Turning health into wealth in Uganda – The Irish Times – Fri, Aug 13, 2010.

Dr. Ian Clarke, IMG Chairman, interviewed by The Irish Times:

“What we have been trying to do is to use the income made from our private patients to upgrade the services at both the private hospital and the community clinics, thus positively impacting health services in the country for everyone.”

Read more here…

Sometimes programmes do not go according to plan, regardless of best intentions or the significant needs that we are trying to address. After almost 2 years we have, regretfully, decided to withdraw from our partnership with the District Health Office in Pader.

Pader Health Centre:

A public-private-partnership established in October 2008 by International Medical Foundation with the Ministry of Health, Pader District Health Office and Local Government in Pader to renovate, equip and improve the running of a Health Centre III with the goal of upgrading it to a Health Centre IV.

In addition a project in partnership with the Ministry of Gender, Labour and Social Welfare to provide treatment to Landmine survivors with support from UNDP.

Unfortunately, after many attempts to rectify operational issues, particularly issues related to district staff who were not reporting to work and not co-operating with our Medical Officer, the In-Charge, we had no option but to withdraw.

It is a shame that this is the outcome of a venture that held so much promise but it was not all for nothing. Almost 12,000 people were helped in our time there, as follows below.

Dr. Ian wrote about this outcome for his column in The Sunday Vision: click here to download a copy.

IMF Contribution:

• Staff and technical support to run the health facility. A contribution in 2010 of UGX 22m (£6,200) to cover operational costs for the clinic.

Other Partners’ Inputs

• Funds through Suubi Trust to purchase drugs and meet other costs in running the clinic; UGX 10m (£2,800) in the first half of 2010.
• In the 2008 and 2009 Suubi Trust provided funding totalling UGX 148m (£42,000). Some of these funds were used to refurbish the health centre so it could once again be used to treat patients, service the ambulance and supply solar panels, batteries and the cables for installation of an electricity supply.
• HIPS provided over UGX 16m (£4,500) to help treat those with HIV/AIDS.
• In 2010 UGX 59m (£16,800) was received from UNDP to provide treatment for the landmine survivors.

Project Outcomes and Impact:

Between January and May 2010 1,517 charity patients were registered and treated as IMF patients and 5,688 were treated as Ministry of Health patients, all made possible through our partnership and support. In the last few months of 2008 and throughout 2009 more than 3,500 patients were treated.

In April, May & June 2010, 737 landmine survivors received treatment in Pader, Gulu, Lira, Loro and Anyeke through International Medical Centres. Five patients were sent to Hope Ward – International Hospital Kampala for complex surgeries.

Patient Stories:

You can read about some of the patients that we helped during our time in Pader by clicking here.

Exchange rates as at August 1st 2010.

Summit Business Review: You have set up IHK successfully and you have been prominent in providing affordable healthcare in the country. How have you managed to achieve all that?

Dr. Ian Clarke: I am a Ugandan citizen, although I come from Northern Ireland. I have lived in Uganda for 22 years now. I have therefore experience in both a developing and a developed country. My passion is for accessibility and sustainability of healthcare delivery.  If I had continued spending all my time seeing individual patients, I would not have had time to develop and facilitate, the systems and the people as part of International Medical Group. My vision has been to set up facilities that are recognised as a centre of excellence in the provision of health services and  because I have chosen to do this in the private sector, I also have to make the model work commercially so that I can pay my staff and run the infrastructure.

We have three things that drive our business decisions: First, is the normal bottom line of being commercially viable – you have to make some money to do that. Second is social impact i.e. to make a difference to people through our delivery of medical services. And third is advocacy – to influence policy for the better.  Those are the values that have influenced our strategy and business model.

In health care, one must be willing to sacrifice. I started off from the village treating people under a tree deep in Luwero, just after the war that brought the current Government to leadership. From there, we started a mission hospital – Kiwoko hospital. After 6 to 8 years, I saw a gap in health care delivery in Uganda – especially the provision of quality health services. We have built up the infrastructure of International Medical Group and with my team, we have also been finding ways to use our own infrastructure to reach out to the poor. We do sort of cost sharing – whereby we charge the middle class, and channel some resources to the poor through International Medical Foundation.  We have actually used the private sector to develop the facilities which are then also used to reach out to the poor. (an example of this is our clinic in Lira, Northern Uganda)

Summit Business Review: Comment on the state of the Government Hospitals in terms of service provision compared to the private sector.

Dr. Ian Clarke: The government allocates funds towards to the public hospitals. The private sector gets no support at all. We are currently in the process of lobbying to get more incentives towards the provision of health care by the private sector. The private sector providers take care of the health of around 50% of the population thus saving the government money.  However when one invests in advanced medical equipment which is expensive, the service provider must then charge a relatively high fee in order to recoup the investment. This equipment is also often purchased through a bank loan at high interest rates. Often the general public cannot afford to pay for such services, hence the Government could subsidize the cost of the equipment in order that we charge less when they send us patients.

We are currently advocating public private partnerships (PPPs) and Ministry of Finance is currently looking at the best operating modalities. One practical proposal is where government, for example, could contract a private hospital to deliver a basket of services in a region, to a specified number of people on the basis of capitation fees, i.e. a fee per person per year. And the hospital can be audited on the fulfilment of the services by a reputable audit body which is beyond being compromised.

There are different models that can be used to organise the health sectors if somebody thought outside the box.

Dr. Ian Clarke: Chairman International Medical Group

Summit Business Review: Quality health care is very expensive in Uganda.  What do you think should be done to make it affordable? What is IHK doing in this regard?

Dr. Ian Clarke: Good health care is not necessarily expensive, but private healthcare is just perceived by the public to be expensive. This of course depends on where they have gone for treatment and the drugs which have been prescribed. At International Medical Group (IMG) which operates International Hospital, International Medical Centres, IAA health care, International Health Science University and International Medical Foundation there are different ways of accessing medical care. International Medical Foundation takes care of charity and community projects and is non-profit. International Hospital provides secondary and tertiary level care. International Medical Centres provide primary and family practice care. IAA Healthcare is a health maintenance organization (HMO) which provides prepaid schemes for both individuals and companies at affordable prices. For example a company would generally pay not more than 350,000 per person per year for the delivery of medical services which includes ambulance in emergency situations, general practitioner (GP) services, drugs, consultations, investigations and hospitalisation. I would say that this kind of package is affordable for many people, but Ugandans are not good at budgeting, especially planning for their medical care and the related emergencies.  It is only after they are involved in an accident and are taken to the intensive care unit (ICU), that they find it expensive, but such emergencies would be covered if they were on an insurance of a prepaid health scheme.

At IHK, our fees are below the industry rates, considering the nature of treatments we provide. Some of them are complex diagnoses and obviously the pricing is a bit higher, although affordable.  IMG seeks to provide a complete medical service, with compassionate nursing and excellent patient conditions at an affordable price. This is achieved by using modern medical equipment and the highest standard of medical expertise.

IHK and the IMC centres seek to provide quality healthcare to the middle income segments of the market. For the very low end market, we operate the foundation, People who have complex medical conditions like heart related diseases can be taken care of through IMF and Hope Ward.

I was watching the match at Kisemente, but decided to go home at half-time since the match was boring. As I was driving past the Ethiopian Village Restaurant I noticed some unusual activity, but did not realize that a bomb had gone off. When I reached home I got a call that there had been a bomb and that the casualties were being brought to IHK. I drove to the hospital while calling in other doctors and when I arrived found Moses the surgeon already there. He had assessed two patients and was preparing to take them to theatre. Emergencies come in waves, the first may not seem too bad, but then there is another and another and if the hospital is not prepared it will be overwhelmed. I took charge of co-ordinating and got on the phone to call in more help. I called four surgeons, two neurosurgeons, four anaesthetists, one orthopaedic surgeon, the whole radiology team, the director of nursing, the director of clinical services, more nurses and the electricians and maintenance people and everyone came in willingly and quickly. The relatives of the injured were around but they were generally orderly, except for one woman who was falling down and creating a fuss. We eventually found there was nothing wrong with her, but she diverted attention from others who were really sick and got up and threw her arms around another of the patients, weeping and wailing. We disentangled her and found she had stolen his wallet (some people never give up). We restored the wallet to the patient and threw her out.

The surgeons and medical officers were triaging and assessing, while the nurses were cleaning up the wounds and blood. As patients were moved to the ward or theatre more arrived to take their place. I asked the cleaners to clean up the blood urgently and the nurses to disinfect the couches as we went along, so that new patients were not put on bloody couches. Then a man was carried in with a bad head injury; at this stage we did not realize another bomb had gone off, but other casualties began to arrive, most with head injuries and the police then called to ask us to send ambulances to Kyadondo. The ambulance picked up three seriously injured cases, brought them back and went for more. By this time the waves were really coming and there were many relatives and onlookers. I ordered everyone to wait outside unless they were an immediate relative as we dealt with the casualties, since we wanted to get on with our work with as little chaos as possible. A policeman was stationed at the door and managed to keep order – we wouldn’t even let the press in.

In such an emergency one has to select the patients one can help the most. Those who appear to have minor injuries can wait and be re-assessed later. Sadly, those who are very badly injured and passed hope cannot have your attention either; one must concentrate on those for whom there is still hope. One doctor was dealing with two bad head injury patients, but he could see that the young girl was deteriorating before his eyes and there was nothing he could do – she died within an hour. People were now carrying in severely injured victims on tarpaulins and laying them on the beds; one man was covered in blood and was already dead, but another, who was lying face down in his own blood was still breathing and had a chance. We got the dead shifted to the mortuary and dealt with the living. The waves were now moving through the hospital departments – from accident and emergency department to radiology, to Intensive Care Unit, to theatre, to the wards. Theatre block had three theatres working at once, ICU had nine seriously injured patients, the wards had the more stable patients.

There were two main types of injury – the serious head injuries and those who had penetrating wounds from ball bearings, nails or secondary missiles. One man had hardly a mark, except for one small puncture wound on the chest, but he was dead on arrival – a piece of shrapnel had punctured his lungs. Another man had what looked like a ball bearing on X-ray, neatly lodged in his spine. He also had some small innocuous wounds on his side. It turned out that the ball bearing was harmless, but other bits of shrapnel had pierced his abdomen, tearing holes in his liver and gut. He was taken to theatre where they were repaired. Some of the victims had had been peppered with shrapnel and it took the surgeons hours to explore all the wounds and pick out the debris.

Meantime we were doing CT scans on the people with head injuries – the damage was devastating. Not only were skulls fractured and shattered, with some people having blood and brains oozing out, the scans showed that there was bleeding and bruising throughout the brains. We knew that many of those with head injuries would not survive, but their best chance was to put them on ventilators (life support machines) and give them drugs to reduce the swelling of the brain. By this time it was approaching morning and the activity had shifted to ICU, where we had nine patients, but only four ventilators available. Once again we selected those who had the best chance of survival and treated them most aggressively. For the others we did what we could, but several died within twenty-four hours. The staff who had been working all night were now tired, but early in the morning more staff had heard about the bombs and came in to help, so they were fresh and the operations in theatre continued working throughout the next day. Everyone had a heavy heart, but we had no time to grieve.

As I write now five days later I am filled with sadness for all those who died so pointlessly. As a doctor one learns to be professional and get on with the job at the time, but afterwards one sees the images: the young people who were enjoying life one moment and had their lives snuffed out the next.

I want to thank the Ugandan nurses and doctors who worked tirelessly to save the bomb blast victims at both IHK and Mulago – they were professional and caring and can hold their heads high. I wish that the mortuary part had been handled better. The police insisted that all bodies be taken to City Mortuary, but the scenes there were shocking, the least we owed the victims was some dignity in death. We need to remedy this situation for the future.

As you’ve probably heard by now Kampala was rocked by multiple bomb blasts on Sunday taking over 70 innocent lives and counting. This meant an extremely busy night at International Hospital Kampala (IHK) the hospital where Clea and I both work (though as administrators not medics). One of the bombs was detonated in a local restaurant called the Ethiopian Village in a district called Kabalagala, less than ten minutes drive from the hospital. Kabal … Read More

via Kampala Camera

Hopefully the following 2-pager from Dr. Ian will help. He lays out how IMG began more than 20 years ago and how it has developed into the largest private healthcare provider in Uganda, employing more than 700 staff and treating more than 200,000 patients each year.

You can download a pdf version by clicking here.

>>>

The growth of International Medical Group, which includes International Hospital, International Medical Centres, IAA Healthcare, International Health Science University and International Medical Foundation has occurred during the period of stability and increased security which has been overseen by the current government.

For the full story of International Medical Group one must go back to Luweero in 1987, just after the end of the civil war between the Obote Two regime and the NRA. Dr Ian Clarke made a visit to this troubled part of Uganda and decided to relocate from his native Ireland, in order to carry out community health work. From small beginnings, where patients were treated under a tree or in the vestibule of the local church, the community health work quickly grew into a health-centre four and then to a full hospital (Kiwoko Hospital) and the Clarke family spent the next six years living and working among the people of Luweero.

Subsequently, in 1996 Dr Clarke relocated to Kampala, where he set up a private clinic. This was in response to the growing demand for private medical services from the Ugandan middle income group, which was beginning to emerge after a decade of peace. The number of patients coming to the clinic, known as International Medical centre, quickly grew hence Dr Clarke decided to develop a small hospital. A building in Old Kampala was renovated and became the first International hospital, officially launched in the year 2000. However this was not a purpose-built hospital and was barely adequate for the growing demand for medical care in Kampala.

One of the driving factors in the rapid growth of International Medical Group has been the method of payment which was established through IAA healthcare. IAA Healthcare offered companies and NGOs a means to pay for the healthcare for their staff at very reasonable fixed yearly rates. In these medical schemes over 80% of the service provision was through IMG’s own hospital and growing number of clinics, thus all the funds paid by the companies were going back into the provision of the medical service and development of better facilities and not to a third party such as an insurance company.

Over a period of ten years IMG opened a number of clinics throughout Uganda – in Kampala, Jinja, Entebbe, Mrarara, Lira, Pader, Gulu and even in Juba South Sudan. The organization also set up clinics for private companies such as flower farms, factories and schools. With the growing number of patients, it became obvious that there was the need for a purpose-built hospital to facilitate modern medical equipment and state of the art medical care in Uganda. A four and a half acre green field site was located within Kampala at the foot of Tank Hill and work was commenced on the building of the new International Hospital Kampala. By 2008 the new purpose built hospital was fully functional, with 110 beds, a busy outpatient department, a well equipped theatre suite and an intensive care unit. International Hospital was the first hospital to carry out keyhole surgery in Uganda, plus open heart surgery and their outpatient base has grown to over 200,000 outpatient visits per year within Kampala alone.

As the facilities were developed and improved, IMG recognized the need for training health professionals to cope with the acute shortage of health workers and the developing human resources for health crisis in Africa. They responded to this need by setting up International Health Science University, the first private university in Uganda to specialize in the training of health professionals. The university is housed in the well equipped top floor of International Hospital building and not only includes a Nursing Faculty and Health Management and Policy Faculty, but the first distance learning Masters Degree programme in Public Health in Uganda. Students on this course are able to access teaching materials through the internet and also to have interactive discussions with the tutors and lecturers, through an open source platform.

Recognizing the need to increase the level of expertise in the healthcare field in Uganda, IMG formed a collaboration with a centre of excellence in India and have sent more than twenty nurses for specialized training in the fields of intensive care, theatre management, coronary care, renal dialysis and hospital management. This collaboration will also result in the installation of the first cardiac catheterization unit in Uganda, as International Hospital develops MIMS International Cardiology Centre to be opened later this year.

IMG also realized that there are many poor people who cannot afford to access their services, so they set up an NGO – International Medical Foundation to reach out to the poor. One of the IMF projects within IHK itself is Hope Ward, for the treatment of complex conditions for the destitute. IHK pays 30% of the cost of treatment, while raising money from other sponsors within and outside Uganda through its sister foundation in the UK known as Suubi Trust. Other charitable and community programmes include treatment of those with HIV and TB in Namuwongo through ‘Touch Namuwongo’, HIV projects in Kasesse, Mukono and Lira, a public private partnership to improve the services of the District Health Centre in Pader and a TB research project to make the diagnosis of TB through culture more rapid and affordable.

IHK has recently embarked on a programme to upgrade its facilities and equipment to those of a tertiary level referral hospital which will compete at regional level. To this end it has become a reference hospital for Toshiba, in partnership with a large South African equipment company known as TECMED. IHK will not only install a cardiac catheterization unit, as part of its cardiology centre, but is installing a 128 slice Cardiac CT. This is the most advanced CT scan in sub-Saharan Africa, even overtaking the Kenyan private hospitals. This scan can carry out CT angiograms, ie take a picture of the vessels of the heart, without the need for any tubes of needles. IMG is also in the process of forming a collaboration with some external universities, such that it can embark on a project to establish a full medical school for the region with the aim of having accreditation to international standards.

While there is still much to be done, there has been significant growth of International Medical Group over the past decade and a good foundation has been established for the group to become a regional referral centre and to ensure that Uganda competes with its neighbours in the health sector. International Medical Group contributes to the essential medical services of the country, but as a private player recognizing that sustainable development cannot be purely donor driven. IMG has not only focused on the top end of the market – on those who can pay, but has programmes reaching into the community to the base of the pyramid and also targets medical education and the building of capacity within the country. IMG employs over seven hundred people in its various enterprises and by the end of 2010 will be training seven hundred students at its university. Currently the vast majority of its resources and investment has been privately funded, but the group is looking forwards to increasing partnership with the government in the development of public private partnerships in this sector in order that quality medical services can be availed to all members of the community.

As I write this column I am sorrowful, because I have lost a good friend and a good man. Moses Munezero was killed in the night bus ambush which happened on the Mbarara- Kabale road this week.

He was a young doctor working in Lira who first worked on a community HIV project in Hima and then moved to Lira to help me set up a clinic, where we not only treat those who can pay, but hundreds of charity patients and those with HIV.

I visited him four weeks ago and he was excited about the possibility of extending the clinic to have a theatre to carry out emergency caesarean sections and other operations. Moses was the kind of person whom one depended on, because he was steady and never let people down. He was that rare breed of person who was truly unselfish and spent his life helping others. He wanted to be good at what he did and considered the patients more important than his own personal needs.

Moses represented the very best of Uganda, in these days when we hear a lot about corruption and Ugandans who are in a hurry to get rich quick by any means. He was a role model, the kind of person you would be happy for your daughter to marry — competent, serious-minded and compassionate. He was a Ugandan who restored hope when one was tempted to feel the society was rotten. It is this which makes his death all the more tragic — because he was killed by Ugandans who illustrate the level to which our society has fallen.

The thieves placed big stones across the road, which the bus crashed into and then overturned, killing at least five people and injuring many. The thieves were not appalled by what they had done, but boarded the bus and systematically robbed the dead and the dying. The worst of society had killed the best in society. Is this the kind of place that Uganda has become?

We have so many good people, but they are being pushed aside by those who have no conscience, feel no tenderness and show no mercy. Uganda has been here before — when the State Research Bureau disposed of people as if they were pieces of meat; we have only just got rid of the menace of Kony, but now it has become dangerous to do everyday things, like taking a bus ride at night.

One of the main purposes of government and civil society structures is to maintain law and order, so that people can go about their daily lives without fear of molestation. The death of Moses is an indictment of these organs of society. His death was due to a combination of lack of law and order and lack of care by the driver and the operators of the bus company. If the driver had been going more slowly within the speed limits, he could probably have seen the stones and stopped. If policing is now so weak, that thieves can operate with impunity along a major highway, then the system is ineffective.

The combination of these two deficiencies resulted in the death of a fine young Ugandan, and let us not kid ourselves, this death could have been avoided. But will anyone take responsibility? Will the Police, who have failed to enforce speed regulations on the buses and to patrol the road? Will the government, who have allowed an incipient lawlessness to take hold, which breeds violence and death? Or will everyone just shake their heads and agree that it was a tragedy, while we wait for the next hold-up or next bus accident to happen?

We are losing the good people in our society, because we are failing to control the worst elements.

Published on: Saturday, 19th December, 2009