During this review, it has become obvious that if we want these programmes to be sustainable then we will have to ration the services being provided and be more selective about the population being served. These have not been easy decisions to make and in many ways are very similar to those being faced by health planners in the UK and USA. I read a thought-provoking, or perhaps simply provoking, article by Peter Singer on the subject “Why We Must Ration Healthcare”; well worth a quick skim.

Affordability is a complex study; we may immediately think that this is simply about how much the patient can afford to pay, but there are many other interested and affected parties.

The actual cost of providing Primary Healthcare in these communities might be as much as £30 per person per year; those receiving care may only be able to afford £1-2 per visit, probably no more than £5-10 per year, per household. A lot has been written about the pros and cons of user fees and the need for patients to contribute at the point of receiving service. This remains a matter that divides opinion.

When we make healthcare affordable for the poor, we have to also consider the impact this has on others who are subsidising that cost. These include tax payers who contribute, and may be asked to pay more, to the government budget. Other government sectors, such as education, may be squeezed if the government increases its budget allocation to the health sector.

Donor funds and Charitable giving are not limitless and deserve to be used in the most effective and efficient manner. We need to ensure that these very necessary funds are put to best use but, because they are limited, there is a tension between use for Prevention or use for Treatment and also in the selection of the most worthy diseases. There are divided opinions about how these limited funds should be shared between e.g. Health, Education and Infrastructure.

Many health service providers serving these communities are operating from a faith or humanitarian basis and want to help serve the poor and needy. They are not doing it for profit and they depend on funds from all of the various sources: the user, the government, charitable giving and donor funds. When these funds are not enough and the sick continue to arrive at the centre, then what should the facility owner do? Do we turn them away or do we treat and dig deep into our own pockets to meet the shortfalls?

Times are hard, perhaps global economies are still getting worse, rather than better, and many in the UK are saying that it would be wrong for the Government to meet our pledge to raise overseas aid to £10.6 billion in 2014-15. Why should we persist in giving to other countries when there are so many problems at home?

The Telegraph writes that Bill Gates, when interviewed on Radio 4, urged Britons to be proud of the positive impact our donations are having on the world’s poorest people.

I agree, we should be proud and now is not a time to consider cutting back. The 0.7% of national income proposed as overseas aid impacts the lives of many millions in ways that are often life-changing.

Just in this last week new research shows that the numbers of deaths from Malaria are actually double what we had thought; now estimated at 1.24m a year. Many of these are children under 5, for whom Malaria causes 24% of all deaths.

When we discussed and agreed our proposed approach to rationing we decided to focus attention on prevention and treatments for Children under 5. We know that Malaria is a significant problem for this population and in the week we decide to ration, we now learn that the numbers of those affected may be double what we thought!

Related articles

• Primary Healthcare in East Africa (suubitrust.org.uk)
• Malaria toll ‘is twice as high’ (bbc.co.uk)
• Malaria cases around the world: how many are there? (guardian.co.uk)

When exhausted stop at a local shop (for local people) buy an ice-cold coca-cola and drink it from the bottle.

It doesn’t matter where you are in Uganda, you can always find somebody selling Coca-Cola, usually from one of those red fridges and often cold. That made me think about the delivery of primary healthcare. Now I’m not about to equate the distribution and supply of a cheap commodity such as a soda with PHC, but I do think there are some principles that we could adopt.

Coca-Cola is available, accessible and affordable to all in Uganda. Those buying it can be assured of its consistent quality and the price is known to all parties before the transaction begins. Sometimes we may choose to pay more, for nicer surroundings, to have it brought to the table and served in a glass with ice – but it is just the same coke as that bought from the shop in the picture above. There is something quite equitable about this.

Healthcare planners should be seeking to ensure that primary healthcare is available, accessible and affordable to all in Uganda. It will take some effort and perhaps legislation or self-regulation to ensure a consistent quality of care. The price thing is something that should be easier to make happen. Wouldn’t it be better if there were set prices for consultation, test and treatment of the common ailments; so that those wanting to use the services know, before coming, how much they will be asked to contribute? Making it affordable, that’s the next challenge.

Isn’t it great when you get to freewheel downhill, makes all that effort seem worthwhile.

Last week International Health Sciences University, in Kampala Uganda, held its 2nd Graduation Ceremony. 91 students graduated, 35 of whom successfully attained their Master of Public Health, MPH.

This is still a very young institution and for those in the UK, these numbers might seem quite small, but I think they are significant for these two reasons.

According to the WHO World Health Statistics Report 2011, Uganda has just 1.2 Physicians per 10,000 population and 13.1 Nurses/Midwifes. In the UK these same counts are 27.4 and 103 respectively. Uganda has a serious shortage of trained doctors and nurses.

In the last few months I have had discussions with directors of health service providers in Uganda who are finding it very difficult to recruit and retain such trained medical staff, especially for rural up-country settings. One of the challenges facing us is that Donors and NGOs are also actively recruiting such staff and they are willing and able to offer higher remuneration packages. This is somewhat ironic when you consider that the aims of these worthy organisations is to help strengthen the country’s health system. The positions being filled are most often programme design, implementation, management and evaluation, not clinical roles. So we see Clinicians being removed from clinical roles and appointed to programme management.

Wouldn’t it be so much better if these roles were filled by non-clinicians, trained and skilled in public health? That’s one of the ways in which IHSU is trying to make a difference to the delivery of healthcare in Uganda; by providing well trained, willing and able graduates who can implement and manage public health programmes, leaving the doctors, nurses and midwifes to continue treating and caring for our patients.

My second reason is that studying for your MPH involves a lot of relevant reading, discussion and, most importantly, critical analysis. It is my own personal experience that such exposure helps make us much more considered in how we approach the design, implementation and evaluation of required interventions. I think I’m a lot less naive than I was a few years ago. I used to wonder why we couldn’t just get on with it, to do it, to make it happen and quickly (whatever “it” was).

Some of my recent public health conversations have been about the reported unmet need of family planning; according to Guttmacher, 7 out of every 10 women in Uganda who want to avoid pregnancy, cannot easily and regularly access such services. I can hear you say, “surely that must be easy to fix, and it’s cheap, an IUD costs just a few pence.”

Of course it is much more complex and there might be many reasons why an unmet need exists. There will be numerous hurdles to overcome to ensure a sustained delivery of accessible and affordable service.

Those MPH students graduating last week are now well equipped to tackle such matters and better placed than they were before to now ensure successful achievement of the desired outcomes.

Hopefully I’ve now finished my exams and can move on to starting my research and learning some more. Many years ago I used to have the dream (nightmare) outlined above, thankfully it’s never been reality.

About 3 years ago I sat with another good friend, Dr. Ian Clarke, and we talked about the 5 year plan that we had developed for his organisation in Uganda, International Medical Group. I’ve known Ian since 1979 when he was my landlord in a student house in Belfast. In the mid-eighties I was at the church meeting in Bangor when the congregation prayed blessings on him and his family as they made their way out to Uganda to start a hospital in the bush (which became Kiwoko Hospital), in the middle of the Luwero Triangle which was only just beginning to recover from the Amin madness.

Now some 23 years later we were sat in a hotel in Kampala and having discussed the IMG 5 year plan, I was telling him of my mad idea that I wanted to come out to Uganda and work with him to make it happen. With the gracious acceptance by Pamela and our children, I started my full-time role as MD of the group, soon to be the CEO, in May 2009.

An essential element of that 5 year plan was to bring on board equity investors who could provide the capital and expertise that would help us to achieve our shared vision. I don’t really know what I thought I was coming to, somewhere in the back of my mind I thought that this would be a great way to give something back and to make a difference in the lives of those that had less than we were used to in the UK; how wrong, or at least naive, was that, International Development and Public Health is much more complex, certainly less black and white (no apology) than that.

In the early part of 2009 we were made an offer by a leading private equity firm operating in East Africa, which had a special interest in Healthcare. The offer was just far too low and came with too many conditions, so we rejected it and then continued to manage IMG for the next two and a half years, not being able to fully move forward with our capital expansion plans and every day needing to consider careful management of cash-flow (a bit like most businesses in the UK today). Managing a business in the developing world is, in my experience, no different from managing one in the UK; it is always about MONEY and PEOPLE.

International Medical Group employs more than 750 staff, constitutes probably the best private hospital in Uganda (IHK), 10 primary care health centres (IMC) (GP surgeries) and provides pre-paid health plans (IAA) for 41,000 members. We serve more than 250,000 patient visits each year. We have an NGO, IMF, that provides essential basic healthcare to the poor, with a special focus on community based reproductive health services. We also have a health sciences university, IHSU, which today had its 2^nd graduation ceremony and is training more than 850 students of nursing, health management and public health.

In its first 10 years Dr. Ian and the team had continued to grow and extend the services of IMG from whatever surpluses they could make from the revenue being generated. This had worked very well in the early years but now we had reached a stage of our corporate development when we needed a much more significant injection of capital.

It seems that for most of 2011 I’ve been working on the 5 year Business Plan, re-working the financials, the cost-benefits and selling our potential. Early in 2011 we had 2 serious equity investment offers, both of which were definitely of interest, but we had to chose just one and after a very intense 6 months of due diligence, it is just so great to have finally closed and to have executed a deal. We now have new private equity investors, with a capital investment that will enable us to start moving forward with our development plans. Just as importantly, these new shareholders will also bring essential corporate and medical experience and a link into the largest healthcare group in India. Now we can we start the next phase of the 5 year plan. So we have definitely reached the “end of the beginning”.

On a personal note, I need to now spend the next week being a student at IHSU and do my last 4 exams and start my thesis for my MPH, that too has taken more than 2 years.

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PHC in East Africa: Preface

If you are a healthcare practitioner or student you will know that there are already thousands of books exploring and expounding each and every aspect of Primary Health Care. So why have we added another one?

It may be wrong to claim that specific health issues facing Uganda are unique but perhaps we can at least say that when combined together in the local context they become unique. It is that local context that we have set out to explore more fully in this book. We have written about primary healthcare as it applies to Uganda and we have written it for those that are providing, and for those that hope to provide, healthcare services to its people.

Healthcare policy in Uganda is very well designed and documented. The second National Health Policy (NHP II), issued in 2010, lays out those elements that are a particular focus for the period up to 2015. This policy seeks to prioritise the effective delivery of the Uganda National Minimum Health Care Package (UNMHCP) and the policy is operationalised in the third Health Sector Strategic Plan (HSSP III). These two documents detail the services that should be provided and the organisational structure required for delivery. There is a very close fit to the key principles proposed in the Alma-Ata Declaration on Primary Health Care. UNMHCP comprises these four clusters:

i. Health Promotion, Disease Prevention and Community Health Initiatives

ii. Maternal and Child Health

iii. Prevention and Control of Communicable Diseases

iv. Prevention and Control of Non-Communicable Diseases.

The HSSP III outlines the organisational architecture, strongly promoting a decentralised structure in which delivery starts in the community through specially trained volunteers (VHT) who are supervised by, and can refer to, nurse/midwife led health centres (HCII) which are located very close to each community. In turn the HCII can refer patients needing specific medical care, e.g. c-sections, to a nearby HCIV. District and referral hospitals complete the structure and are tasked with general surgery and an expanding set of tertiary services. The strategy details the services that should be provided at each level, the cadres and numbers of staff that each level of facility should have and the numbers of each different type of facility needed to serve the whole population, ensuring equitable access for all, in the most efficient manner possible.

NHP II clearly states that seventy five percent of the total disease burden in Uganda is still preventable through health promotion and disease prevention. The above strategies and plans are designed for doing exactly that. So why then is the country still struggling to reduce the very high rates of mortality and morbidity? Why are we seeing slow progress on reducing the under-5 and maternal mortality rates that are measured by the Millennium Development Goals 4 and 5? Why is the country still suffering under a very high burden of malaria, which significantly impacts the quality of life for the individual and the economic performance of the country as a whole? This is measured in MDG 6, as is the prevalence of HIV, which after some notable reductions during the 1990s and early 2000s is now beginning to rise again.

What’s going wrong and what must we do to make it right?

We don’t need to look any further than the NHP II; it lays out quite clearly what many consider to be the major cause for the failure in implementation, a very simple lack of adequate funding. The current cost of delivering UNMHCP in all facilities across the country, serving the whole population, is estimated at almost $48 per capita, per annum. The Government of Uganda allocates just less than 10% of its budget to healthcare, which equates to approximately $10 per capita. So even if the government kept its commitment to meet the Abuja Declaration target of 15%, that would still only meet about one third of the estimated cost for delivery.

This significant gap in budget causes many operational problems in the public facilities; badly maintained facilities without adequate staff and even when staff are there, they often lack equipment, consumables and drugs to enable the provision of necessary care and treatment. In Uganda the private sector provides more than half of the total health services delivered, but that still falls far short of ensuring equitable and universal access for all. These private organisations need to charge for the services provided, which even after subsidy from donors, means that essential, basic services are not affordable for the vast proportion of the population. Current estimates indicate that the out-of-pocket health expenditure is about 9% of household budgets and a growing number of households in Uganda are being pushed into impoverishment because of medical bills. As the demographic shift continues to increase the number of those financially dependent on others, this is just going to get worse.

Private Health Insurance and pre-paid Health Membership Schemes are available and are being used to meet the costs of high quality healthcare services, but only for 150,000 of the population. The annual premiums for these schemes are currently far beyond the reach of those Ugandans who are not employed by the larger private corporates or International NGOs.

Uganda is planning to implement a National Health Insurance Scheme, which it suggests will address this budget shortfall. Like the national health strategy and policy, the NHIS is well designed and has much to be commended. Except for one major flaw; the national tax base is far too small. There are just one million employees in the formal sector, from whom the government can levy taxes (the overall population is about 34m). It is proposed that a total of 8% will be raised in additional taxes, to be shared between the employees and their employers. That would be enough to provide a good level of service to these one million. It might even be possible to use some of the funds raised to provide some basic services for their households, but it is definitely not enough to make up any of the shortfall for the remaining 85-90% of households.

We need to find some way to increase the GoU budget allocation, perhaps by reallocating budget from other sectors or from future oil revenues? Alternatively we need well designed community based, risk-pooling schemes that can make better use of the monies that households are already spending out-of-pocket. That, however, may take quite some time to gain sufficient conceptual understanding and acceptance by those in the communities. Experience to date tells us that, in particular, the concept of paying before you become sick and that of pooling monies to be shared out with others, is difficult for many to understand and accept.

We need to conduct a detailed review of how budgets and donor funds are currently being allocated. It may be that too much is being spent at the referral hospitals for tertiary services that are clearly much more expensive and serving a very small number of the population. These specialist, tertiary services are not included in those to be delivered by the UNMHCP. These same funds spent on much needed primary healthcare could benefit a much larger number of patients. Any such debate on rationing, and the re-allocation from expensive tertiary medical services to public health and primary healthcare, is bound to be difficult and divisive, but nonetheless it has to be done.

One aspect of PHC that Uganda should focus more on is that of Reproductive Health, with a specific aim of reducing the very high rates of infant and maternal mortality. The State of Uganda Population Report 2011, outlines the commitment that Uganda made at the UN General Assembly in September 2011, specifically to focus on the following:

i. Increasing comprehensive Emergency Obstetric and Newborn Care (EmONC) in hospitals from 70% to 100% and in health centres from 17% to 50%; ensure that basic EmONC services are available in all health centres; and that skilled providers are available in hard to reach/hard to serve areas.

ii. Reducing unmet need for family planning from current 40% to 20%

iii. Ensuring that Emergency obstetric and neonatal care services are available in all health centres

iv. Increasing focused antenatal care from 42% to 75% with special emphasis on Prevention of Mother-to Child Transmission (PMTCT) and treatment of HIV.

Uganda has one of the highest fertility rates in the world at 6.7, leading to a very significant demographic shift; already more than half of the population are below the age of 18. This high fertility rate is a prime driver for the very high rates of maternal and infant mortality and birth related morbidity. The population is doubling every 20 years and development of the economy, essential infrastructure and public services are simply not keeping pace. Perhaps it is not surprising to learn that Uganda also has the highest unmet need for modern contraception, as noted in ii. above. Measured another way, the unmet need among those women who want access to family planning is as high as two-thirds. Research by the Guttmacher Institute indicates that meeting this demand could reduce overall fertility by one third and make a very significant improvement in the mortality rates.

So surely that’s pretty simple then, we just make family planning more readily accessible and the health indicators will start to improve. As you continue to read, you will perhaps start to see that resolving these issues is not so simple, not so straightforward as one might initially think. As PHC practitioners we will find ourselves challenged to be much more considered and detailed in our thinking about possible solutions and interventions. The above at first seems very easy to fix, until you learn that the country has a gap of more than 2,000 adequately trained midwifes to deliver these services and that very often essential medical staff don’t want to move out of the large towns to stay and work in the rural villages, where the need is greatest.

The challenge of providing Uganda with universal access to basic primary healthcare is very demanding, it will be very difficult to achieve but the difference that we can make and the outcomes that we can influence are enormous. So let’s keep pushing on…

Kevin Duffy
Chief Executive Officer
International Medical Group
PO Box 8177
Kampala

I am re-posting this, it was first published on February 20th, 2010.

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Last year there were almost 250 patients cared for on Hope Ward. I am always inspired when I read the patient stories and I wanted to share this one in particular; in summary Mubiru’s story is:

• Abused by his grandmother at age 12, locked in a metal box,
• Rescued by his neighbours,
• Thought to be dying, handed over to a hospice,
• Brought by the hospice nurse to Hope Ward, unable to move, talk or look after himself,
• After very many months of loving care and treatment now looking for a new home and a new start.

You can read his story below or by clicking here.

If you would like to help Mubiru and our other patients on Hope Ward click here to find the many different ways in which you can give. Please tell others.

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Mubiru Lwasa is a young 12 year old boy who has suffered a great deal. Mubiru has never really had a place to call home. His mother and father are separated and have moved on to marry other partners and have other children. He lived with his mother for several years and she took him to primary school however he fell sick and she took him back to his father. At this point she had five children with her current husband (not Mubiru’s father) and she could not continue to care for him. This would mark the beginning of a long period of suffering and abuse in Mubiru’s life.

Mubiru was taken out of school and did hard labour for his grandmother and at some point was beaten so badly that his hand and leg were fractured. He was locked up in a metallic box and starved almost to the point of death. When Mubiru’s father noticed that his son was dying, he took him back to his village in Mpigi for fear of the cost of transporting a dead body.

When Mubiru’s father arrived in Mpigi the people in his village were shocked by the site of the boy’s emaciated body. The villagers refused to let Mubiru’s father rest until he had taken him to hospital. On arrival at Mulago hospital the nurses and others who saw Mubiru’s father carry his crippled smelly body into the hospital were so outraged they wanted to lynch him. Mubiru’s father was then ‘rescued’ by the police and taken to Luzira prison.

However now that Mubiru’s father was taken away there was no one left to take care of Mubiru while he was at Mulago. Fortunately a kind Ugandan lady (Mable) had compassion on him and chose to look after him, though she did not really have much to offer him but loving care.

Medical personnel at Mulago thought Mubiru was dying and contacted a nurse who works for Hospice Uganda. This lady contacted Hope Ward and asked us to admit him for treatment as she did not think he was terminally ill.

When Mubiru first arrived at Hope Ward, he was in very bad shape. He had sores and wounds all over his body. He could barely support himself in the wheelchair and the slightest movement would make him scream. Mubiru could neither talk nor feed himself, he was incontinent, he was very pale and the hair on his head was so thin, his lips were pale dry and chapped, he looked like a patient with full blown AIDS.

In September 2009:

Mubiru had been on the Hope Ward for about two months. With an improved diet, constant care and daily physiotherapy as well as constant dressing of his wounds, Mubiru’s condition had greatly improved. At this point he was still feeding through a nasal tube most of the time, though he had started a little self feeding. He regained ability to talk and even sang a song to one of our visitors on Hope Ward at the time. Mubiru is a charming naughty boy and all on Hope Ward became very fond of him. One nice cool evening he even requested his carer Mabel to take him out on the wheel chair to enjoy some fresh air in the hospital compound. The physiotherapist noticed that he tried to move his arms and legs (though he would cry while doing so) during his physio sessions.

By November 2009:

Almost all Mubiru’s wounds had healed, his hair had grown back, he was finally fit enough to start a series of surgeries to treat infections in his bones and to straighten his contracted legs. However at this time Mubiru was incontinent and had been wearing diapers since he came to Hope Ward…he had lost ability to control his bladder and bowels because of his long period of abuse.

At this time, Mubiru had gained more strength and began to talk more, much of his memory had returned and he began to give more details of what happened to him before he was brought to Hope Ward. His father had a final court case in the same month (November); Mubiru gave his police statement for the case and we were hopeful that justice would be served but he was only accused of neglect and given an eight month sentence.

We witnessed a very emotional moment on Hope Ward when we called Mubiru’s mother and had him talk to her, he cried really hard and yet she did not commit to come visit him, she was afraid that she would be arrested. Mubiru’s mother has several children from different men, she had left Mubiru with her mother who died shortly after and Mubiru was taken to be with his father where he was abused and almost killed. On the day we put Mubiru in touch with his mother, he asked her when she would come and take him and she said she couldn’t come for him and this really broke his heart. At the time, she had just delivered another baby with her current husband and was not ready to travel to Kampala or take up responsibility for Mubiru.

Today (Feb 2010): We would say that Mubiru has undergone remarkable transformation (as you can see from the pictures). He has had multiple surgeries on his legs, he has had intensive nutritional care and he has grown into a lovely cheeky, healthy boy. He no longer wears diapers and can control his bowels and bladder again; he can feed himself and no longer needs the nasal feeding tube. Mubiru is now receiving physiotherapy to strengthen his muscles and we are training him to walk again. We had braces fitted for his legs which he wears to gradually straighten them. Mubiru’s condition today is much more hopeful than it was about eight months ago when he first came to Hope Ward.

A physiotherapist told me that if you are confined to a bed or if you do not move at all for about three weeks; your body can deteriorate at a very fast rate, and your muscles will atrophy to the extent that you will not be able to walk without rehabilitative physiotherapy. Mubiru was confined to a box and not fed for months; he was left with untreated wounds that transmitted infection to his broken bones. That is why he is unable to walk today. With improved nutrition, tender loving care and good physical exercise, Mubiru will walk again; though this may take a long while.

Presently the hospital ward is not an ideal place for Mubiru to be, if anything he is more exposed to infections from other admitted patients. We have hope that Mubiru will recover and can regain the health and joy a young boy his age should have. However the reality is that his father is now in prison and he cannot return to the people who abused him, broke his bones and left him to die. We are in the process of trying to find a suitable home for Mubiru and we will continue to partner with the home to provide free physiotherapy and any surgery if he needs it to facilitate his return to the normal life of an active and happy young boy. Your kind consideration of our request and compassion for Mubiru will be highly appreciated.

I am really pleased to announce that we have now started the build!!!

The site is being cleared and levelled, ready for the foundations.

Here’s what the site looked like before we started:

and now at the end of Week 1:

Last December I posted the photo below and an update outlining our intention to build this theatre. You can read that post by clicking on the photo or read more about our work in Lira by clicking here.

New Life Church has been collecting each week to support our work and I was very pleased to be there in person to receive their latest donation of £500.

Click here to read about their previous donation, referred to as “Scooby-Doo Money”.

In 2010, IHK gave 2.5% of its income to support the work of the group’s foundation, International Medical Foundation.

As we continue to support IMF in 2011, and beyond, we are keen to ensure:

1. that savings are made where possible, without impacting the quality of the care being provided,
2. that all of our programmes deliver value for money,
3. and most importantly that these programmes maximise the impact being made for the communities and people being served.

Kevin.

Last year when I was with Alan and Lyn in Menorca they asked me to say something about our work in Lira, which Pamela followed up with on her recent visit. Since then the church members have been giving their loose change each week.

Lyn sent us the following:

New Life has certainly embraced Suubi Trust in a big way. They refer to the “Scooby-Doo money” and are so faithful to bring their loose change each week which soon mounts up to a reasonable amount. We originally pledged 50Euros per month from our change but have had other sums come in as well which have brought us to 100Euros!

This extra money came from:

• Offering from Carol Service
• Hermann asked for his birthday gifts to be donated
• One of our members is the Entertainment guy at a holiday resort and had two people donate their Bingo winnings when they heard about Suubi Trust
• Trisha asked for her birthday gifts to be donated.

Thank you so much for the funds and your continued support and promotion of Suubi Trust, we really appreciate it.

Kevin.