UK Aid as a share of National Income

In the last few weeks there’s been a lot of discussion about UK overseas aid. (on Twitter #AidReview)

DFID has just completed a thorough review of all the programmes that it supports and has announced some changes planned for the next few years.

Essentially the UK Government is committed to sharing up to 0.7% of our national income to deliver results such as:

  • secure schooling for 11 million children – more than we educate in the UK but at 2.5% of the cost
  • vaccinate more children against preventable diseases than there are people in the whole of England
  • provide access to safe drinking water and improved sanitation to more people than there are in Scotland, Wales and Northern Ireland
  • save the lives of 50,000 women in pregnancy and childbirth
  • stop 250,000 new-born babies dying needlessly
  • support 13 countries to hold freer and fairer elections
  • help 10 million more women get access to modern family planning.

Getting to 0.7% will mean an increase of some 50% in cash terms over the next 4 years.

I first came across this chart on Owen Barder’s Blog:

In his announcements last week Andrew Mitchell noted that UK Aid to Uganda will increase from £68m pa to £98m and will be focussed on these top priorities:

  1. Improving the quality of essential services, especially for the most vulnerable
  2. Supporting the recovery in northern Uganda
  3. Improving maternal and reproductive health
  4. Driving growth through training, job creation, financial services and trade
  5. Improving government accountability and transparency so that future oil revenues are spent effectively.

I am hoping that our projects in Lira and in the Makindye Division of Kampala might benefit from some of this funding, as we seem to be closely aligned on the first 3 in particular.

Advent: Day 22 Charis – IMC (Lira)

Over the last 3 years, I’ve had the great pleasure of watching our work in Lira grow and reach more and more of the people in that community with an ever-increasing range of services.

Earlier this year we relocated to a facility owned by Charis, represented by Dr. Joel at the far left in the photo above.

Since then Dr. Leonard (2nd left above) and his team have been able to extend the services to include in-patient care, particularly for young children with severe malaria. The team has expanded its maternal health services, through Yer Yotkom which is focussing on reproductive health, preventing unwanted pregnancies and preventing the transmission of HIV between mother and child and by offering safe delivery.

Next year we will build an operating theatre suite which will allow the team to perform C-sections and emergency obstetrics care. Dr. Mike, on the far right above, has committed to providing the funds to buy and install all of the necessary equipment for this. Dr. Richard and Patricia have started to raise funds in the UK to meet the cost of building the theatre.

Also pictured above with Dr. Ian Clarke is Phil Knight who will manage the building project.

Once the theatre is completed the Charis-IMC centre will be designated a Health-Centre-4, which is the small hospital category, with facilities capable of providing safe maternity services and some minor operations. Such centres usually provide service for local populations of 50,000 – 100,000. Given its population Lira should have 4 such facilities; currently there are none and the regional referral hospital is desperately overcrowded, under-staffed and lacking some essential facilities.

Advent: Day 17 Primary Care

International Medical Foundation (IMF) provides public health and primary care to the communities living around IHK and the up-country clinics (mentioned in Day 12). This includes for example: health education, family planning, reproductive health, HIV testing and treatment, immunizations and treatments for the common acute conditions such as malaria, respiratory infections and diarrhea.

We operate these services on a cross-subsidised model, meaning that our community work is not charged for facilities, it does not contribute towards central services such as HR, IT and Finance and some of the clinical staff costs and most of the management staff costs are paid by IHK and IAA (the private-for-profit companies within International Medical Group).

On the whole these community services cost about $7 per patient treated. Some of the services are supported by funded programmes such as Yer Yotkom and Touch Namuwongo, in which case the care and treatments are free of charge to the community. For those services that are not funded we sometimes ask the patient to make a small contribution of up to $3. This is how we are providing the clinic services at Charis-IMC in Lira. The charge for a child with malaria is a flat-fee of just $2 which includes the consultation, test and treatment, which may sometimes need to include IV fluids and an overnight stay on the in-patient ward. The actual cost of these clinical treatments can be as much as $15.

Our thanks and appreciation go out to the sponsoring corporates both in Uganda and from overseas and the many individual supporters and well-wishers from across the globe. Your continued support and funding allows us to continue to extend the scope of our programmes ensuring the provision of more holistic care and treatment.

Charis IMC Lira, developing a MCH programme: part 5 of 5

By Clea Meynell:

The IMG team has developed a draft plan of the proposed operating theatre (see below). There is ample space around the existing buildings on-site, and under the proposed plans the theatre would be easily accessible from the main facility building, leading straight onto the ward dedicated to post-operation patients and post-natal care. The theatre would also be easily accessible from the delivery suite in an emergency.

We are hoping to raise GBP 40,000 to complete this building and as mentioned in earlier postings we already have a commitment from Direct Relief International for the provision of the required theatre equipment.

If you would like to help with this venture then please do get in touch.

Proposed Theatre at Lira

Charis IMC Lira: part 4 of 5

By Clea Meynell:

IMG recognises that the success of this initiative wholly depends on a number of key partnerships and ongoing collaborations to leverage resources and support. These are as follows:

Ongoing partnerships

There are three ongoing collaborations which form the basis of this initiative. The first relates to the unique set-up which exists between the various IMG entities. IAA Healthcare provides a significant regular income, which helps to defray the clinic’s fixed costs, including e.g. staff salaries. IHK provides the overall management and supervision of the clinic, ensuring Patient Safety and Quality of Care. It also ensures reliable provision of drugs and medical consumables. IMG Construction (the team that has built and maintains International Hospital Kampala) has already been deployed to make some minor renovations to the Charis facility and this will be the team used to build the Theatre Suite once funds have been raised. By using our own internal workforce we can control costs and ensure quality and timely delivery. International Health Sciences University (IHSU) will deploy its research students and lecturers to continue inputting into baselines and evaluating the outputs and outcomes at Charis-IMC. This adds an academic and objective rigor to our planning and assessments.

The partnership between Charis-IMC and Fields of Life is another important relationship which is central to the success of this model, and one which would be furthered through the provision of financial support in constructing the operating theatre. It is due to the vision and generosity of those involved in FoL that this clinic has been established in the first place. That vision was for a community hospital serving the poor in these communities and we are now very close to making this a reality.

Dr Joel’s continued involvement brings the additional benefit of his wealth of experience and knowledge of Ugandan Healthcare. Dr. Joel is a well respected local resident in Lira and he is able to help establish the local links and partnerships with the District Health managers and senior staff at many other facilities.

Lastly continued collaboration with the Ministry of Health, both at District and National level will be important to ensure buy-in and to feed back findings to key policy makers.

Project-specific partnerships

The portfolio of IMF projects being implemented from Charis IMC will vary over the coming years depending on project length and each project will have a range of stakeholders specific to its focus. At present there are a number of donors who are currently supporting IMF activities at Charis IMC.

The Positive Action for Children Fund (PACF) supports the new Yer Yotkom Project, a 3-year Sexual Reproductive Health (SRH) project being implemented in partnership with the National Community of Women living with HIV/AIDS (NACWOLA). The PACF is a fund set up by two global pharmaceuticals, Pfizer and Glaxo Smith Kline.

Suubi Trust helped to establish the initial charity based work at the Lira IMC. Its funds supported provision of primary care to more than 3,000 patients in the last year, initiated an Immunisation programme and helped meet the cost of some essential equipment.

Hands of Help Australia has been a long-standing donor to IMF with financial assistance being provided for two community projects, one in Jinja and one in Lira. The Aldo Project provides HIV/AIDS prevention, testing and treatment services to community members in Lira. It is a small but successful project which is due to finish in January 2010. IMF are in the process of finding funding to continue and expand this service.

Team at Charis IMC

A key gap in service provision for Lira District highlighted to IMF by the Aldo Project was the lack of CD4 machines which were functional in the District. Samples were being sent to Gulu for analysis, causing a high cost onto the patients. Therefore, IMF approached the HIPS Initiative (Health Initiatives for the Private Sector) to partner with IAA Healthcare (IMG) to cost-share on the purchase of a new CD4 machine for Lira IMC. Both parties contributed just over USD 15,000 each. This machine is now successfully installed and in operation. A pricing model has been established in which the margins charged to private and IAA pre-paid clients are used as a cross-subsidy to provide CD4 tests for our community clients at a reduced price.

Voluntary Services Overseas (VSO) have a longstanding relationship with IMG, with IHK receiving numerous VSO volunteers on a regular basis. Three such volunteers have had a considerable input into the development of the Charis IMC model. Dr Richard and Patricia Feinmann were based in Lira for 3 months working with the team to do an assessment of training needs and to develop initial ideas and potential models for the initiative. Diane Lockhart, an experienced midwife, has recently spent 3 weeks with the team up in Lira, focussing specifically on maternity services and related training needs. IMF are currently in the process of working alongside VSO to identify future roles for volunteers to be based at Charis IMC in Lira.

In the pipeline

The vision for Charis IMC is such that the collection of partnerships and collaborations outlined above will be both expanded and formalised in the future. In terms of expansion, there are already a number which are currently being developed through proposals and ongoing discussions. These include:

– Further collaboration with Target TB and Comic Relief to increase the TB-related work that Charis IMC is involved with. TB diagnosis and treatment is a particularly under-resourced area in Lira District and preliminary investigations hint at a problem which is growing, particularly in the urban areas of Lira Municipality.

– As mentioned above, there is a need to find additional funding for the HIV/AIDS related work undertaken in Charis IMC. The IMF team are in the process of approaching a number of donors, namely Civil Society Fund and the Global Fund to fill this gap.

– Recent conversations with the UK Department for International Development (DfID) were particularly positive and there was a great deal of cross-over between the approach described here and their current thinking for support to Northern Uganda, particularly concerning maternal health.

In the long-term IMF is considering the idea of creating a consortia of donors and other stakeholders so as to formalise these relationships and to leverage further resources. This would facilitate easier marketing of the various initiatives involved in Charis IMC and would hopefully attract new interested parties.

Charis IMC Lira: part 3 of 5

By: Clea Meynell

The target population will be the communities surrounding Charis IMC. Initially the idea is to extend service provision to all residents within Ojwina and Central Divisions in Lira Municipality, thereby covering 62,100 (59%) of Lira Municipality residents. Charis IMC is located in Bar Ogole Parish of Ojwina Division.

This document shows a table which outlines the target population by parish:

The current bed capacity of the facility stands at 24 beds and the aim is to have one ward (12 beds) dedicated to post-operation care (6 beds) and post-natal care (6 beds) whilst the remaining 12 beds will be for in-patients (largely women and children) admitted from the outpatient and community based clinics.

Charis IMC Lira: part 2 of 5

By: Clea Meynell

Proposed approach

Senior level staff at International Medical Group (IMG) are in the process of developing a model of healthcare that is closely aligned with the district level services, ensuring cross-sector collaboration and capacity building as well as clear coordination with government and NGO services currently on offer in the District. Central to this model is the use of Village Health Teams (VHTs) and a well functioning referral network with close ties to other service providers in the area. Through strengthening the link between the private sector and the District Health Team, innovative public-private partnerships will be forged, addressing a key gap highlighted in the new Health Sector Strategic Plan (HSSP) III for 2010/11-2014/15.

The aim would be for a private facility at health centre IV level to provide care and treatment to a catchment area of 50-100,000 much the same as a government HCIV is supposed to do at present. This facility would be linked into the government network, essentially taking on the role of a government facility, thereby taking the burden off of the Regional Referral Hospital.

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The Lira IMC Service Model

Charis International Medical Centre (IMC) is an outfit operating through a partnership between IMG and Dr Joel Okullo. The facility was built by Fields of Life and donated to Dr Joel. IMG employs and manages all of the staff at this centre and it has full responsibility for the day-to-day clinical governance and operations management.

IMG is keen to pilot this sustainable private-not-for-profit model of healthcare at Charis IMC in Lira, with a view to rolling it out across other facilities available through the IMG network in the future. It is hoped that this pilot will demonstrate the potential which exists in forging these public-private partnerships, therefore increasing the government’s ability to provide high quality healthcare to those most in need in Uganda.

The model is characterised by an approach which is focussed on tackling the most prevalent acute health issues occurring in the surrounding communities. In Lira, as is the case in most Ugandan communities, the majority of maternal and infant mortality (and morbidity) can be overcome by interventions which address these acute issues such as malaria, diarrhoea, respiratory tract infections, and maternal health complications. This coupled with an emphasis on preventative and promotive health rather than purely reactive, curative healthcare, as is seen in most health facilities across the country, would go a long way to tackling the vast health inequalities currently found in Uganda.

Pricing for these services has been developed with input from consultations with members of the target communities as well as with other service providers active in the area. The resulting price scheme is a simple one which is underpinned and made possible by the relationship with IMG. The International Air Ambulance (IAA) healthcare schemes are a central element of the IMG model, and in Charis IMC IAA clients represent 60% of patients that pay for service and account for 75% of the money received. Charis IMC will continue to treat IAA clients as in other IMG facilities, however under the new model, the profits from these clients are used as a cross-subsidy to provide a much reduced price for community clients. The community prices which are being trialled at present are as follows (full list included as Annex 1):

– Children under 5 years: 5,000 UGX.

– Adults (anyone over 5 years): 12,000 UGX. This covers initial consultation, testing, resulting treatment costs (including drugs) and admission to the ward if required.

– Antenatal Services: 20,000 UGX for an antenatal package (including medical consultation, all ANC visits, baseline tests, tetanus immunisation, blood grouping, HIV, syphilis, routine triage and IPT).

– Delivery Services: 30,000 UGX for a normal delivery. At present, without operating facilities, if any complications arise referral to the Regional Referral Hospital or Lira Medical Centre is made.

There are certain exceptions to these rules, for instance some services will be covered by community-based projects implemented by the International Medical Foundation, the NGO arm of IMG. These include care and treatment of HIV/AIDS patients (under the Aldo Project) and provision of contraceptives (under the new Yer Yotkom Project, summary included in Annex 2).

This latter project is of some interest to this proposal as it aims to provide an integrated sexual reproductive health (SRH) service focussing on the first two WHO pillars of PMTCT (primary prevention of HIV and preventing unwanted pregnancies, particularly amongst women with HIV/AIDS). Currently the third pillar (PMTCT of HIV during pregnancy and birth) is not available at Charis IMC, and referrals to the over-burdened Regional Referral Hospital are the only option. The long-term aim is therefore to extend services available at Charis to include this through the construction and equipping of an operating theatre to perform life-saving C-sections for the surrounding communities.

Bridging the gap – Construction and equipping of an Operating Theatre

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At present the facility is operating at Health Centre III level, however plans are underway to upgrade it to level IV and operate it as a small community hospital. In order for this to happen, a number of structural developments are required, principally an operating theatre must be built, equipped and staffed to enable the facility to provide EmOC and C-sections. In time, IMG would also like to extend the facilities to include a microbiology lab (to enable rapid TB diagnostic services) and possibly a maternal waiting home.

With the addition of an operating theatre, the focus would sit firmly on provision of maternal and child healthcare for the surrounding community, thereby working to address a large proportion of the most acute health issues found in these communities.

Creating an operating theatre is in fact already more than a mere idea as IMG has secured a promise of funding to cover the equipment required for the operating theatre, including a new ultra-sound and additional related equipment, from an American donor, Direct Relief International. At present the key gap in moving this project forward, is funding for the construction of the theatre.

Charis IMC Lira, Developing a Maternal-Child-Health Programme: part 1 of 5

By: Clea Meynell

Background and context to the IMF initiative

Charis International Medical Centre (IMC), one of the 9 IMG health centres around the country, is in the process of transformation from a quiet Health Centre (HC) III to a small community hospital (HCIV). The model being developed for this initiative involves an innovative approach to high quality not-for-profit health service provision based on public-private partnerships and ongoing collaboration with key stakeholders.

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The proposed focus for the facility will be on provision of maternal and child health-care for the surrounding communities, a focus which requires Charis IMC to develop comprehensive on-site facilities for emergency obstetric care (EmOC). This is the first installment in a series of five which will be posted to this website on a daily basis this week introducing the new model of care for Charis IMC. The first install outlines the background to the initiative, giving an idea of the existing problems which we are trying to address.

The Population of Lira

Lira District lies in the Northern Region of Uganda. The 20-year armed conflict between the Lords Resistance Army (LRA) and the Ugandan Government Forces has only very recently abated leaving Northern Uganda in a dilapidated and fragile state. At the peak of the conflict in 2004, 1.7 million people, over 80% of the region, were displaced in squalid Internally Displaced People (IDP) Camps lacking access to basic resources. In Lira District the population has now largely moved out of the camps, with high numbers gravitating to the urban centres (i.e. Lira Municipality). This resettlement is taking place in an unplanned and haphazard manner, leading to the creation of new slum communities being served by poor infrastructure and under-resourced government services.

The population of Lira District currently stands at 669,900 and that of Lira Municipality at 105,200 (2010 District Health Office Statistics). Of this population in Lira Municipality, there are approximately 21,250 women of reproductive age. For these women there are few safe options; access to affordable quality maternal health care, particularly emergency obstetric care (EmOC), is poor in this region. The estimated maternal mortality ratio is 550 maternal deaths per 100,000 live births.

This is a country where 16 women die every day while giving birth or during pregnancy largely due to direct obstetric complications that occur around the time of childbirth (hemorrhage, hypertension, sepsis, and obstructed labor) or non-pregnancy related infections, such as HIV/AIDS, malaria and pneumonia. These conditions are generally easy to manage in a functioning health facility with well trained midwives and necessary clinical support. Sadly the reality is that only 29.9% of women in Northern Uganda reportedly deliver in a health facility (one of the lowest proportions country-wide); the majority of those facilities would be under-resourced, providing poor quality of care. For those delivering outside of a facility the reality is even worse, with poor sanitation and hygiene posing a serious threat, and the lack of a skilled attendant at birth increasing the risk of problems during or after birth.

Lira Health Indicators

Health indicators in Lira district lag far behind the national average, and the coverage of vital services is poor. There is a high prevalence of malnutrition, high incidence of malaria, diarrhea, upper respiratory tract infection, and worm infestations. Nutrition (or lack of it) is a major concern. The 2006 Uganda Demographic and Health Survey (DHS) reported the Northern Region to have the highest proportion of women (15-49 years) with anemia out of all of the regions of the country (64%).

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HIV/AIDS is a considerable problem in Lira. The 2005 Ugandan HIV/AIDS Sero-Behavioural Survey reported HIV prevalence in the North Central Region at 8.2%, although this may be conservative, and records from testing services offered at Charis IMC through the Aldo Project indicate a higher prevalence closer to 20%. Uganda is world’s 6th highest burden country in terms of mother to child transmission of HIV (MTCT), with an estimated 82,000 women in need of PMTCT services; access to these services in Northern Uganda lags far behind the rest of the country.

Other Medical Service Providers in Lira District

Lira District Health Office manages the network of government facilities across the District. In addition to the 27 government dispensaries (level II), there are 9 health centre III’s which should provide maternity services for normal deliveries and 5 health centre IV’s which should have a working operating theatre with twenty four hour C-section capability. The reality is that even if these services exist, the majority are under-staffed and under-resourced, meaning that the maternity service provision is poor and in some cases non-existent.

The Lira Regional Referral Hospital serves a population of 1million, acting as a referral facility for the region including residents of Lira District as well as those from surrounding Districts. Facilities to provide EmOC, however a recent visit to the hospital by IMG staff confirmed that this facility suffers from similar problems to the district ones and is particularly over-burdened, with quality of care being a major concern.

In Uganda over 65% of health service provision is in the private sector (including private-not-for-profit and NGO providers), representing a considerable portion of available healthcare. In Lira District, private health facilities include 3 health centre III’s and 1 hospital which provides EmOC, but at a considerable price: a normal delivery costs 42,000 UGX and a C-section costs 180,000 UGX.


UNICEF 2009. State of the World’s Children Newborn and Maternal Health. Annual number of deaths of women from pregnancy-related causes per 100,000 live births.

2006 Uganda Demographic and Health Survey

2006 Uganda Demographic and Health Survey

WHO (2010) PMTCT Strategic Vision 2010-2015

The 2006 Ugandan DHS: 95% of women in the North Region reported at least 1 difficulty accessing health services

The Yer Yotkom Project

The Yer Yotkom Project
‘Choose Health’

In the midst of all the trauma in the last week we have had some really good news. Clea, one of our volunteers from the UK, working as part of the management team at International Medical Foundation, has just had news that we have been granted £270,391 to run a 3 year program in Lira aimed at increasing access to integrated sexual and reproductive health (SRH) services for men, women and youth.

Access to such services in Northern Uganda lags far behind the rest of the country.

One of the key issues that the project aims to address is that of preventing mother to child transmission of HIV (PMTCT). Uganda is the world’s 6th highest burden country in terms of PMTCT, with an estimated 82,000 women in need of services.

Yer Yotkom translates as ‘Choose Health’ in Lango, the language spoken in the Northern areas.

Well done Clea.