By Anjali Chowfla
This past week the Uganda MDP team completed our health sector rotation, which proved to be a sobering experience. Despite the many successes the project has made in improving health outcomes in the community ( a decrease in maternal and child mortality and malaria deaths and an increase in the number of HIV positive individuals on ARVs to name a few), touring the health sector is a constant reminder of what is lacking here – personnel, lab equipment, infrastructure – and what a big impact lacking these things makes.
Our first home visit with a CHW was to follow up on a neonatal death that had occurred the previous week. Despite having been delivered in a health center we discovered that the infant had died within an hour of its birth. The mother, a 20 year old woman, had arrived at the health center with labor pains and was attended by a trained midwife. The amniotic membranes ruptured too early, causing the baby to remain in the birth canal for a prolonged period of time. Normally when the amniotic membranes rupture early, drugs are given to strengthen the mother’s contractions and ensure the baby is delivered quickly. The midwife attending this birth, however, was responsible for 10 expectant mothers. Had she known the severity of the problem (it is not clear that she did) she was still so overstretched that it is easy to see how the problem was overlooked. Due to the prolonged birth the baby’s lungs were damaged and it died within an hour. Had there been oxygen available there is a possibility that the baby may have lived.This case brings to attention the severe resource constraint these health centers are under.
On Tuesday we visited a Health Center II. A Health Center II is the lowest ranking according to the Government of Uganda classification system and implies that the center provides mainly outpatient services – malaria testing and treatment, family planning, STD screening, etc. A Health Center II typically does not have a maternity ward or a laboratory.
As a result of the lack of laboratory tests for malaria are done using RDTs. While RDTs are very effective at diagnosing malaria, they only detect one strain. Many of the people who test negative for malaria are prescribed Coartem anyway in order to treat for other strains of malaria they might potentially have. While the National Health Stores provide Coartem to the health centers every three months free of charge the health center we visited runs out of its supply within the first two weeks. The health officer in charge mentioned that the volume of patients they receive declines significantly when the health center is out of drugs and that we were lucky that we had chosen to visit the day after the drug supply was restocked as the health center was teeming with patients. A functioning laboratory (with a microscope) would allow the health center to use blood smears to diagnose malaria more accurately thus allowing the health center to better ration its supply of drugs.
On Wednesday we visited the Kabuyanda Health Center, classified as a level IV due to its operating theater. As the biggest health unit in the project area it handles the largest amount of patients and offers the broadest range of services. Complicated cases are referred to Kabuyanda from other health centers in the cluster area using the ambulance and emergency referral system implemented by the project. More often than not the cases that are referred are complicated deliveries that require a C-section.
Despite being the most well stocked of all the health units in the area, Kabuyanda is not without its own problems. The health center boasts an HIV clinic which started with 42 patients in 2008 and now treats 932 HIV positive individuals- 150 of whom are on anti-retroviral therapy (ARVs). HIV positive patients are not put on ARVs until their CD4 counts drop below 250 (350 for pregnant women). While the clinic conducts pre and post-test counseling, lab tests for opportunistic infections and helps patients manage and live with the disease, the clinic does not have the equipment to test CD4 counts. As a result patients are sent to Mbarara (the nearby town) for testing, at a cost of 40,000 Ugandan shillings ($20 USD). For a lot of patients this cost, plus the cost of transport to Mbarara, is prohibitive. Those who cannot travel to Mbarara are assessed using the WHO Clinical Staging methodology with patients in advanced stage III and stage IV being given ARVs.
Staffing presents another problem for the Ruhiira health sector. Though Kabuyanda has a laboratory it only has two lab technicians, one of whom is about to go on maternity leave. Each lab tech processes around 80 blood slides a day. Even more problematic is that there are only two doctors for the nearly 150 patients that are seen per day. The doctors work all day, every day, and are on call every night. They trade off weekends, leaving only one doctor on call at a time. In addition to the 2 doctors there are 3 clinical officers, 10 nurses and 6 midwives – none of which seems even close to enough to deal with the volume of patients that the Kabuyanda Health Center handles. There is only one operating room which means that if 4 women need a C-section, the 4th in line will probably lose her baby by the time she is operated on.
There are 150 patients admitted to the inpatient ward each month and only 20 beds. As the doctor explained, the recommended spacing between hospital beds is 1 meter yet most patients in the ward are forced to sleep on mattresses on the floor crammed between beds and in the aisle way. There is no separate post-operative wing, meaning that Post-op patients are mixed in with all of the other inpatients, greatly increasing their risk of infection.
Despite all of these challenges there is some good news. The project is building an oxygen producing plant in Kabuyanda (they already have the compressor and two cylinders and are only waiting for a generator) which will be 1 of 2 of its kind in all of Uganda. When Tommy Hilfiger, a major donor to the Ruhiira Millennium Village, cluster, visited the health center last month he promised money for 2 more operating theaters which will allow for more surgeries to be performed (provided more doctors could be hired…it was not clear if this was on anyone’s agenda). Most women now choose to give birth at a health center, which has dramatically reduced the incidence of maternal death.
Though I ended my health rotation with an overwhelming feeling of how hard it must be to be one of the doctors or nurses working in these health units I also left with a positive feeling that lifesaving changes were being made every day.