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Francis is still in a critical situation, though some problems have got settled.

The important problem that looks settled is the air leak, which was causing swelling all over his body and face. Also, he has become more stable lung wise and is mostly off ventilator for over 5 days. He had breathing problems last night and needed ventilator support for a few hours. His left lung is OK and right lung is also partially working. He is needing very low support of oxygen since morning and is breathing by himself.

He is still paralyzed below chest. Can write and communicate. Both upper limbs are OK.

We took him for a CT Scan of chest and neck a week ago. At the same time we did a barium swallow study to assess the status of Oesophagus. They were very informative.

The CT Scan of neck – shows shadow of metallic shrapnel within the spinal cord at the Vertebral level T1, or at the junction of chest and neck. The neuro-surgeons here are of the opinion that it should be removed by surgery and are confident of doing the operation. But he is still not stable for that major surgery.

The CT Scan of chest showed what we expected – the problems with the lung and pleura.

The Barium meal study was done principally because we found that food from his stomach was coming out through the right chest tube. The film clearly shows the barium contrast leaking from the neck (Oesophagus) to the right Pleural cavity/chest. This means that there is a communication between his Oesophagus (Food pipe ) and right chest cavity.

After seeing this, we had to stop giving him feeds through naso-gastric tube and had to start on Total Intravenous (parenteral) nutrition, which is very expensive and having its own risks too. The ENT surgeons and Cardio-thoracic surgeons in this country are not operating on Oesophagus regularly and hence not coming forward to do a surgical correction. Also, it is very risky to operate on neck unless one is experienced and confident. (as it has a lot of vital structures in small area).

Oesophagus is routinely operated in many other countries, including India. So, I had contacted Dr.Radhakrishna P., senior consultant surgical gastro-enterologist in Apollo hospital, Chennai, India, who is a friend of mine. He had advised to do Esophagoscopy, locate where the leak/defect is and close it directly with a covered/metallic stent. We cannot do this as we do not have experts who can deploy Esophageal stents (stent is not available also) here.

So, he advised to do an alternative of surgery to insert a tube into lower part of intestine (feeding Jejunostomy) to give him food, so that he can survive and another surgery in the neck- Esophagostomy/ opening of Esophagus out, so that saliva can be diverted from going down to the chest. The defect can be repaired later when he is more stable. This will improve his chest also.

Dr. Moses has done the feeding jejunostomy 3 days back. But 1 day after the surgery, he vomited greenish(bile containing ) Fluid, which started coming through the chest tube also. This has improved and we have started giving liquid food through the feeding jejunostomy tube.

Esophagostomy is yet to be done.

Dr.Edward (ICU in-charge) was suggesting to get surgeons from abroad to operate on Francis and settle the problems. We are still looking for options. Family was also asking about this possibility. Getting a surgeon from India also is not very easy.

He is maintaining good blood pressure and pulse. Urine output /kidney function is good and is looking forward with hope! So is the family.

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.

However this is just a part of the whole picture, yes a very important part, but there is more.

Uganda’s disease patterns progressively show an increase in diabetes, hypertension or sometimes heart disease that can be preventable. Cancer cases have also increased leading to premature death, especially among women. These diseases, once thought to be just in the West, are becoming matters of concern amongst healthcare professionals working in Sub Saharan Africa.

About one year ago we established a Well Clinic to offer health screening services at International Hospital Kampala. Recently we expanded this to include similar services for our community clients. Our latest initiative is to provide these services to Corporates in the form of Employee Health Days and on Friday we offered such a day to our own employees at IMG.

Through the Well Clinic, IHK has conducted Cancer Awareness campaigns, screenings such as PAP smears and educated individuals to carry out self-examination (breast and testes) that hopefully will mean that any abnormalities will be found early. Clients are counselled about aspects of lifestyle that may affect their health: being too heavy, eating the wrong foods, drinking too much alcohol and of course all matters related to Sexual Reproductive Health.

Joy and Bwine are a humble couple that loves their son Mathew Ayebare (Pictured) deeply and have done their best to take care of him.  Mathew is a little over two years old and has been in and out of hospital since he was a year old.

Joy noticed that Mathew at nine months did not seem to respond or behave like her other two children. However, she did not read too much into it at the time. When he made a year, Mathew started getting seizures. When he was taken to hospital, they were told he had epilepsy and he was started on treatment.  But the seizures did not stop.

The anxious young parents took Mathew back to hospital where he had a CT scan that revealed bleeding in his brain. This is when they learned that their son had a very complex and rare congenital defect known as arteriovenous malformation. An arteriovenous malformation (AVM) is when there is abnormal connectivity between arteries and veins.

www.brain-aneurysm.com says that most brain AVMs present with a brain hemorrhage (severe headache, nausea, vomiting, and collapse/loss of consciousness). Instant death rate is believed to be at about 10% for first-time hemorrhages from a brain AVM, and this is about the same as the instant mortality rate for first-time brain aneurysm ruptures. Many AVMs present with seizures, and some present with neurological symptoms (paralysis or sensory disturbance) due to the mass of the blood vessel tangle causing direct compression of brain tissue.

Joy and Bwine desperately needed a “miracle” for their son.  They were referred to Dr. Hussein Ssenyonjo who agreed to perform the operation. However, it would be a very complex operation with a long stay in Intensive Care after the operation. The family could not raise money to have the surgery done and; so, they approached Hope Ward at International Hospital Kampala.

Hope Ward is a charity ward at the International Hospital Kampala that partners with various companies, organizations and individuals to provide complex medical treatment for the very needy in Uganda. Sponsors include Bead for Life, Muvule Trust, Stanbic Bank, MTN, Narrow Road, Hwan Sung, Suubi Trust, Bless a Child Foundation, IAA Health Care and the International Hospital Kampala (IHK).

Mathew was admitted to Hope Ward and had a successful surgery at IHK. His family was only asked to contribute Shs 2m out of a total of Shs 6.2m.  The International Hospital covered 30% of the  bill and does the same for all Hope Ward patients. The balance was covered by donations from Hope Ward supporters. Dr. Ssenyonjo waived his fee and his only concern was saving Mathew’s life.

Before surgery, Mathew had a 10% chance of living but his future is much brighter now.

So Gordon Brown made his political re-appearance here in Kampala. It’s an interesting speech in which he says some things that I absolutely agree with, see below, and sort of wish he might have been more vocal about the same whilst he was UK Prime Minister. You can download the full speech here.

To help economies develop across Africa, he said nations needed to increase access to broadband internet, which he said less than 1% of people currently had access to.

Agreed, I’ve seen the huge difference that fast internet has made to life and business in the UK; so badly needed here in EA.

Turning his attention to the developmental aid given to Africa, he said this needed to increasingly focus on private sector wealth creation, and not just providing services for the poor.

“The job of aid is to kick-start business-led growth and not to replace it,” he said.

“And so I believe we need to focus not just on poverty, but on wealth.”

I agree and that’s what we’re looking for; developmental aid that will help the private sector to grow and expand its services. This sector already provides more than 70% of healthcare services in Uganda and could do a lot more, better and faster, with adequate and appropriate funding (long-term loans not hand-outs).

We must of course maintain the focus on what matters, saving and improving lives:

After the speech, Bernard Aryeetey, from the charity Save the Children, said a long-term growth strategy for Africa was vital but should not be to the detriment of investment in health systems and education.

“Making sure that children are able to go to a clinic when they are ill and get a decent education must be tackled in parallel with a drive to increase economic growth through technological advance.

“Saving children’s lives does in fact contribute to economic growth.”

I get annoyed that services that are run effectively and efficiently cannot access the help they need to continue their work. I hope that your proposal for a PPP is accepted as it a great idea!

BTW: this is old programme but wondered whether you saw it http://news.bbc.co.uk/1/hi/programmes/panorama/7738297.stm

You can link to the posting by clicking here.

This Panorama programme is almost 2 years old but sadly it is still very current.

picture inserted here, if I had any bandwidth

More than 70% of healthcare services are delivered in Uganda by the Private sector (which includes for-profit, Mission and not-for-profit NGOs) and yet very little of the total Aid and, for that matter, such a small percentage of the country’s healthcare budget, ever finds it way into this sector.

Private is not bad, and just because an organisation is set as a For-Profit is not a good enough reason to shun it.

IMG is a private-for-profit employing more than 800 local people right across the organisation, from top level directors to temporary staff engaged from time-to-time when we need more maintenance or another building. We pay our own way. Our ethos is not one of “for-profit”, in fact most of our profit has been re-invested as we continue to build and develop our services. We believe in Development and Outcomes.

We run and support our own not-for-profit, NGO, called International Medical Foundation. Through IMF we reach out to thousands of Ugandans who cannot afford to access healthcare services and that includes not being able to afford services provided at public centres. Service at the latter is not “free”. You may be able to get a free consultation, if the clinical staff are present and available, but you still have to pay for tests and treatments.

Uganda needs the private sector healthcare organisations and these need to be included in overall country budgeting and in the design and planning of new Aid disbursements.

We could do more, better and faster with the right interventions and partnerships. Donor countries and organisations could help by providing access to long term borrowings at decent interest rates (as outlined recently by the IFC, World Bank). Lack of available and appropriately priced funds is a serious impediment to the growth and development of the private sector. We’re not seeking hand-outs but we do need well structured long-term finance.

We need Development not Aid.

1. Sustained fracture of his right femur and multiple perforations in his intestines. Pain is controlled. Can take oral feeds. Steadily improving.

2. Had abdominal surgery. Pain controlled, he can eat and move out of bed. He is much better. Getting nightmares and sleeplessness. Put on medication. Slept better last night. Much better.

3. Had abdominal surgery. Pain controlled, he can eat and move out of bed. Marked improvement. Has shrapnel in his pelvis. Surgeon to determine need for surgery.

4. Severe head injury. Still unconscious but responds to pain by opening eyes. Had fever free night. Some improvement.

5. Had abdominal surgery. Pain controlled. She can eat and move out of bed-much better. Broken finger operated 2 days ago.

6. Sustained head injury. Her sight is steadily improving. Power in her arms is also improving. May need surgery to remove shrapnel form her skull. Surgeon to determine.

7. Sustained spinal, neck, airway and esophageal injury. Got air leakage to the skin and body swelling. Body swelling has reduced markedly and can move his arms. Patchy sensation in the legs. Will need surgery to close the hole connecting his airway and esophagus and to remove the shrapnel in the neck when he is stable.

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.