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.

International Medical Foundation has been working with Kasese Cobalt Company Limited since October 2006 to provide basic health services to the poor living in three communities close to the KCCL facility in Kasese, West Uganda; Muhokya, Kahendero and Hamukungu.

This programme has been supported by Health Initiatives For The Private Sector, HIPS, a USAID funded project.

Together we have provided HIV voluntary counselling and testing to 4,151 adults, of which 638 tested positive. We have enrolled 467 onto our treatment and care programme and currently 161 are receiving anti-retroviral therapy, ART.

Those enrolled are able to have regular health checks, including a CD4 test which provides a clinical indication of the strength, or weakness, of their immunity system. When the CD4 count has fallen to a given threshold the client is then started on ART.

From time-to-time we are able to provide other health related support, such as these, which we were able to provide in 2011 thanks to the additional funds from HIPS:

Sometimes of course it doesn’t work out and sadly in 2011, 17 of those enrolled on ART died from AIDS related conditions. These individuals joined our programme too late for the treatment to make a long-lasting impact on their infection. That’s why its important that we continue to conduct regular, community based, outreach in which we can provide health education and encourage people to come forward and be tested, before they start to feel sick.

The programme is, we think, a good example of how companies and agencies can work together, sharing cost, resources and expertise, to provide life-changing health services to those that need it most.

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.

The TB Lab now has its roof on and work has started on the internal structure.

The Theatre Block is taking shape, the internal layout is now very evident and the walls are ready for the windows.

The full picture set can be found here.

Related articles

• We’ve Started the Build! (suubitrust.org.uk)
• Jackie and Gary Raise Funds for Charis Theatre (suubitrust.org.uk)
• New Life Church, Supporting Mothers in Lira (suubitrust.org.uk)
• Suubi Trust Annual Returns (suubitrust.org.uk)

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.

Our key focus at this time is raising funds to build a maternity theatre at Charis Health Centre in Lira, Northern Uganda. This is an essential project that will provide a facility from which local women will be able to access safe maternal delivery services and emergency obstetrics as required. Building works are underway; you can watch progress by clicking on the image below.

We continue to provide funding to support treatment of cancer patients on the charity “Hope Ward” at International Hospital Kampala (IHK), Uganda. These funds help to ensure that such care and treatment is accessible to those that otherwise could not afford it.

Most of the funds raised by Suubi Trust come from individual supporters.

We are grateful to Richard and Pat who have led the fund raising for the theatre build in Lira. Rose and Becci helped to get this fund started.

Alison, her family and friends, including Helen, continue to support the work in Namuwongo that Alison was involved with during her time there as a VSO volunteer.

Kate and Caroline, to name just two, are keen supporters of the Cancer Care fund and are amongst the first to use standing orders and Give As You Earn.

Jamie, Louise, Emily, Sean and Rose helped to raise funds using Justgiving pages.

Our thanks also to church members in Hazlemere and Menorca.

All money raised by Suubi Trust is used to support the work of International Medical Foundation in Uganda. Our Trustees are volunteers and do not charge for any services or expenses. The only administration costs covered by the funds raised, and the associated gift aid, are bank charges and the cost of having the online giving facility at Justgiving.

You can review our accounts and annual returns on the Charity Commission website by clicking on the image below.

Thank you all for your kind and generous support and we wish you all a great 2012.

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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

Jackie and Gary are nurses working with Dr. Richard in the UK. They recently got married and instead of presents, asked their friends to give donations to Suubi Trust for the theatre build at Charis in Lira. They raised over 4 million shillings (about £1,000).

We send them our thanks and very best wishes.

We’re raising money for Hope Ward Cancer Care, the charity ward of International Hospital Kampala. I’m growing a moustache, you’re donating money. Hopefully.

You can donate online by clicking here.