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 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.

Update from Dr. Richard

Dr. Richard posted the following update about his work at our health centre in Lira, north Uganda. We are working here in collaboration with Charis and Fields of Life. You can read Richard’s Blog here.

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Half way through our time now so back to Kampala for debrief.
We prepared a list of areas we need to change to achieve our aims. Some require lots of investment and a discussion as to whether its reasonable to provide the service or not. Some are smaller and relate to training, decor of the centre,use of space, HR issues etc.
Very positive discussions all day. We have a really good team at IHK to support us. Kevin (the CEO) and Dr Andrew started us off in the morning with positive support for our big ideas. Some will require investment from Fields of Life, and hopefully they will agree as they too want affordable care at HC4 level.

Health Centre Level four
Population served 50,000-100,000
The average district has 4-7 level four facilities
In addition to services provided at level three there will be a working operating theatre with twenty four hour C section capability for emergency Caesars.*
Ultrasound should be available with a qualified technician*
Maternal waiting homes are found at this level in some countries and patients may be fed from hospital kitchens. In Uganda the guardian system is operated and relatives have to feed the patients.
Outreach activities by other agencies are often available at these facilities such as tubal ligations by MSI and VVF camps by AMREF.*
Other expected services at level fours:
• Basic dentistry by dental technicians
• DOTS for TB and HAART programmes for HIV*
• Laboratory facilities with a lab technician
• Pharmacy and supply chain to distribute pharmaceuticals and supplies to level three and level two health centers
Staff at level four:
• Qualified doctor in Uganda or in other countries specialist clinical officers
• Clinical officers
• Nurse anaesthetist*
• Midwives
• Nurses
• Laboratory staff
• Pharmacist*
• Nursing aids
An ambulance should be available for referring patients to the district hospital.*

We would really be the only HC4 in Lira municipality(population in the district is 750,000!).There is a referral government hospital but it is overwhemed and serves a population of about 2 million with only 254 beds and skeleton staffing. Other smaller NGO and private health centres but a major problem is staffing and keeping good people, especially doctors and sadly the turnover and often the lack of doctors limits the health service ‘up country’. We will plan to rotate doctors to Lira from Kampala and incentivise them to stay

So, as a result of our discussions, we have ironed the more straight forward issues and agreed that with the Fields of Life support we will provide all the services on this list. Some like our dental services, we can move forward now and some like the Theatre and surgery will take longer. Not too long though, as building in Uganda happens very quickly….planning permission etc what’s that?

Back to Lira today and start to plan the outreach services and o some training.