Exam Time

I sat in the exam room staring at the paper and slowly it dawned on me, I couldn’t answer any of it. I could feel the panic rising and, as is normal in this situation, I was buck naked.

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.

Justice Julia Sebutinde awarding degrees to the Master of Public Health students at IHSU.

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.

Primary Healthcare in East Africa

Dr. Nick Wooding kindly asked me to write a preface for a book about to be published by International Health Sciences University which discusses the many aspects and issues related to the delivery of primary healthcare in the developing world, and in Uganda specifically.

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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?

Continue reading

Value for Impact

International Hospital Kampala, IHK, is the largest, and some say best, private hospital in Uganda.

In 2010, IHK gave 2.5% of its income to support the work of the group’s foundation, International Medical Foundation.

As we continue to support IMF in 2011, and beyond, we are keen to ensure:

  1. that savings are made where possible, without impacting the quality of the care being provided,
  2. that all of our programmes deliver value for money,
  3. and most importantly that these programmes maximise the impact being made for the communities and people being served.

Kevin.

 

IMG Will Perform 2,000 Male Medical Circumcisions

International Medical Group has been asked by the Infectious Disease Institute, IDI, to perform 2,000 male circumcisions (MC) in Kampala as part of a Male Sexual Health initiative branded AMAKA, which will deliver a total of 5,000 MC by September 2011. The initiative is being funded by the Centre for Disease Control (CDC).

Observational studies from the mid-1980s suggested that circumcised men had a lower prevalence of HIV compared to uncircumcised. More recently a number of formal randomised controlled tests, across a number of countries in East and South Africa (ESA), including one in Rakai District in Uganda, have consistently shown that MC can be up to 60% effective in reducing the incidence of HIV.

In 2007 WHO/UNAIDS started to recommend MC as part of a comprehensive HIV prevention package and suggested that countries with low MC rates and high prevalence of HIV among heterosexuals should consider how best to scale up MC intervention.

Apart from the obvious benefits for the individual, mass MC could prove to a very cost-effective means of reducing the long-term cost and burden of treating those that become HIV infected. WHO, PEPFAR, UNAIDS and USAID strategists are now recommending programmes across ESA that will lead to 80% prevalence of MC for both adults and children.

It is hoped that this 80% prevalence might be reached within the next 5 years. It will cost $1-2 billion, but will help to prevent up to 4m new infections (about 20% of new infections in ESA), which in turn could save $20b in years to come. On average, over a 10 year period, it is hoped that for every 5-15 MC performed, 1 new HIV infection might be prevented.

In Uganda 25% of males are already circumcised, largely due to tradition and religion. HIV prevalence is still high at over 6% of the adult population. In order to reach the 80% MC prevalence in Uganda 4.2 million procedures will be needed in the next 5 years.

Over the next few months IDI and its partners in Uganda will be evaluating outcomes and learning from programme delivery at IMG and other key service providers. One matter that IMG is exploring relates to the design for performing volume MC and how some tasks might be shared or shifted to lower credentialed but highly trained healthcare staff. Moving much of the work away from experienced surgeons will be essential if the significant volume targets are to be achieved. This will need careful planning, detailed training and rigorous review in these early pilot stages.

Those interested can read more about MC by visiting the Male Circumcision Clearing House website at www.malecircumcision.org.

Hope Ward Annual Report 2010

By Jemimah Kiboss:

In the 11 months to the end of November 2010 Hope Ward admitted 227 patients for a total of 2,730 bed-nights.

This year, funds raised for Hope Ward amounted to UGX 89.4 million (~£25,000); 43% of these funds came from our corporate sponsors – Bead for Life, Mvule Trust & Narrow Road.

Most (80%) of the Hope Ward expenses amounting to approximately UGX 459 million (~£130,000) were paid by International Medical Group.

Please click on the image below to download the annual summary report which has some further financial details and a few patient stories.

The Overall Aim of Hope Ward is to

cater for the underprivileged in need of high quality complex treatment, who would otherwise not afford this much needed and often life saving care. We intend to do what we can to alleviate the suffering and improve the quantity and quality of life of our patients.

We have some spare capacity in Hope Ward and with additional funding we could help many more needy people in 2011. Please support us in whatever way you can.

IMG – Doing Business as a Means of Development

Suubi Trust continues to support the work of International Medical Foundation, IMF.

IMF, one of four companies within International Medical Group, is the group’s NGO (registered charity) providing a wide range of charitable health services to the poor ranging from community based health education, preventative services including family planning and ART, TB diagnosis and treatment, complex medical and surgical procedures and oncology. IMF receives funding from a variety of sources including international donors, businesses in Uganda and UK, individual supporters from around the world, Suubi Trust and from International Hospital Kampala, IHK, its largest donor.

IHK, is the largest private health service provider in Uganda and has gained an enviable reputation for the safety and high quality of the care provided. This is reflected, for example, in its successful performance of 29 open heart surgeries in the last 3 years and the specialist trauma and intensive care provided to the victims of last year’s bombings in Kampala.

IAA Healthcare is Uganda’s leading provider of pre-paid health schemes, with 40,000 members being served in IHK and at 9 health centres across the country.

International Health Sciences University, IHSU, is now in its third academic year with 600 students of nursing, health management and public health.

IMG is one of Uganda’s larger employers, with more than 750 staff. It generates income from its pre-paid members and those patients paying cash for service. IMG is not government or donor funded and as such is an excellent model of private business as a means of development.

You can read more about IMG here.

Advent: Day 18 1st Graduation Ceremony at IHSU

Masters in Public Health students graduating at IHSU

On Saturday 18th December IHSU held its first graduation ceremony.

In the photo above The Chancellor, Hon. Justice Julia Sebutinde, awards 31 students their Master of Science in Public Health. The Vice-Chancellor, Dr. Nick Wooding stands with her and The Chairman of Council, Dr. Moses Galukande looks on from the stage behind. The Dean, Prof. Dr. David Ndungutse, can be seen having just read the name of each graduand.

The graduation is another significant milestone in the development of International Medical Group.

International Health Sciences University is a niche university offering health-related courses. IHSU provides professionally-trained workers for the health sector in various specializations and continuing medical education for health professionals already working in the field, with the specific aim of making a difference to health care in Uganda.

Hope Ward Cancer Charity

We will be posting over the next week or so some patient stories and information about cancer care being provided to our Hope Ward (charity) patients.

Introduction

The word “cancer” in Uganda brings thoughts of death, confusion, and stigma. People feel hopeless and impotent with nowhere to turn. The Hope Ward Cancer charity was founded in 2006 as a response to the great needs of underprivileged cancer sufferers in Uganda. Since the Hope Cancer charity launch, complex cancer care for the vulnerable has been delivered to hundreds of destitute children, orphans, widows and refugees who have received sponsored, lifesaving cancer treatment.

The cancer unit is led by a London trained, Ugandan based, Consultant Oncologist‐ Dr. Helena Nam ‐ and four internationally trained chemotherapy nurses.*

People treated from January‐November 2010

In the first half of the year, UGX54 million for Hope Ward patients was received and UGX110million was spent on essential treatments, including the cancer service. The shortfall has been met by IHK on a cross-subsidised model e.g. IHK provides facilities free of charge and meets salary costs for the nursing team, in addition to the purchase of some of the necessary treatments.

Approximately one third of the patients treated were children, many of whom would have lost their lives or suffered terribly, without treatment. Some of their stories will be posted on this Blog later. Many of our female patients have breast cancer. One third of the patients were suffering from Kaposis Sarcoma which is a cancer that is AIDS ‐ related.

* The specialist nurses have received chemotherapy training from India and UK – We are grateful to lead nurse trainers from Kent and Canterbury NHS who provide ongoing medical education (Wendy Hills and Jane Orwell).