Soliciting for capital donations (e.g. medical and office equipment) from
alumni and other local individual and corporate friends of the hospital
• Build capacity for the hospital in preparation for the proposed National
Health Insurance Scheme (NHIS)
44
• Advocating for an increase of the PHC Conditional Grant (PHC-CG) from

the central government (using UCMB, DLG etc)
• Establish Associations that can support the hospital such as: 1) Born or
Delivered) in Nkozi Association to support Maternity Services, 2) Friends
of Nkozi to support general services.
Strategy 4: To create additional sources of revenues for the hospital

(Income generating activities)
Interventions:
• Identification of external partners who can support the hospital
financially (to consider friends, research institutions, NGOs, charitable
organizations, foreign governments, the Holy See, banks, bilateral and
multilateral agencies)
• Writing project proposals for external support
• Soliciting for in-kind support from the government and external partners
e.g. staff secondment, volunteer health workers etc.
• Reviewing the financial feasibility of taking bank loans for critical capital
investments e.g. construction of hostel which will bring in more financial
resources
• Mobilize for an endowment fund for investing in an income generating
venture such as students hostels or building a hospital restaurant
5.7.4 Strategic objective 4: IMPROVING GOVERNANCE, MANAGEMENT AND

OPERATIONAL SYSTEMS OF THE HOSPITAL
The governance and management structure were described is as described in

chapter two. The next five years of implementing the strategic plan shall lay
emphasis on the need to strengthen the organisation and operations of the
established structure for governance and management of the hospital. This
section outlines the objectives and strategies to be used to achieve this objective:
Strategy 1: To increase the effectiveness of the Board of Governors (BOG)

Interventions
• Build capacity for leadership and management for the members of the
BOGs.
o Conduct induction/orientation of the new members of the new BOG
45
o Conduct a Training Needs Assessment (TNA) for the skills necessary

for BOG members
o Training members of the BOG in specific skills necessary to perform

their responsibilities
• Develop and implement monitoring and evaluation system on
performance of the BOGs.
• Establishing a mechanism for following up the implementation of BOG
decisions
Strategy 2: To strengthen the performance of the Management Team

Interventions
• Develop and implement monitoring and evaluation system on
performance of the Hospital Management Team
• Strengthen capacity for leadership and management among the senior
hospital staff (including the Hospital Management Team).
• Providing exposure opportunities (e.g. through study visits, scientific
talks etc. ) to members of the BOG, Management Team, Managing
Congregation and staff
• Establishing a mechanism for following up the implementation of
Management Team decisions
• Conducting joint retreats between the BOG and Management Team
(e.g. one every two years, in which the BOG emphasizes the strategic
direction of the hospital and their expectations to the Management
Team)
• Conducting retreats of the Management Team members (at least once a
year, for team-building and to consider and approve the annual plan of
the following year, among others)
Strategy 3: Strengthening the general management systems

Interventions
• Review and update the existing hospital constitution
• Review and update the existing management hospital manuals:
Employment manual; Financial management manual, etc.)
• Develop Quality Assurance Guidelines and Standards (QAGS) for the
46
hospital
• Constituting internal support supervision teams
• Conduct regular general staff meetings (at least twice a year)
• Implement the hospital financial management manual
Strategy 4: Strengthening the equipment, space, plant and infrastructure

management systems
Interventions
• Developing a Space and Housing policy for the hospital (covering issues
such as acquisition, use, equitable distribution, tenancy, maintenance,
master planning, location of buildings, location of activities, etc.)
• Establishing a Space and Housing committee for the hospital
• Establishing a policy on the management of equipment and plant
(covering issues such as acquisition, maintenance, use, user-training
and disposal)
• Instituting regular inventory, inspection and maintenance of equipment,
buildings and plant
• Establish a system for monitoring (reporting, recording and responding
to reports of breakages and malfunction) equipment.
5.7.5 Strategic objective 5: IMPROVE HEALTH STANDARDS FOR THE

COMMUNITY LIVING IN MAWOKOTA
SOUTH HEALTH SUB-DISTRICT (HSD)
Nkozi hospital shall continue to support HSD service delivery. The core functions
HSD include planning and budgeting, support supervision, resource mobilisation
and coordination of service delivery in the HSD. Nkozi hospital is the referral
health facility for the catchment area and beyond.
Strategy 1: Strengthen coordination of HSD services

Interventions
• Support and coordinate Government/MoH health programmes in the
HSD.
• Conduct regular planning and budgeting meeting.
• Coordinate regular (quarterly) HSD performance review meetings
• Conduct regular support supervision for the HSD
47
• Strengthen PHD department at Nkozi Hospital (HSD transport, computer,

staff, logistical requirements etc.)
Strategy 2: Strengthen Primary Health Care (PHC) activities

Interventions
• Coordinate community health focused interventions (immunization,
health education and promotion)
• Participate and coordinate in Government health programmes
o Child Days Plus and Mass Immunization campaigns, etc.
• Conduct integrated community outreaches
• Conduct school health programmes
Strategy 3: Coordinate control of communicable diseases

This shall focus is on reduction of mortality and morbidity rates and improve
standard of living among people living in Mawokota South HSD
Interventions:
• Operationalise Integrated Community Case Management (ICCM) in the
HSD
• Coordinate TB, Malaria and HIV counselling and Testing services
• Procure and distribute commodities for prevention of communicable
diseases such the Insecticide Treated Mosquito nets (ITNs)
• Improve sanitation services by coordinating effort to improve latrine
coverage and access to safe water.
Strategy 4: Contribute to reduction of maternal and neonatal morbidity

and mortality
This strategy shall aim at increasing number of mothers delivering in health units,
reduce maternal and neonatal mortality rates and reduce HIV mother-to-child
transmission. The following strategies shall be used:
Interventions
• Coordinate provision of sexual and reproductive health services within
the community and at the lower level health units.
48
• Coordinate HSD regular (quarterly) maternal and peri-natal death

review meetings.
• Strengthen provision of the comprehensive emergence obstetric and
neonatal care (EmONC) services.
• Strengthen antenatal and the elimination of mother to child transmission
of HIV/AIDS (e-MTCTC) and safe delivery.
Strategy 5: Improve HSD transportation services

The HSD requires vehicle for effective coordination of services at the different
levels of service delivery. This include transportation of the sick to the referral
HSD health facility and beyond to the bigger referral units depending on the
condition of the patient. The lower level health facilities require motor cycles and
bicycles.
Interventions
• Mobilise resources to procure low fuel consumption ambulance; multi-
purpose HSD vehicle; motor cycles and bicycles for the HSD.
• Plan and coordinate regularly maintenance of HSD vehicles.
• Plan for availability of sufficient fuel for the vehicles
Strategy 6: Improve HSD quality of services
This strategy shall priorities operationalisation of the health sector quality

improvement framework and strategic plan by the MoH. There shall be additional
emphasis on improving safety, infection control and waste management.
Interventions
• Introduce and operationalise quality improvement (QI) structures
(Quality Improvement Committees/Teams-QIC/Ts and Work
Improvement Teams-WITs)
• Coordinate regular quality improvement meetings and reporting
• Plan and budget for provision of logistical supplies for QI
• Develop workers and patient safety guidelines
o Maintaining well serviced fire extinguishers
o Construct a perimeter wall around the hospital
49
50
Section 6: MONITORING AND EVALUATION OF THE STRATEGIC PLAN
NKOZI HOSPITAL
MONITORING AND EVALUATION FRAMEWORK FOR NKOZI HOSPITAL STRATEGIC PLAN FOR 2015/16 –
2019/20
STRATEGIC OBJECTIVE 1: INCREASE UTILISATION OF SERVICES IN NKOZI HOSPITAL
Activities / inter- Indicators / out- Means of 5 year Responsible Yr. Yr. Yr. Yr. Yr. Critical As-
Strategic plan: 2015/16 - 2019/20
1 2 3 4 5
vention put verification Target office / Unit sumptions
Ensuring steady Availability / stock Inventory and Hospital Ad- The demand
supply of med- out of medicines, stock records ministrator remains rel-
icines, sundries sundries and atively the
and equipment equipment same
Improving patient Cross-infection Client satis- MD Staffs active-
clinical and nurs- rate, ALOS, cure faction survey ly involved
ing care and satis- rates report in improving
faction clinical and
Number of clients HMIS reports, nursing care/
satisfied with the Annual re- satisfaction
services ports
Ensuring that pa- Number of pa- HMIS reports, MD
tients access ser- tients utilizing the
vices at reduced hospital services User fees
user fees rates
Procuring reagents Number of re- Procurement Hospital Ad- The chemis-
for automatic liver agents LFT/ RFT records, in- ministrator try machine
and renal function machines in place ventory list donated for
machines the ART pro-
gramme can
be shared for
other non
ART cases
Increasing avail- Number of units Blood register MD The supply
ability of and ac- of blood in place of blood
cess to blood from the
blood bank is
maintained
Introduce a nu- Nutrition unit in Nutrition unit MD Integrative
trition clinic and place records approach is
employ a nutrition feasible
nurse Nutrition Nurse Staff list
recruited
NKOZI HOSPITAL
Introduce diabetic Diabetic and hy- Diabetic and MD Staff are

and Hypertension pertension clinics hypertension motivated
clinic in place unit records to learn and
attrition is
minimal.
Strategic plan: 2015/16 - 2019/20
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52
Strategy 2: To expand ancillary services
NKOZI HOSPITAL
2.1 Introduce ophthalmology services

- Recruit Ophthal- No. of Ophthalmic Staff list MD Staff are
mic Clinical Officer Clinical Officers motivated
OR (OCO) recruited Ophthalmology to remain
(1) Treatment reg- working and
- Train existing C/O ister there is low
in ophthalmology No. of Clinical attrition
Strategic plan: 2015/16 - 2019/20
services Officers trained in

Ophthalmology
services e.g. cat-
aract surgery etc)
(1)
- Recruit Ophthal- No. of Ophthalmic Staff list MD
mic Assistants Assistants recruit-
ed (1)
- Train nurses in No. of existing Duty plan MD Low attri-
eye care nurses trained in tion of the
eye care (2) trained staff
- Procure basic eye Basic eye care Ophthalmology MD and ad-
care equipment equipment pro- dept inventory ministrator
cured
- Procure basic mi- Basic minor sur- Ophthalmology MD and ad-
nor surgery equip- gery equipment dept inventory ministrator
ment for eye care for eye care pro-
cured
2.2. Introduce orthopedic services
Recruit one Ortho- Orthopaedic Offi- Staff list MD Staff are
pedic Officer cer recruited motivated
to remain
working and
there is low
attrition
Recruit one Ortho- Orthopaedic As- Staff list MD
paedic Assistant sistant recruited
Obtain basic or- Basic orthopaedic Inventory MD and ad-
thopedic equip- equipment pro- ministrator
ment cured
Expand dental care services
NKOZI HOSPITAL
Recruit one Dental 1 Dental Officer Staff list MD

Officer recruited
Obtain basic den- Basic dental Inventory MD and ad-
tal equipment equipment pro- ministrator
cured
2.4 Expand laboratory services
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54
Introduce culture Number of cul- Lab register
tures grown and
NKOZI HOSPITAL
and sensitivity
testing sensitivity tests
done
Introduce haema- Number of hema- Lab register MD
tology investiga- tology tests done
tions
Introduce labora- Number of tests Department lab MD and ad-
Strategic plan: 2015/16 - 2019/20
tory investigations carried out at the register ministrator

in different de- departments
partments
Training staff in Number of staff Staff list Nursing Direc- Staff appre-
technical quality trained in quality tor ciate Quality
of care of care of care
Training staff in Number of staff Staff list Nursing Direc- Staff appre-
customer care trained in custom- tor ciate cus-
er care tomer care
Developing or Number of specif- Displayed SOPs MD Staff appre-
adapting and ic SOPs available ciate pro-
adopting technical and displayed tocols and
quality of care standards
protocols and
standards (e.g.
Standard Operat-
ing Procedures for
the laboratory)
Conducting and Number of sur- Survey results/ MD and ad-
utilizing surveys veys conducted report ministrator
on patients’ ex-
pectations Number of rec-
ommendations
implemented Activity report
Organising open Number of open Attendance list MD/Admin

forums on a quar- forums conducted and minutes
ter basis
NKOZI HOSPITAL

using patients’ ex- veys conducted report ministrator
perience surveys
to improve quality
of care
Number of rec- Activity report
ommendations
implemented
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56
veys conducted report ministrator
NKOZI HOSPITAL
utilizing findings
of patient satisfac-
tion surveys
Number of rec- Activity report
ommendations
implemented
Conducting tech- Number of evalu- Evaluation re- MD and ad-
Strategic plan: 2015/16 - 2019/20
nical evaluation ations carried out port ministrator

of quality of care/
service provision
assessment
Training staff in Number of staff Staff list Nursing direc-
patient safety trained in patient tor
safety
Developing / Number of safety Displayed pro- MD
adopting and protocols avail- tocols
implementing pa- able/ displayed in
tient safety proto- the hospital
cols for the Hospi-
tal (e.g. for surgi-
cal procedures, for
Proportion of staff
vaginal delivery,
with knowledge
for prescription
about the safety
practices etc)
protocols
Beginning / Number of inci- Incident report- Assistant Nurs-
strengthening dents reported ing forms ing director
error reporting
mechanisms in
various hospital
departments
Establishing an Infection Control Minutes Nursing direc- Hospital can
Infection Control Committee in tor adequately
NKOZI HOSPITAL
Committee place fund com-

mittee ac-
tivity
Establishing an Number of clients Isolation unit in MD Resources
isolation unit with- admitted in the place are available
in the hospital isolation unit
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58
NKOZI HOSPITAL
Training staff Number of staff Staff list Nursing direc-

in CPC (target: trained in CPC tor
at least 2 staff
trained per year)
Training staff in Number of trained Staff list Nursing direc-
counselling ser- counsellors avail- tor
vices (the other able
Strategic plan: 2015/16 - 2019/20
option is to recruit
qualified counsel-
lors)
Recruiting a quali- Qualified counsel- Staff list Nursing direc-
fied counsellor lor in place tor
Recruit a medical Medical social Staff list MD
social worker worker in place
Strategy 6: Improve medical records management
Computerize the Data management Departmental Administrator Computers
data management system comput- computers and Accoun- available,
system in all de- erized tant packages
partments Computerized available,
data access staff trained
points
Create new office Records office/ Records office Administrator
space for records department in
place
Procure filling Number of filling Procurement Administrator Resources
cabins cabinets procured documents available
Inventory
Strategy 7. Expand and furnish hospital infrastructure
Expanding the Maternity ward Maternity the- Administrator Demand for
Maternity Ward expanded atre in place maternity
and put Theatre services
keeps rising,
funds be-
Bed capacity of
come avail-
maternity ward
able
Construction of Accident and A& E Building Availability
the accident and Emergency unit in of funds
emergency unit place Administrator
NKOZI HOSPITAL
Relocation of the Antenatal clinic Antenatal clinic

antenatal clinic to relocated in a different
create space for location
parking
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60
Constructing a Patients’ shelter Patients’ shelter Administrator
NKOZI HOSPITAL
kitchen and a shel- and kitchen con-

ter for patients’ structed
attendants
Patients’ kitchen
Procuring televi- Number of TV sets Physical verifi- Administrator
sion sets and radi- and radios pro- cation
os for patients cured
Renovating the HIV/AIDS clinic Renovation re- Administrator
Strategic plan: 2015/16 - 2019/20
HIV/AIDS clinic renovated ports

Shelter the path- Number of path- Sheltered Path- Administrator Funds are
ways connecting ways sheltered ways available
wards and theatre
Construct a shade Pharmacy shade Construction Administrator Funds are
at the pharmacy in place report available
Demarcate a place Hospital parking Designated Administrator Space avail-
for hospital park- area in place parking area in able for reor-
ing place ganization
STRATEGIC OBJECTIVE 2: IMPROVE HUMAN RESOURCES IN NKOZI HOSPITAL
Strategy 1: Ensure there are competitive and equitable salaries for staff of Nkozi Hospital
Conducting bian- Number of sur- Survey reports Hospital Ac-
nual salary and veys conducted countant
working condi-
tions surveys in
equivalent insti-
tutions within the
region just for
comparison
Conducting a re- Proportion of Payrolls Hospital Ac-
view of salaries staffs who had a countant
every two years, salary increase
with a view to
Review reports
increase as and
when the means
allow
NKOZI HOSPITAL
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62
Making the pay- Salary scale in Salary scale Hospital Ac-
place countant
NKOZI HOSPITAL
ment structure of
the hospital more
equitable internal-
Payroll
ly and externally
Strategy 2: Put in place attractive working and welfare terms and conditions
Establishing a Space manage- Policy docu- Administrator
Space Manage- ment and utiliza- ment
Strategic plan: 2015/16 - 2019/20
ment and Utilisa- tion policy in place

tion Policy for the
hospital (which
governs eligibility
and entitlement
for accommoda-
tion and office
space, duration of
tenancy, sharing
of space etc)
Providing housing Number of key Staff accommo- Administrator
for all key staff of staff housed at the dation report
the hospital who hospital
should be housed
on site
Providing suitable Number of staff Physical verifi- Administrator
housing for all houses refurbished cation
housed hospital to be more suit-
staff by refurbish- able for the staff
ing houses that
need it
Making statutory Proportion of staff Staff list Administrator
contributions to for whom statu-
the Social Secu- tory contributions Payroll
rity of all staff are made
employed by the
hospital
Making statutory Proportion of eligi- Staff list Administrator
deductions to- ble staff for whom
wards PAYE for statutory deduc- Payroll
all eligible staff tions are made
employed by the
hospital
NKOZI HOSPITAL
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64
Assisting staff to Proportion of staff Verbal interview Administrator Presence of
accessing state- computers
NKOZI HOSPITAL
obtain regular
financial statements of their
ments on their NSSF deposits Staff com-
NSSF deposits puter skills
and willing-
ness is guar-
anteed
Introduce and im- Terminal benefits Benefits policy Administrator
Strategic plan: 2015/16 - 2019/20
plement a policy policy in place

on terminal bene-
fits for long-serv-
ing staff of the
hospital
Providing afford- Proportion of staff Staff list Administrator
able medical in- covered by the
surance cover for medical insurance
the staff of the scheme
hospital
Computing and Number and Benefits policy Administrator
communicating monetary value of document
the monetary val- benefits provided
ue of all benefits by the hospital to
currently provided its staff
by the hospital to
the staff
Reviewing the Number of reviews Review reports Administrator
package of fringe on fringe benefits
benefits provided provided to the
to staff every two staff
Benefits policy
years with a view
to increase them
and keep them
attractive (e.g.
funeral expenses,
medical care etc.)
NKOZI HOSPITAL
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66
Strategy 3: Establish a “Trans-generational” bond between the hospital and the staff
NKOZI HOSPITAL
Establishing a pol- Number of long Trans-genera- Nursing direc-

icy on “Trans-gen- serving staffs tion policy tor
erational” rela-
tionship between
the hospital and
Number of staff Staff attrition
staff (to ensure
being recruited rate
that staff are
committed for a
Strategic plan: 2015/16 - 2019/20
long term, and

to reward staff Number of staff
who have been leaving the hos-
committed to the pital
hospital for a very
long time)
Identifying and Number of Trans-genera- Administrator
supporting chil- long-serving staff tion policy
dren of long-serv- whose children are
ing staff in their benefiting from
education (e.g. the hospital sup-
Beneficiaries
with recommen- port
register
dation for schol-
arship by donors,
offering them hos-
pital scholarships
in the NTS, pref-
erence in recruit-
ment as hospital
staff, requesting
for scholarship
from the Universi-
ty, etc)
Assisting long Number of staff Beneficiaries Administrator
serving staff to who accessed register
NKOZI HOSPITAL
acquire loans for loans for personal

personal develop- development with
ment e.g. house hospital assistance
construction,
motor-vehicle pur-
chase etc.
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68
Strategy 4: Develop different skills among staff through specific professional training and development programmes
NKOZI HOSPITAL
Conducting Number of assess- Assessment re- Nursing direc-

Training Needs ments carried out ports tor
Assessment (TNA)
annually
Establishing a Staff Staff Development Staff Develop- MD
Development Poli- Policy in place ment Policy
cy for the hospital
Strategic plan: 2015/16 - 2019/20
(which covers is-

sues like eligibility
for sponsorship/
recommendation
for sponsorship,
conditions for rec-
ommendation for
further studies,
which courses will
be sponsored etc)
Preparing a Staff Staff Development Staff Develop- Administrator
Development Plan Plan in place ment Plan
for the hospital
(which covers
issues like what
skills, knowledge
or expertise are
currently required
for the hospital,
which people will
be sponsored over
the next 5 years
and in what order
etc)
Developing an in- Internal CPD plan CPD schedule MD
ternal Continuous in place
Professional De-
velopment (CDP)
CPD plan
plan (including
NKOZI HOSPITAL
exchange visits)
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70
Conducting train- Number of train- Training register MD
ing sessions con-
NKOZI HOSPITAL
ing to develop
specific knowl- ducted
edge, attitudes
and skills among Number of staff
the staff trained
Searching for Number of short Certificates of MD and Ad-

and identifying courses supported graduates ministrator
short courses for by the hospital
Strategic plan: 2015/16 - 2019/20
which staff of
the hospital can
be sent, in order
to develop local Beneficiary list
capacity (NB: In
some cases, there
are some short
courses which
have a scholarship
already attached
– e.g. UCMB
courses, Stichting
Porticus, a Dutch
organisation,
which offers schol-
arships mainly for
religious people
for bachelors and
masters degrees.
The hospital could
tap into this to
develop a num-
ber of Ggogonya
sisters into health
professionals who
can carry more
responsibilities in
the hospital.
NKOZI HOSPITAL
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72
Providing staff Number of ses- CPD register MD
sions presented
NKOZI HOSPITAL
with opportunities
for sharing infor- by staff returning
mation especially from short cours-
on return from es and workshops
courses in which
they represented
the hospital (in-
cluding exchange
Strategic plan: 2015/16 - 2019/20
visits)
Developing a pol- Hospital men- Staff/ mentors Administrator
icy on Mentoring torship policy in list
for the hospital place
(NB: This may
need training of
staff in mentoring)
Strategy 5: Determine the actual workload-based requirements for staff
Determine activity Number of ser- Activity stan- MD and Nurs-
standards (activ- vices offered in dards ing director
ities and time it each department
takes the staff to
execute them) Number of activ-
ities undertaken
for each service
Duration of each
activity
Determine the an- Total number of HMIS annual MD and Nurs-
nual workload individuals access- report ing director
ing each service in
a year Departmental
registers
NKOZI HOSPITAL
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74
Determining the Number of staff WISN report MD and Nurs-
required in each ing director
NKOZI HOSPITAL
actual staffing re-

quirements basing department
on the workload
levels using a
suitable approach
(e.g. WISN meth-
od)
Distributing avail- Proportion of Duty plans MD and Nurs-
Strategic plan: 2015/16 - 2019/20
able staff equita- positions filled by ing director

bly on the basis qualified staff in
of workload e.g. each department
during rostering of
nurses
Strategy 6: Improve staff retention within Nkozi hospital
Conducting exit Number of staff Staff list Nursing direc-
interviews with all left the organiza- tor
departing staff to tion
determine their
Interview re-
causes of depar-
ports
ture and how such
Number of exit
reasons can be
interviews con-
addressed for re-
ducted
maining staff
Conducting Number of exit Interview re- Nursing direc-
post-exit inter- interviews con- ports tor
views with staff ducted
who left the hos-
pital earlier, to
obtain their views
on how the work
environment of
the hospital can
be improved
Increasing the Number of chan- Flow charts Administrator
channels for con- nels for conflict
flict prevention prevention and
and resolution resolution
Organogram
within the hospital
Establishing staff Number of staff List of schemes Hospital Ac-
incentive schemes incentive schemes countant
(e.g. salary ad- available
NKOZI HOSPITAL
vance, hospital
loans, security for
loans, staff SAC-
CO, awards for
long service, extra
privileges for long
service etc)
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76
Conducting staff Number of staff Survey reports Nursing direc-
satisfaction sur- tor
NKOZI HOSPITAL
expectations sur-
veys/frontline pro- veys conducted
vider assessment
to determine staff
expectations and
how they can be
met by the hospi-
tal annually
Strategic plan: 2015/16 - 2019/20
Refining the staff Staff appraisal Staff appraisal MD and Nurs-

appraisal system forms in place form ing director
of the hospital,
with the participa-
tion of the staff
Number of hospi- Filled appraisal
tal staff appraised forms
Introducing a sys- System of public System in place MD and Ad-
tem of public ac- acknowledgement ministrator
knowledgement of in place
staff (e.g. on end-
of-year parties, on
notice boards etc)
Number of staff
acknowledged
publicly
STRATEGIC OBJECTIVE 3: ENSURE SUSTAINABLE FINANCIAL BASE FOR THE HOSPITAL
Strategy 1: Reduce non-critical expenditure in the hospital
Establishment of Hospital Efficiency Hospital Effi- Administrator
a Hospital Effi- Committee in place ciency Com-
ciency Committee mittee
(whose role is to
identify, monitor
and help to plug
areas of wastage
in the different Minutes
aspects of the Number of meetings
hospital including held by the commit-
utilities, personnel tee
costs, medicines
and supplies)
Number of areas of
wastage identified
Operationalising Committee in place Composition MD
NKOZI HOSPITAL
the medicines and and

Therapeutics Com-
mittee (MTC) Minutes
Number of meetings
held
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78
Conducting regu- Number of pharma- Audit re- MD
ceutical audits carried ports
NKOZI HOSPITAL
lar (e.g. bi-annual)

pharmaceutical out
audits
Conducting Number of cost-con- Attendance MD
cost-conscious- sciousness/awareness list
ness/awareness training sessions held
training sessions
for all hospital
Strategic plan: 2015/16 - 2019/20
CPD register
staff
Strategy 2: Improve financial management
Installing an ac- Accounting package Accounting Hospital Ac-
counting package installed package countant
suitable for the
needs of the hos-
pital in relevant
Backup system in Backup sys-
computers with a
place tem
suitable back-up
system
Training account- Number of staff Staff inter- Hospital Ac-
ing and finance trained in use and views countant
staff in the use maintenance of the
and maintenance installed accounting
of the installed ac- package
counting package
Implementing Number of copies of Copy of the Hospital Ad-
fully the hospital’s the manual available Financial ministrator
Financial Manage- Manage-
ment Manual ment Man-
ual
Networking Computer network Computer Hospital Ac-
finance and ac- connecting finance network countant
counting comput- and accounts depart-
ers for easy shar- ment in place
ing of information
Reports
Appointment of a Internal hospital audi- Internal au- Administrator
NKOZI HOSPITAL
substantive Inter- tor in place ditor

nal Auditor for the
hospital
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80
Opening and de- Amount of funds Bank state- Hospital Ac-
deposited on the re- ments countant
NKOZI HOSPITAL
positing funds on
reserve fund ac- serve fund account(s)
counts for all key
capital items
Cash flow
statement
Investing annu- Total of annual sur- Bank state- Hospital Ac-
al surpluses in pluses ments countant
Strategic plan: 2015/16 - 2019/20
high-return ven-
tures (e.g. trea-
sury bills and fixed
Amount of funds in- Cash flow
deposit accounts)
vested in high return statement
ventures
Strategy 3: Increasing local revenues from different sources for hospital activities
Appointing a full- Full-time focal person Amount of Hospital Ac-
time focal person for fundraising activi- funds raised countant
for fundraising ac- ties in place
tivities for specific
hospital projects
(feasibility to be
further explored)
Increasing the Number of individ- Bed occu- MD and Nurs-
bed occupancy uals accessing in- pancy rate ing director
rate in the private patient services on for private
ward through im- private ward ward
proved client care
both clinical and
non clinical care
(which bring in
more revenue)
Increasing the Proportion of in- Private pa- Hospital Ac-
charges in the crement of patient tients price countant
private ward (af- charges on private list
ter improving the ward
quality of services
in that ward)
Ensuring full time medical officer for Doctors duty MD
availability of a private ward patients rota
medical officer in place
NKOZI HOSPITAL
for private ward

patients even on
weekends.
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82
Introduce 14” co- Number of 14’’ co- TV sets Administrator
lour TV sets procured
NKOZI HOSPITAL
lour TVs in the in-

dividual rooms of
the private ward
Ward inven-
beginning with 2
tory
rooms as an ex-
periment to see
whether the de-
mand increases)
Strategic plan: 2015/16 - 2019/20
Soliciting for capi- Number of capital do- Receipt doc- Hospital Ac-
tal donations (e.g. nations received uments countant
medical and office
equipment) from
alumni and other
local individual
and corporate
friends of the hos-
pital
Positioning the The hospital accredit- Accredita- MD and Ad-
hospital to provide ed to provide service tion report ministrator
the service for the for NHI
proposed National
Health Insurance
(NHI) [This re-
quires that the
hospital improves
its quality of care
to a level where it
can be accredited
to provide the ser-
vices.].
Advocating for an Percentage increase Income Hospital Ac-
increase of the in PHC conditional statement countant
PHC Conditional Grant
Grant (PHC-CG)
from the central
government (using
NKOZI HOSPITAL
UCMB, DLG etc)

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83
84
Establish Associa- Number of Associa- Associations Administrator
tions established to register
NKOZI HOSPITAL
tions that can sup-

port the hospital support the hospital
such as: 1) Born
or Delivered) in
Support re-
Nkozi Association
ports
to support Mater-
nity Services, 2)
Friends of Nkozi
Strategic plan: 2015/16 - 2019/20
to support general
services.
Strategy 4: Mobilize resources for continued income generation and sustainability
Identification of Number of partners Hospital re- Hospital Ac-
external partners financially supporting ports countant
who can support the hospital
the hospital finan-
cially (to consider
List of part-
friends, research
ners
institutions, NGOs,
charitable organi-
sations,
foreign govern-
ments, the Holy
See, banks, bilat-
eral and multilat-
eral agencies)
Writing project Number of project Proposal Administrator

proposals for ex- proposals written documents
ternal support Nursing direc-
tor
Soliciting for in- Number of staff Staff list MD and Nurs-

kind support from seconded by governing director
the government ment
and external
partners e.g. staff
secondment,
Number of volunteer
volunteer health
health workers
workers etc
NKOZI HOSPITAL
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85
86
Mobilize for an Endowment fund in IGAs Administrator
place and
NKOZI HOSPITAL
endowment fund
for investing in an
income generating Hospital Ac-
Cash flow countant
venture such as
Number of IGA in statement
students hostels
place
or building a hos-
pital restaurant
STRATEGIC OBJECTIVE 4: IMPROVING GOVERNANCE, MANAGEMENT AND OPERATIONAL SYSTEMS OF THE HOSPITAL
Strategic plan: 2015/16 - 2019/20
Strategy 1: Increase the effectiveness of the Board of Governors (BOG)

Conducting induc- Number of new Induction Administrator
tion/orientation of members of BOG in- report
the new members ducted
of the new BOG
Developing and Number of criteria Criteria in Administrator
implementing developed and imple- place
local and appro- mented
priate benchmark
criteria for moni-
toring the perfor-
mance of the BOG
Conducting a Number of TNAs car- TNA reports Administrator
Training Needs ried out
Assessment (TNA)
for the skills nec-
essary for BOG
members
Training members Number of members Training cer- Administrator
of the BOG in of the BOG trained tificates
specific skills nec-
essary to perform
their responsibil-
ities
Developing and Performance criteria Performance Administrator
applying criteria to in place report
monitor the per-
formance of indi-
vidual members of
the BOG
NKOZI HOSPITAL
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88
Establishing a Number of action Minutes Administrator
points from BOG
NKOZI HOSPITAL
mechanism for
following up the meetings implement-
implementation of ed
Hospital re-
BOG decisions
ports
Follow up mechanism
in place
Strategic plan: 2015/16 - 2019/20
Harmonising the Policy document on Policy docu- Administrator

understanding roles and relation- ment
of the roles and ships of the different
relationships of stakeholders
the Owner, the
Board of Trustees,
the Board of Gov-
ernors, the Man-
agement and the
Managing Con-
gregation among
these different
stakeholders
Strategy 2: Strengthen the role of the Managing Congregation in supporting the hospital
Developing and Benchmark criteria Criteria Medical Direc-
applying bench- in place tor
mark criteria for
monitoring the
role of the Manag-
ing Congregation
Assisting the Managing Congrega- Develop- Administrator
Managing Congre- tion capacity devel- ment plan
gation in capacity opment plan in place
development to
enable them to
fulfill their role
Strategy 3: Strengthen the performance of the Management Team
Developing and Benchmark criteria Performance MD
applying bench- in place report
mark criteria for
NKOZI HOSPITAL
monitoring the
performance of
the Management
Team
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90
Developing and Benchmark criteria Performance Administrator
in place report
NKOZI HOSPITAL
applying bench-
mark criteria for
monitoring the
performance of
the individual
members of the
Management
Team
Strategic plan: 2015/16 - 2019/20
Developing man- Number of staff Staff list Administrator

agement skills trained with training
among senior hos- in management of
pital staff (includ- hospital services
Training cer-
ing Management
tificates
Team members) to
develop capacity
for management
roles in the hos-
pital
Providing expo- Number of members Exposure re- Administrator
sure opportuni- benefiting for expo- ports
ties (e.g. through sure opportunities
study visits, sci-
entific talks etc)
to members of
the BOG, Man-
agement Team,
Managing Congre-
gation and staff
Establishing a Follow up mechanism Implementa- Medical Direc-
mechanism for in place tion reports tor
following up the
implementation
of Management
Team decisions
NKOZI HOSPITAL
Strategic plan: 2015/16 - 2019/20
91
92
Conducting joint Number of joint re- Hospital re- Administrator
retreats between treats held between ports
NKOZI HOSPITAL
the BOG and the HMT and BOG

Management
Team (e.g. one
Retreat re-
every two years,
ports
in which the BOG
emphasizes the
strategic direction
Strategic plan: 2015/16 - 2019/20
of the hospital and

their expectations
to the Manage-
ment Team)
Conducting re- Number of HMT re- Retreat re- MD
treats of the Man- treats conducted ports
agement Team
members (at least
once a year, for
team-building
and to consider
and approve the
annual plan of the
following year,
among others)
Strategy 4: Strengthening the general management systems
Reviewing (and Number of amend- Up-to-date MD
updating if need ments discussed and hospital
be) the existing included in the hospi- charter
hospital constitu- tal charter
tion
Reviewing (and if Up to date manuals Up-to-date MD
need be updating) in place manuals
the existing manu-
als of the hospital
e.g. employment
manual, financial
management
manual etc)
Establishing Qual- QAGS in place QAG MD
ity Assurance
Guidelines and
Standards (QAGS)
NKOZI HOSPITAL
QAS
for the hospital
Strategic plan: 2015/16 - 2019/20
93
94
Constituting Inter- Internal supervision Supervision Nursing direc-
teams in place schedule tor and Ad-
NKOZI HOSPITAL
nal Support Super-

vision Teams ministrator
Supervision
reports
Holding regular Number of open gen- Minutes MD
open (town hall) eral staff meetings
Strategic plan: 2015/16 - 2019/20
general staff meet- held

ings (at least twice
Attendance
a year)
list
Strategy 5: Strengthening the equipment, space, plant and infrastructure management systems
Developing a Space and Housing Space and Administrator Staff actively
Space and Hous- policy in place Housing policy engage and
ing policy for the champion
hospital (covering policy re-
issues such as views as
acquisition, use, well.
equitable distri-
bution, tenancy,
maintenance,
master planning,
location of build-
ings, location of
activities etc)
Establishing a Space and Housing Space and Administrator Hospital can
Space and Hous- committee in place Housing com- adequately
ing committee for mittee fund com-
the hospital mittee ac-
NKOZI HOSPITAL
tivity
Number of meetings
held Minutes
Strategic plan: 2015/16 - 2019/20
95
96
Establishing a Equipment and plant Equipment and Administrator Staffs active-
plant policy ly engaged
NKOZI HOSPITAL
policy on the man- policy in place

agement of equip- and cham-
ment and plant pion policy
(covering issues reviews as
such as acquisi- well.
tion, maintenance,
use, user-training
and disposal)
Strategic plan: 2015/16 - 2019/20
Instituting regular Number of up-to- Departmental Administrator

inventory, inspec- date departmental inventory
tion and mainte- inventories
nance of equip-
ment, buildings
Inspection re-
and plant
ports
Establish a system Breakages and mal- Breakages and Administrator
for the reporting, function Reporting malfunction
recording and system in place reports
responding to re-
ports of breakages
and malfunction
Implementing
fully the Human
Resource Manage-
ment Manual
Establishing a Number of Staff Per- Staff Perfor- MD Adminis-
Staff Performance formance Reviews mance Re- trator
Review Board to conducted ports
advise the Man-
agement Team on
staff performance
Establishing a Hospital HIV/AIDS Hospital HIV/ MD
Workplace Policy policy in place AIDS policy
on HIV/AIDS and
other chronic ill-
nesses
Establishing a Staff Staff and Patient Safe- Staff and Pa- MD
NKOZI HOSPITAL
and Patient Safe- ty Policy in place tient Safety

ty Policy for the Policy
hospital (covering
issues such as hos-
pital-acquired in-
fection, violence,
sexual assault etc)
Strategic plan: 2015/16 - 2019/20
97
98
Strategy 7: Streamlining procurement and contracting procedures
NKOZI HOSPITAL
Forming a Tender- Tendering Committee Tendering Administrator

ing Committee in place Committee
Minutes
Number of meetings
held
Reviewing pur- Number of purchase Review re- Hospital Ac-
Strategic plan: 2015/16 - 2019/20
chase prices every prices reviews carried port countant

six months out
Issuing Local Pur- Number of local pur- Cash book Hospital Ac-
chase Orders on chases countant
all purchases LPO file
Number of LPOs is-
sued
Raising Goods Re- Number of purchases Cash book Hospital Ac-
ceived Note on all made countant
purchases Goods Re-
ceived Note
duplicates
Goods Received Note
Inspecting all the Number of purchases Cash book Hospital Ac-
items purchased made countant
each time of de- Inspection
livery Number of inspec- reports
tions carried out
Taking stock Number of times Stock cards Hospital Ac-
monthly stock-taking has been countant
carried out
Conducting medi- Number of times Stock book Hospital Ac-
cines and supplies stock-out checking countant
stock-out checking has been carried out
quarterly
NKOZI HOSPITAL
Strategic plan: 2015/16 - 2019/20
99
100
STRATEGIC OBJECTIVE 5: CONTRIBUTE TO IMPROVED HEALTH FOR THE PEOPLE LIVING IN MAWOKOTA SOUTH HEALTH
NKOZI HOSPITAL
SD
Strategy 1: Strengthen Primary Health Care (PHC) Department
Conduct integrat- Number of out- Outreach MD
ed community reaches conduct- schedules
outreaches ed
Outreach re-
Strategic plan: 2015/16 - 2019/20
ports
Conduct school Number of school School health MD
health pro- health programs program sched-
grammes implemented ule
Number of ben-
efitting schools
Cover immuniza- Number of Outreach MD
tion expenses planned immuni- schedule
zation outreaches
carried out
Outreach re-
ports
Participate in Child Number of CDP CDP report MD
Days Plus(CDP) activities carried
and Mass Immuni- out
zation
Mass immuniza- Mass immuniza-

tion campaigns tion reports
carried out
Strategy 2 : Prevent spread of communicable diseases
Innovate strat- Number of strate- Malaria treat- MD
egies to make gies innovated ment charges
malaria treatment
more accessible to
the communities
Patient surveys
Innovations re-
port
NKOZI HOSPITAL
Conduct RCT and Number of indi- VCT report HIV/AIDS clinic

VCT for HIV viduals tested Coordinator
Strategic plan: 2015/16 - 2019/20
101
102
Conduct Health Number of health Activity/ session Nursing direc-
education ses- reports tor
NKOZI HOSPITAL
Education on
Prevention and sions carried out
control of HIV/
AIDS, TB, Malaria
and Water-borne
diseases
Lobby for and dis- Number of indi- Procurement Administrator
tribute mosquito viduals who re- reports
Strategic plan: 2015/16 - 2019/20
nets ceived mosquito

nets
Distribution reg-
ister
Prevent water - Number of purifi- Distribution re- MD
borne diseases ers distributed to ports
through provision the community
of water purifiers
HMIS/ Case
% change in num- summary sheet
ber of cases with
water borne dis-
eases
Identify and col- Number of sectors Hospital reports MD and Ad-
laborate with and partners par- ministrator
other sectors and ticipating in dis-
partners with an ease prevention
interest in disease
prevention
Strategy 3: Contribute to reduction of maternal and neonatal mortality
Provide sexual Number of SRH Hospital reports MD
and reproductive services offered
health services within the commu- Supervision re-
within the com- nity ports
munity and at the
LLHU reports
lower level health
units
Hold quarterly Number of meet- Minutes MD
maternal mortality ings held
audit meetings
and whenever
NKOZI HOSPITAL
there is an inci-
dent
Fulfill EmOC cri- Provision of CE- Evaluation re- MD and Nurs-
teria (providing mOC services ports ing director
comprehensive
EmOC services) EmOC score
Strategic plan: 2015/16 - 2019/20
103
104
Provision of EMOC Number of ob- MD and Nurs-
stetric emergency ing director
NKOZI HOSPITAL
services
cases HMIS reports
Neonatal mortality Annual reports

rates
Maternal mortality
rates
Strategic plan: 2015/16 - 2019/20
Sensitize mothers Number of sensi- ANC Activity re- Nursing direc-

during antenatal tization sessions ports tor
visits on PMTCT carried out
and safe delivery
Strategy 4: Improve hospital transportation services
Purchase a low New ambulance Procurement Administrator
fuel consumption and van in place documents
ambulance and
van / lobbying Log book
from MoH
Regularly maintain Number of vehi- Service reports Administrator
the hospital vehicles serviced and
cles maintained
Maintenance
reports
Ensure provision Proportion of func- Vehicle log book Administrator
of fuel for the ve- tional vehicle
hicles
NKOZI HOSPITAL
Strategic plan: 2015/16 - 2019/20
105
106
BUDGET FOR NKOZI HOSPITAL STRATEGIC PLAN FOR 2015 /16– 2019/20
NKOZI HOSPITAL
STRATEGIC OBJECTIVE 1: INCREASE UTILISATION OF SERVICES IN NKOZI HOSPITAL

Activities / interventions Reference Unit Unit cost Quantity Amount Sources of
funding
Ensuring steady supply of month 20,000,000 12 240,000,000
medicines, sundries and
Strategic plan: 2015/16 - 2019/20
equipment
Improving patient clinical Quarterly meeting/ 60,000 4 240,000
and nursing care and reviews
satisfaction
Ensuring that patients - - - 0
access services at reduced
user fees
Procuring automatic pc 20,000,000 1 20,000,000
liver and renal function
machines
Increasing availability of Person transport 30,000 52 1,560,000
and access to blood
Introduce a nutrition clinic Person time 300,000 12 3,600,000
and employ a nutrition
Food demonstration 100,000 4 400,000
nurse
Introduce diabetic and Person time 15,000 12 180,000
Hypertension clinic
Introduce ear, nose and Quarterly support 500,000 4 2,000,000
throat (ENT) unit
Strategy 2: To expand ancillary services
2.1 Introduce ophthalmology services
- Recruit Ophthalmic Person time 700,000 12 8,400,000
Clinical Officer OR
- Train existing C/O in

ophthalmology services
- Recruit Ophthalmic Person time 300,000 12 3,600,000
Assistants
- Train nurses in eye care Person 300,000 3 900,000
- Procure basic eye care Pc 5,000,000 1 5,000,000
equipment
NKOZI HOSPITAL
- Procure basic minor Pc 5,000,000 1 5,000,000

surgery equipment for eye
care
2.2. Introduce orthopedic services
Recruit one Orthopedic Person time 700,000 12 8,400,000
Officer
Strategic plan: 2015/16 - 2019/20
107
108
Recruit one Orthopaedic Person time 300,000 12 3,600,000
NKOZI HOSPITAL
Assistant
Obtain basic orthopedic Pc 5,000,000 1 5,000,000
equipment
Expand dental care services
Recruit one Dental Officer Person time 700,000 12 5,000,000
Obtain basic dental Pc 5,000,000 1 5,000,000
Strategic plan: 2015/16 - 2019/20
equipment
2.4 Expand laboratory services
Introduce culture and Pc 30,000,000 1 30,000,000
sensitivity testing
Ensure constant power Servicing 1,000,000 4 4,000,000
supply for Culture and
sensitivity •
Introduce haematology Pc 18,000,000 1 18,000,000
investigations
Introduce laboratory Person time 300,000 12*4 14,400,000
investigations in different
departments
Training staff in technical Person time 300,000 4 1,200,000
quality of care
Training staff in customer Person time 300,000 4 1,200,000
care
Developing or adapting Person time 60,000 2 120,000
and adopting technical
quality of care protocols
and standards (e.g.
Standard Operating
Procedures for the
laboratory)
Conducting and utilizing Person time 50,000 2 100,000
surveys on patients’
expectations
Conducting and using Person time 50,000 2 100,000
patients’ experience
NKOZI HOSPITAL
surveys to improve quality

of care
Conducting and utilizing Person time 50,000 2 100,000
findings of patient
satisfaction surveys
Strategic plan: 2015/16 - 2019/20
109
110
Conducting technical Person time 400,000 2 800,000
NKOZI HOSPITAL
evaluation of quality of
care/service provision
assessment
Training staff in patient Person time 300,000 4 1,200,000
safety
Developing / adopting Person time 40,000 1 40,000
Strategic plan: 2015/16 - 2019/20
and implementing patient

safety protocols for the
Hospital (e.g. for surgical
procedures, for vaginal
delivery, for prescription
practices etc)
Beginning / strengthening QI meeting 40,000 6 240,000
error reporting
mechanisms in various
hospital departments
Establishing an Infection Committee 400,000 4 1,200,000
Control Committee functionality
Establishing an isolation
unit within the hospital
Training staff in CPC Person time 300,000 4 1,200,000
(target: at least 2 staff
trained per year)
Training staff in counselling Person time 700,000 2 1,400,000
services (the other option
is to recruit qualified
counsellors)
Recruiting a qualified Person time 700,000 12 8,400,000
counsellor
Recruit a medical social Person time 700,000 12 8,400,000
worker
Strategy 6: Improve medical records management
Computerize the data pc 6,000,000 1 6,000,000
management system in all
departments
Create new office space Office 400,000 1 400,000
for records
NKOZI HOSPITAL
Procure filling cabins pc 500,000 10 5,000,000

Strategy 7. Expand and furnish hospital infrastructure
Procuring an ECG machine pc 6,000,000 1 6,000,000
Strategic plan: 2015/16 - 2019/20
111
112
Expanding the Maternity Structure 400,000,000 1 400,000,000
NKOZI HOSPITAL
Ward and put Theatre

Constructing a kitchen Structure 50,000,000 2 100,000,000
and a shelter for patients’
attendants
Procuring television sets Pc 700,000 6 4,200,000
and radios for patients
Renovating the HIV/AIDS Structure 167,000,000 1 167,000,000
Strategic plan: 2015/16 - 2019/20
clinic
Shelter the pathways Structure 50,000,000 1 50,000,000
connecting wards and
theatre
Construct a shade at the Structure 5,000,000 1 5,000,000
pharmacy
Demarcate a place for Plot 60,000,000 1 60,000,000
hospital parking
STRATEGIC OBJECTIVE 2: IMPROVE HUMAN RESOURCES IN NKOZI HOSPITAL
Strategy1: Ensure there are competitive and equitable salaries for staff of Nkozi Hospital
Conducting biannual salary Person time 100,000 2 200,000
and working conditions
surveys in equivalent
institutions within the
region just for comparison
Conducting a review of Person time 40,000 3 120,000
salaries every two years,
with a view to increase as
and when the means allow
Making the payment Person time 100,000 4 400,000
structure of the hospital
more equitable internally
and externally
Strategy 2: Put in place attractive working and welfare terms and conditions
Establishing a Space Person time 200,000 4 800,000
Management and
Utilisation Policy for the
NKOZI HOSPITAL
hospital (which governs

eligibility and entitlement
for accommodation and
office space, duration of
tenancy, sharing of space
etc)
Strategic plan: 2015/16 - 2019/20
113
114
Providing housing for all
NKOZI HOSPITAL
key staff of the hospital

who should be housed on
site
Providing suitable housing 3,000,000 2 6,000,000
for all housed hospital
staff by refurbishing
houses that need it
Strategic plan: 2015/16 - 2019/20
Making statutory 3,500,000 12 42,000,000

contributions to the
Social Security of all staff
employed by the hospital
Making statutory 3,500,000 12 42,000,000
deductions towards
PAYE for all eligible staff
employed by the hospital
Assisting staff to Person time 40,000 4 160,000
obtain regular financial
statements on their NSSF
deposits
Introduce and implement Person time 200,000 4 800,000
a policy on terminal
benefits for long-serving
staff of the hospital
Providing affordable Premium 150,000 150 22,500,000
medical insurance cover
for the staff of the hospital
Computing and Person time 200,000 2 400,000
communicating the
monetary value of
all benefits currently
provided by the hospital to
the staff
Reviewing the package of Person time 200,000 4 800,000
fringe benefits provided to
staff every two years with
a view to increase them
and keep them attractive
(e.g. funeral expenses,
medical care etc.)
Strategy 3: Establish a “Trans-generational” bond between the hospital and the staff
NKOZI HOSPITAL
Strategic plan: 2015/16 - 2019/20
115
116
Establishing a policy on Person time 200,000 4 800,000
NKOZI HOSPITAL
“Trans-generational”
relationship between
the hospital and staff
(to ensure that staff are
committed for a long term,
and to reward staff who
have been committed to
the hospital for a very long
Strategic plan: 2015/16 - 2019/20
time)
Identifying and supporting Person time 100,000 3 300,000
children of long-
serving staff in their
education (e.g. with
recommendation for
scholarship by donors,
offering them hospital
scholarships in the NTS,
preference in recruitment
as hospital staff,
requesting for scholarship
from the University, etc)
Assisting long serving Person time 20,000 12 240,000
staff to acquire loans for
personal development
e.g. house construction,
motor-vehicle purchase
etc.
Strategy 4: Develop different skills among staff through specific professional training and development programmes
Conducting Training Person time 600,000 3 1,800,000
Needs Assessment (TNA)
annually
Establishing a Staff Person time 200,000 4 800,000
Development Policy
for the hospital (which
covers issues like
eligibility for sponsorship/
recommendation for
sponsorship, conditions
for recommendation for
NKOZI HOSPITAL
further studies, which

courses will be sponsored
etc)
Strategic plan: 2015/16 - 2019/20
117
118
Preparing a Staff Person time 3,000,000 1 3,000,000
NKOZI HOSPITAL
Development Plan for the

hospital (which covers
issues like what skills,
knowledge or expertise
are currently required for
the hospital, which people
will be sponsored over the
next 5 years and in what
Strategic plan: 2015/16 - 2019/20
order etc)
Developing an internal Person time 200,000 12 2,400,000
Continuous Professional
Development (CDP) plan
(including exchange visits)
Conducting training Person time 150,000 4 600,000
to develop specific
knowledge, attitudes and
skills among the staff
Searching for and Airtime 40,000 12 480,000
identifying short courses
for which staff of the
hospital can be sent, in
order to develop local
capacity (NB: In some
cases, there are some
short courses which have
a scholarship already
attached – e.g. UCMB
courses, Stichting Porticus,
a Dutch organisation,
which offers scholarships
mainly for religious people
for bachelors and masters
degrees. The hospital could
tap into this to develop
a number of Ggogonya
sisters into health
NKOZI HOSPITAL
professionals who can

carry more responsibilities
in the hospital.
Strategic plan: 2015/16 - 2019/20
119
120
Providing staff with Hour 2 hours 48 96 hours
NKOZI HOSPITAL
opportunities for sharing

information especially on
return from courses in
which they represented
the hospital (including
exchange visits)
Developing a policy Person time 3,000,000 1 3,000,000
on Mentoring for the
Strategic plan: 2015/16 - 2019/20
hospital (NB: This may

need training of staff in
mentoring)
Determine activity Person time 50,000 12 600,000

standards (activities and
time it takes the staff to
execute them)
Determine the annual Person time 200,000 3 600,000
workload
Determining the actual
staffing requirements
basing on the workload
levels using a suitable
approach (e.g. WISN
method)
Distributing available staff
equitably on the basis
of workload e.g. during
rostering of nurses
Strategy 5: Improve staff retention within Nkozi hospital
Conducting exit interviews
with all departing staff to
determine their causes of
departure and how such
NKOZI HOSPITAL
reasons can be addressed

for remaining staff
Strategic plan: 2015/16 - 2019/20
121
122
Conducting post-exit
NKOZI HOSPITAL
interviews with staff who

left the hospital earlier, to
obtain their views on how
the work environment
of the hospital can be
improved
Increasing the channels
for conflict prevention
Strategic plan: 2015/16 - 2019/20
and resolution within the

hospital
Establishing staff incentive
schemes (e.g. salary
advance, hospital loans,
security for loans, staff
SACCO, awards for long
service, extra privileges for
long service etc)
Conducting staff Person time 100,000 4 400,000
expectations surveys/
frontline provider
assessment to determine
staff expectations and how
they can be met by the
hospital annually
Refining the staff appraisal Person time 40,000 3 120,000
system of the hospital,
with the participation of
the staff
Introducing a system of 5,000,000 1 5,000,000
public acknowledgement
of staff (e.g. on end-of-
year parties, on notice
boards etc)
STRATEGIC GOALOBJECTIVE 3: ENSURE SUSTAINABLE FINANCIAL BASE FOR THE HOSPITAL
NKOZI HOSPITAL
Strategy 1: Reduce non-critical expenditure in the hospital

Strategic plan: 2015/16 - 2019/20
123
124
Establishment of a Person time 50,000 15 1,250,000
NKOZI HOSPITAL
Hospital Efficiency
Committee (whose role
is to identify, monitor
and help to plug areas of
wastage in the different
aspects of the hospital
including utilities,
personnel costs, medicines
Strategic plan: 2015/16 - 2019/20
and supplies)
Operationalising Person time 50,000 6 300,000
the medicines and
Therapeutics Committee
(MTC)
Conducting regular (e.g. Person time 40,000 2 80,000
bi-annual) pharmaceutical
audits
Conducting cost- Person time 100,000 5 500,000
consciousness/awareness
training sessions for all
hospital staff
Strategy 2: Improve financial management
Installing an accounting IN PLACE
package suitable for the
needs of the hospital in
relevant computers with
a suitable back-up system
(not sure if the one of Dr.
Kabuye Rogers captures
this)
Training accounting and Person time 200,000 5 1,000,000
finance staff in the use
and maintenance of
the installed accounting
package (if this becomes
necessary)
Implementing fully
the hospital’s Financial
Management Manual
NKOZI HOSPITAL
Networking finance and Network 800,000 2 1,600,000

accounting computers
for easy sharing of
information
Strategic plan: 2015/16 - 2019/20
125
126
Appointment of a Person time 1,000,000 12 12,000,000
NKOZI HOSPITAL
substantive Internal
Auditor for the hospital
Opening and depositing Bank charge 20,000 12 240,000
funds on reserve fund
accounts for all key capital
items
Investing annual surpluses
Strategic plan: 2015/16 - 2019/20
in high-return ventures
(e.g. treasury bills and
fixed deposit accounts)
Strategy 3: Increasing local revenues from different sources for hospital activities
Appointing a full- Person time 500,000 12 6,000,000
time focal person for
fundraising activities for
specific hospital projects
(feasibility to be further
explored)
Increasing the bed
occupancy rate in the
private ward through
improved client care both
clinical and non-clinical
care (which bring in more
revenue)
Increasing the charges in
the private ward (after
improving the quality of
services in that ward)
Ensuring full time Person time 2,300,000 12 27,600,000
availability of a medical
officer for private
ward patients even on
weekends.
Introduce 14” colour TVs pc 500,000 8 4,000,000
in the individual rooms
NKOZI HOSPITAL
of the private ward

beginning with 2 rooms
as an experiment to see
whether the demand
increases)
Strategic plan: 2015/16 - 2019/20
127
128
Soliciting for capital pc 5,000,000 2 10,000,000
NKOZI HOSPITAL
donations (e.g. medical

and office equipment)
from alumni and other
local individual and
corporate friends of the
hospital
Positioning the hospital to
provide the service for the
Strategic plan: 2015/16 - 2019/20
proposed National Health

Insurance (NHI) [This
requires that the hospital
improves its quality of care
to a level where it can be
accredited to provide the
services.].
Advocating for an increase Airtime 40,000 4 160,000
of the PHC Conditional
Grant (PHC-CG) from the
central government (using
UCMB, DLG etc)
Establish Associations Airtime/ person 40,000 12 480,000
that can support the transport
hospital such as: 1) Born
or Delivered) in Nkozi
Association to support
Maternity Services, 2)
Friends of Nkozi to support
general services.
Strategy 4: Mobilise resources for continued income generation and sustainability
Identification of external partners Airtime 40,000 12 480,000
who can support the hospital
financially (to consider friends,
research institutions, NGOs,
charitable organisations, foreign
governments, the Holy See, banks,
bilateral and multilateral agencies)
Writing project proposals for external Person 1,000,000 2 2,000,000
support time
NKOZI HOSPITAL
Soliciting for in-kind support from the Airtime 40,000 12 480,000

government and external partners
e.g. staff secondment, volunteer
health workers etc
Strategic plan: 2015/16 - 2019/20
129
130
Reviewing the financial feasibility of Person 300,000 3 900,000
NKOZI HOSPITAL
taking bank loans for critical capital time/

investments e.g. construction of transport
hostel which will bring in more
financial resources
Mobilize for an endowment fund for Airtime 40,000 12 480,000
investing in an income generating
venture such as students hostels or
building a hospital restaurant
Strategic plan: 2015/16 - 2019/20
STRATEGIC OBJECTIVE 4: IMPROVING GOVERNANCE, MANAGEMENT AND OPERATIONAL SYSTEMS OF THE HOSPITAL
Strategy 1: Increase the effectiveness of the Board of Governors (BOG)
Conducting induction/orientation of Person 50,000 20 1,000,000
the new members of the new BOG time
Developing and implementing local Person 40,000 4 160,000
and appropriate benchmark criteria time
for monitoring the performance of
the BOG
Conducting a Training Needs Person 100,000 2 200,000
Assessment (TNA) for the skills time
necessary for BOG members
Training members of the BOG in Person 1,000,000 3 3,000,000
specific skills necessary to perform time
their responsibilities
Developing and applying criteria
to monitor the performance of
individual members of the BOG
Establishing a mechanism for
following up the implementation of
BOG decisions
Harmonising the understanding
of the roles and relationships of
the Owner, the Board of Trustees,
the Board of Governors, the
Management and the Managing
Congregation among these different
stakeholders
Strategy 2: Strengthen the role of the Managing Congregation in supporting the hospital
Developing and applying benchmark
criteria for monitoring the role of the
Managing Congregation
NKOZI HOSPITAL
Assisting the Managing Congregation

in capacity development to enable
them to fulfil their role
Strategic plan: 2015/16 - 2019/20
131
132
Strategy 3: Strengthen the performance of the Management Team
NKOZI HOSPITAL

criteria for monitoring the
performance of the Management
Team
criteria for monitoring the
performance of the individual
Strategic plan: 2015/16 - 2019/20
members of the Management Team

Developing management skills
among senior hospital staff (including
Management Team members) to
develop capacity for management
roles in the hospital
Providing exposure opportunities Person 40,000 12 480,000
(e.g. through study visits, scientific time/
talks etc) to members of the BOG, transport
Management Team, Managing
Congregation and staff
Establishing a mechanism for
following up the implementation of
Management Team decisions
Conducting joint retreats between 3,000,000 1 3,000,000
the BOG and Management Team
(e.g. one every two years, in which
the BOG emphasizes the strategic
direction of the hospital and their
expectations to the Management
Team)
Conducting retreats of the 1,000,000 1 1,000,000
Management Team members (at
least once a year, for team-building
and to consider and approve the
annual plan of the following year,
among others)
Strategy 4 : Strengthening the general management systems
Reviewing (and updating if need be) Person 500,000 2 1,000,000
the existing hospital constitution time
Reviewing (and if need be updating) Person 50,000 8 400,000
NKOZI HOSPITAL
the existing manuals of the hospital time

e.g. employment manual, financial
management manual etc)
Establishing Quality Assurance Airtime 100,000 1 100,000
Guidelines and Standards (QAGS) for
the hospital
Strategic plan: 2015/16 - 2019/20
133
134
Constituting Internal Support Person 100,000 4 400,000
NKOZI HOSPITAL
Supervision Teams time

Holding regular open (town hall) Person 100,000 3 300,000
general staff meetings (at least twice time
a year)
Strategy 5 : Strengthening the equipment, space, plant and infrastructure management systems
Developing a Space and Housing Person 1,000,000 1 1000,000
policy for the hospital (covering time
Strategic plan: 2015/16 - 2019/20
issues such as acquisition, use,

equitable distribution, tenancy,
maintenance, master planning,
location of buildings, location of
activities etc)
Establishing a Space and Housing Meeting 50,000 4 200,000
committee for the hospital
Establishing a policy on the Meeting 50,000 4 200,000
management of equipment and plant
(covering issues such as acquisition,
maintenance, use, user-training and
disposal)
Instituting regular inventory, Person 1,000,000 2 2,000,000
inspection and maintenance of time
equipment, buildings and plant
Establish a system for the reporting,
recording and responding to reports
of breakages and malfunction
Implementing fully the Human
Resource Management Manual
Establishing a Staff Performance Person 1,000,000 1 1,000,000
Review Board to advise the time
Management Team on staff
performance
Establishing a Workplace Policy on Person 100,000 1 100,000
HIV/AIDS and other chronic illnesses time
Establishing a Staff and Patient Safety Person 1,000,000 2 2,000,000
Policy for the hospital (covering time
issues such as hospital-acquired
infection, violence, sexual assault etc)
Strategy 7: Streamlining procurement and contracting procedures
NKOZI HOSPITAL
Forming a Tendering Person time 100,000 4 400,000

Committee
Reviewing purchase prices Person time/ 200,000 2 400,000
every six months transport
Strategic plan: 2015/16 - 2019/20
135
136
Issuing Local Purchase Stationery 120,000 1 120,000
NKOZI HOSPITAL
Orders on all purchases

Raising Goods Received stationery 120,000 1 120,000
Note on all purchases
Inspecting all the items Person time 20,000 12 240,000
purchased each time of
delivery
Strategic plan: 2015/16 - 2019/20
Taking stock monthly Person time 100,000 12 1,200,000

Conducting medicines Person time 40,000 4 160,000
and supplies stock-out
checking quarterly
STRATEGIC OBJECTIVE 5: CONTRIBUTE TO IMPROVED HEALTH FOR THE PEOPLE LIVING IN MAWOKOTA SOUTH HEALTH
SD
Strategy 1: Strengthen Primary Health Care (PHC) Department
Conduct integrated Outreach 180,000 12 2,160,000
community outreaches
Conduct school health Visit 150,000 12 1,800,000
programmes
Cover immunization Person time 1,330,000 12 15,960,000
expenses
Participate in Child Days Month 1,100,000 2 2,200,000
Plus(CDP) and Mass
Immunization
Strategy 2: Prevent spread of communicable diseases
Innovate strategies to
make malaria treatment
more accessible to the
communities
Conduct RCT and VCT Person time 1,100,000 4 4,400,000 HIV program
Conduct Health Education Person time 50,000 12 600,000
on Prevention and control
of HIV/AIDS, TB, Malaria
and Water-borne diseases
Procure and distribute TASO,
mosquito nets Malaria
Consortium
NKOZI HOSPITAL
Prevent water - borne Person time 20,000 12 240,000 PACE

diseases through provision
of water purifiers
Identify and collaborate Person time 40,000 12 480,000 Hospital
with other sectors and
partners with an interest
in disease prevention
Strategic plan: 2015/16 - 2019/20
137
138
Strategy 3: Contribute to reduction of maternal and neonatal mortality
NKOZI HOSPITAL
Provide sexual and Person time 100,000 12 1,200,000

reproductive health
services within the
community and at the
lower level health units
Hold quarterly maternal Person time 40,000 4 160,000
mortality audit meetings
Strategic plan: 2015/16 - 2019/20
and whenever there is an

incident
Fulfill EmOC criteria
(providing comprehensive
EmOC services)
Provision of EMOC Person time
services
Sensitize mothers during Person time 5,000 12 60,000
antenatal visits on PMTCT
and safe delivery
Strategy 4: Improve hospital transportation services
Purchase a low fuel Vehicle 200,000,000 1 200,000,000
consumption ambulance
Purchase of a low fuel Vehicle 150,000,000 1 150,000,000
consumption van
Regularly maintain the Vehicle 1,000,000 4 4,000,000
hospital vehicles
Ensure provision of fuel for Litre 250,000 12 3,000,000
the vehicles
NKOZI HOSPITAL
Strategic plan: 2015/16 - 2019/20
139
140
Artistic Impression of the Accident & Emergency Unit
Our Lady Health Of The Sick

Nkozi Hospital
Contact:
Tel.: +256 (0) 392842207;
Fax: +256(0) 38 410100
Email: nkozi@ucmb.co.ug
www.nkozihospital.com

Nkozi Strategic Plan

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Nkozi Strategic Plan

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OUR LADY HEALTH OF THE SICK

OUR LADY HEALTH OF THE SICK

Our Lady Health Of The Sick

I am aware that a number of stakeholders have supported Nkozi Hospital to make

+Cyprian Kizito Lwanga

Finally I allow me to thank wholeheartedly all those that worked tirelessly to

Dr. Ssendyona Martin (MD, MPH)

My fellow management team members, as a whole, cannot be forgotten for their

1. To Increase utilisation of services in Nkozi hospital

2. Improve Human Resources in Nkozi Hospital

3. Ensure sustainable financial base for the Hospital

4. Improving Governance, Management And Operational Systems of the

5. Contribute to improved health for the people living in Mawokota South

This plan will provide an excellent opportunity to build community consensus,

Trauma following road accidents (RTA) contributing 6%.

Section one: BACKGROUND

The hospital is affiliated to and is accredited by the Uganda Catholic Medical

1.2 General Overview

Nkozi hospital enjoys good collaboration with Government of Uganda (GoU)

1.4 National context:

1.5 Development process

Section two: ORGANISATIONAL ARRANGEMENT

2.1 Hospital organisation

this has the hierarchal set up at Nkozi hospital as summarised in the

NKOZI HOSPITAL ORGANOGRAM

Head of the Head of the Head of the Head of Public

Medical and Nursing Accounts / Community

Hospital. The Hospital Management Committee (HMT) is headed by the Hospital

2.2 Hospital functions/services

o General Outpatient Clinic

o General medical, Paediatric and Surgery sections (Female, Male

o Expanded Programme for Immunisation EPI) services

o Human Resource Management section

o Planning, budgeting and coordination PHC services for the HC

Section three: REVIEW OF THE PREVIOUS

1) Improved the human resource in Nkozi hospital

Goal 1: Improving human resources in Nkozi hospital through effective

2) The hospital was able to develop a staff career development plan

3) The hospital managed to conduct Continuing Professional Development

Goal 2: Ensure a sustainable financial base

1) Management wrote funding proposals and was able to receive some

• A hospital restaurant was not constructed as planned

Goal 3: Increase utilization of services offered at Nkozi hospital

1) Stock-outs of essential medicines was reduced significantly in the hospital

• Patients did not access medicines at reduced user fees

• An ECG machine was also not procured

Goal 4: Improve hospital governance and management

1) Some members of the Health Management Team were trained in

Goal 5: Contribute to improved health for people living in Mawokota

1) Quarterly planning and budgeting functions

5) Coordination of HSD Village Health Team (VHT) services

Section four: SITUATIONAL ANALYSIS:

This section provides e situational -analysis of Nkozi Hospital in form of Strengths,

Service Area Strength Opportunities Strategies for Improvement

• Availability of diagnostic sister hospitals with • Consider establishing a

Hospital Assets Manual etc.

4. Finance management • Established finance • Presence of external • Improve efficient

external support for additional sources of

• Availability guidelines on use of • Middle class clients

Service area Weaknesses Threats Strategies for mitigation

• Lack of incentives to attract

streamlined to meet demand • Introduction of service diagnostic services and

• Old infrastructure(old • Programme (ART clinic) • Increase efficiency with

• High operation costs for