Review of the priority needs for redevelopment of Atutur hospital.

Dr Richard Priestley of RHC Health Consulting ltd UK and Ms. Hannah Ryan, Faculty of Medicine, Liverpool University UK visited the hospital in July 2006.  Mr. Jim Opolot of the Pearl of Africa Foundation proposed that a report be prepared with suggestions for the urgent redevelopment of the hospital clinical facilities and the environment in which care is carried out.

Foreword

This report has been prepared at the suggestion of Mr. Jim Opolot of the Pearl of Africa Foundation following a brief visit by the authors to Atutur Hospital in Uganda in July 2006. It aims to make suggestions for the urgent redevelopment of the hospital following our survey of the clinical facilities available and the environment in which care is carried out.

It is timely to pay tribute to all who work at the hospital for their dedication and hard work under very difficult circumstances. In no way should the analysis or comments that follow be viewed as critical of any of the organisations concerned whether at National or Local level. We are very conscious of the great strides forward have been made in the provision of healthcare in Uganda since the conclusion of the long years of civil war.

Equally however it is, we hope, both helpful and appropriate to highlight the issues involved in providing modern healthcare in the 21st century within the conditions now prevailing and to make suggestions for improving both the infrastructure and clinical services of this vital institution which serves a large number of people who would otherwise have great difficulties to access healthcare.

We would particularly wish to thank Dr. Julius Mugweri Medical Superintendent at Atutur Hospital and all his colleagues and staff and Dr. Felix Ocom District Medical Officer for Kumi District for all their help, ideas and comments.

Finally we hope that this report will also help to interest and galvanize potential donor / aid agencies to consider contributing to the essential aspects of the necessary redevelopment of Atutur Hospital.

1. Introduction.

This report has been prepared following a visit to Atutur Hospital near Kumi Uganda in July 2006 by Dr. Richard Priestley, Director of rhc health consulting ltd, United Kingdom and Hannah Ryan 3^rd year medical student at Liverpool University, United Kingdom. The visit was facilitated by Mr.Jim Opolot C.E.O. of the Pearl of Africa Foundation, United Kingdom and Uganda and colleagues.

Dr. Julius Mugweri, Medical Director at the hospital and his colleagues and Dr. Felix Ocom, District Medical Officer for Kumi District accompanied us and all concerned were very helpful in explaining the history of the hospital and the issues it faces. Dr. Mugweri kindly provided a copy of his proposals for development to the Hospital Management and Advisory Board which was very helpful in reviewing the position. We are greatly indebted to all the above colleagues for their kindness, hospitality and patience in answering our many questions which helped tremendously in preparing this report.

2. Background to Atutur Hospital

Atutur Hospital was built in the late 1960's / early 1970's by the Government of Uganda with an inpatient bed capacity of 100 beds and supporting outpatient, diagnostic and treatment services. It serves a scattered predominantly rural population of some 400,000 people within Kumi district and has associated births of 1,200 babies per annum. Its functions as a district referral hospital cover the whole spectrum of clinical conditions. The main factors of morbidity and mortality include malaria, diarrhoea, respiratory tract infections, HIV / AIDS and road traffic accidents. It also plays a major role in community, primary care and health prevention services with a very comprehensive range of services. There are two other hospitals in the district but they are in the private sector and thus many of the population cannot access them. As a government funded hospital it pursues targets and objectives determined as part of the National Health Policy and the Health Sector Strategic Plan.

The hospital buildings and equipment have not essentially been upgraded since it was built more than 35 years ago and present many real challenges in practising medicine in the 21^st century. The hospital remains understaffed, particularly in relation to medical staff - at the time of writing there is only 1 doctor out of an establishment of 5 doctors and 33 trained nurses of all grades out of the official allocation of 65 trained nurses to care for a greatly increased number of patients. Generally there are 1 or 2 nurses on duty per ward at any one time and the hospital was fortunate in that there were some medical students from Makerere University on secondment. Clinical Officers had been trained to undertake much of the work carried out by junior medical staff. The staff are to be very much commended for providing care under such pressures and in such difficult conditions.

There are a number of staff residences which are very dilapidated and considerably overcrowded, are in poor condition due to vandalisation and the effects of the insurgency with no power supply, no WCs, and no running water supply.

Facilities and services including power, sewage and waste disposal have largely broken down.

3. Clinical services provided at Atutur Hospital

The wide range of clinical services available includes:

• 4 inpatient wards

- A male ward of 36 beds

- A female ward of 36 beds

- A maternity ward of 24 beds, including a midwife-led labour suite for deliveries and associated cots.

- A children's ward of 36 beds.

 

The above inpatient bed numbers are nominal and bed occupancy varies considerably.

At the time of our visit there were 129 children on the 36 bed children's ward, the vast majority being accommodated on the ward floor. Most of the children go outside during the day to play in the grounds of the hospital, except for the bedridden patients. On the paediatric ward there is a constant occupancy of 100 to 200 patients, with the average length of stay being three days, making it by far the busiest ward.

The female ward has the second highest occupancy generally around 40 patients, with HIV patients making up 40% of admissions. Malaria cases were also frequent. Surgical cases included patients with uterine fibroids and polyps, hysterectomy or tubal ligation (sterilisation) and early gynaecological cancers. More complex cases, such as those with vesiculo-vaginal fistula following obstructed labour, were referred to Soroti regional hospital.

The maternity ward has a constant occupancy approximating to capacity. Only mothers who have had caesarean sections or a complicated delivery / pregnancy (e.g. malaria during pregnancy, uterine rupture, sepsis, urinary tract infection, vesiculo-vaginal fistula) are admitted as inpatients. Patients are seldom admitted prior to onset of labour. Most patients stay for seven days for monitoring their condition. There is a nursery with two old but functioning incubators, which cannot be used without power, and there is no resuscitation, ventilation or monitoring equipment. Staff reported that the nursery was not used.

The male ward generally has a below capacity occupancy; when we visited only 15 beds out of 36 were occupied. Again, HIV and malaria are the major causes of morbidity, with diabetes, heart disease and alcohol-related illness also contributing to admissions. Accidental injury, particularly road accidents, is another common cause of admission.

Due to the lack of power supply and other facilities, many critically ill patients cannot be admitted and must be referred to other hospitals potentially leading to poor clinical outcomes and increased mortality.

No facilities exist on the wards to support severely ill patients or patients requiring orthopaedic treatment. There is no ventilation equipment and the oxygen cylinders have been empty for some time. No monitoring equipment whatever exists; patients must be managed based on direct observation.

All the wards had toilets, wash basins, bathrooms and kitchen facilities, much of which was in disrepair and the water supply and waste disposal system to the wards did not work. Many of the light fittings did not work. Most of the beds had no mattresses and bedding had to be provided by the patients or relatives, with associated problems of contamination. There were no mosquito nets available and no screens doors or windows. No curtains separate the beds and there is no privacy. There are two private rooms on each ward, but these have an occupancy rate of only about 50% as most patients cannot afford to pay 5000 shillings per day for them and the rooms tend to be used for other purposes. There are two isolation rooms off the paediatric ward with eight beds in each and these are used for cases of highly infectious disease such as measles. Keeping the wards clean is difficult due to the state of disrepair; women employed from the local community come to clean daily. Clinical waste had to be taken away in buckets and burnt. All wards have a store room with very limited drug and clinical materials supplies. This is also where clinical records are kept, but no filing facilities are available so medical records are piled up year by year.

• A mental health clinic based in the sister's office in the male ward.

• A diabetes clinic based in the sister's office in the children's ward.

• A large Out Patient Department open for seven days per week with at least 120 patients being seen each day, with a similar number of children also being seen daily in the Paediatric Out Patient Department.

• An Operating theatre suite with a suction machine, one steam sterilizer, one operating table, and one anaesthetic machine (a mechanical ether-giving machine of considerable age). The two theatre lights were broken and operations are carried out under light provided by light bulbs in the ceiling. The two sterilizers were broken, and there was no patient monitoring equipment. All the equipment was very old and the anaesthetic of choice, or rather necessity, was ether.

• An X-ray department with a basic X-ray machine which was broken and a darkroom facility which had no chemicals for developing films. The assistant radiographer was present, but was unable to do anything with the defunct equipment. The radiographer was attending a course in Kampala. Essentially there was no X-ray service available.

• A Pharmacy / Dispensary which provided drugs as prescribed. The range of drugs available is limited and the Medical Superintendent is forced to choose between essential drugs as the budget is insufficient to cover the real demand. The pharmacy frequently has stock-outs of essential drugs. There are intravenous fluid making machines and a water distiller in the pharmacy, but these are broken, so money has to come out of the drugs budget to supply intravenous solutions.

• A Pathology laboratory which provided a wide range of tests, including:

1. Blood films both thick and thin for the diagnosis of malaria and sickle cell anaemia

2. Dipstick urinalysis and microscopy

3. Stool microscopy

4. Full blood counts which are performed manually, meaning that only 4 / 5 such tests can be completed daily

5. Blood grouping

6. Haemoglobin concentration. However a proper colorimeter to improve the accuracy of this test is lacking

7. Pregnancy testing

8. HIV testing

9. ZN staining for tuberculosis

10. Widal's test for typhoid

11. VDRL test for syphilis

The laboratory is equipped with a water bath, incubator, centrifuge and a shaker, all of which is functioning but is old and subject to malfunction. Clearly, none of these can be used when there is no power. There are four refrigerators, but only two are working, so all samples have to be kept within the ones which are working. The refrigerators can only be on when power is available which is approximately two days a week, so samples cannot be kept cold adequately. There is a quantity of broken equipment. There is only one microscope, so only one technician can be working on microscopy at any one time. No facilities exist to carry out testing for hepatitis viruses which are common in Uganda, and no cultures or biochemistry can be done. No differential blood counts can be done, and no CD4 cell counts are available for monitoring of HIV positive patients. There is one trained laboratory technician who carries out most of the skilled work. He believes that with more equipment and assistance he could greatly expand the capacity and range of the laboratory services. He is training two assistants himself, but it is unclear whether they will be able to carry on working as paid staff at the hospital.

• A comprehensive Mother and Child Health service (MCH) which included community out-reach facilities, health education, antenatal care, family planning, counselling, and immunisation. The immunisation service suffers from a lack of formal record keeping which leads to some children receiving repeated vaccination for the same illness, while others miss out. There is one chest deep freezer which does not function when there is no power, and one refrigerator which is gas run and so can function all the time but requires constant maintenance. There are also two broken refrigerators. A family planning service operates, with occasional support from Marie Stopes International provides community education. Contraceptive options offered include depot progestogen injection, condoms or tubal ligation.

• A Dental Suite with a focus on extraction and dental hygiene services. No facilities for filling or repairing teeth exist, and these cannot be carried out without power in any case. At the time of our visit, there was a medical student from Makerere University who had trained as a dentist prior to commencing his medical studies, and he was carrying out dental work as best he could. When his secondment ends, there will be no trained staff to run the suite.

• A Casualty department which had very limited facilities and essentially was not used for its intended function. Minor injuries were treated by the Orthopaedic Officer, who used a side room to dress wounds and plaster / splint broken limbs. Clearly, this service is limited by the lack of radiological services.

• An Ambulance which was broken.

• A Community Health Education Centre.

• An HIV/AIDS testing and treatment clinic.

Voluntary counselling and testing (VCT) and prevention of mother-to-child transmission (PMTCT) were the main services provided and were entirely run by nursing staff. Antiretroviral drugs could be prescribed, but there are no facilities for patient monitoring and no CD4 counts, viral load tests, resistance testing, chest X-rays; thus prescription is based entirely on clinical findings. There were 320 clients on antiretrovirals when we visited. Clients visit once a month for a check up and adherence monitoring and staff reports that adherence rates are good. Stock-outs of antiretrovirals are a frequent occurrence, meaning that clients taking them may develop resistance to them while they are unavailable; no second-line drugs are available unless the client can afford to go to the nearest large town and buy them. The staff carry out VCT offer pre and post test counselling, sexual health information and free condoms when these are available.

Electricity and power services were only available for an average of two days in every seven days. The emergency generator was broken. This meant that any clinical service which required power availability was extremely difficult to organise and surgical operations could only be carried out intermittently and thus limited greatly the service available. For example no conservation work or fillings etc of teeth could be provided and if an X-ray machine had been available it would only have been able to be used unpredictably.

All food and water for patients is supplied by their families who mostly come and take up residence in the hospital grounds for as long as the patient is there. Old kitchen equipment does exist but has not been used for many years and may be beyond repair. There is no laundry, but as there are no sheets for the wards the only linen to be cleaned is from the Operating Theatre which is steam sterilized, when power is available.

A major problem facing the hospital is an inability to recruit and retain staff. The difficult conditions and remote location clearly act as deterrents, and staff, particularly newly trained staff, are often keen to seek jobs elsewhere. The lack of opportunities for professional development is a major factor in this question. The duty sister present at our discussion expressed her frustration at being unable to offer better training and accommodation to her students, who make up 13 out of 33 total nursing staff.

4. Issues and problems facing the hospital

As can be seen the range of difficulties encountered in the provision of health care services is very considerable. The following represent those issues which are deemed to be the most pressing for action and which would have the greatest positive impact if progress can be made. They can best be summarized as including the need to ensure that the following essential services could be made available in good working order:

• Power / electricity supplies including an emergency generator and solar energy system

• Onsite building / maintenance facilities to maintain equipment and services

• Waste disposal facilities for general, human and clinical waste

• Ambulance transport

• Hot and cold running water, toilets and kitchens on the four wards

• Mattresses and covers for all inpatient beds

• Mosquito nets for all inpatient beds and staff quarters

• X-ray and ultrasound equipment

• Pathology tests / equipment to be extended

• Replacement of operating theatre suite equipment

• Power / electricity / sewage / WCs for the staff quarters

• Security fencing to delineate the hospital boundaries

and of course recruitment of more trained staff in all disciplines.

5. Proposals for action.

From the above it can be seen that ideas and proposals for the most urgent consideration need to focus on some of the most basic and essential areas that would bring the greatest benefit to patients and staff. These must also be proposals which are reasonably capable of action within 1 - 2 years from decisions being made, if resources can be made available. Any such developments in service will need to be sourced locally within Uganda and project-managed locally within an appropriate form of local accountability. They need to be of a very practical nature and should bring clear and immediate benefits. It is suggested that such proposals would include action aimed at impacting very positively on the following:

5.1. Infrastructure 

• The provision of power supplies by means of a 3 phase 50 KVA emergency generator and / or solar energy panels. Power provision must be sustainable and it must be possible to run the generator affordably, accounting for the fact that it should provide power for 70% of the time.

• The renovation of the waste disposal and sewage system

• The provision of clean water supplies

• The renovation of wash hand basins, WCs, bathrooms and kitchens for the wards and clinics

• The establishment of a new post of building / maintenance technician to help keep equipment and services in running order

 5.2. Clinical services

•   The replacement of non-operable equipment including an X-ray machine, operating theatre lights, anaesthetic equipment, sterilizers

• The provision of new equipment including ultrasound , operating theatre table, pathology laboratory equipment

• The expansion of the range of drugs and medication available

• The development of new clinical services including an Eye clinic and associated outreach services

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5.3. Patient services

• The provision of 100 + mattresses with covers, mosquito nets and cooking equipment, dining utensils etc. for inpatients

• The provision of a new ambulance

5.4. Staff facilities

• The renovation of staff accommodation to improve recruitment and provide for visiting staff, including power supplies, WCs , and new staff quarters

• Improve access to staff training and education both on site and access to local and national programmes by means of Continuing Professional Development. Staff should be able to update their skills by having access to books and journals, and by creating links with other facilities.

• The availability of computing facilities with internet access.

5.5. Strategic Planning

• When the most urgent issues have been dealt with then it would be important to determine a longer term Strategy for development of the hospital focussing on a 3 - 5 years programme.

6. Action to achieve the above

The above ideas are not necessarily original but in many cases confirm those desired improvements and concepts which have been locally generated by staff at the Hospital and others. Staff are motivated and keen to improve the services they provide and extend their own skills. Determination of Plans is not the problem but rather the key question is the obvious issue of resource availability. The above ideas would need to be costed locally in Uganda and, as indicated earlier, equipment and materials would need to be sourced locally. Essentially, improvements to the services are perhaps best viewed on a partnership basis involving the following;

• National and local government in Uganda

• The Pearl of Africa Foundation as the conduit / local lead for partnership development / linkage of action

• A professional survey undertaken by qualified engineers relating to the infrastructure issues in paragraphs 5.1 and 5.4 above.

• Costing of equipment etc on paragraphs 5.2 and 5.3 above.

• Funding support from Donor / Aid agencies in the UK and internationally.

• Voluntary organisations in the UK who might provide volunteer staff to help with refurbishment.

• Establishing links with a hospital in the UK to facilitate knowledge exchange via e.g. The Tropical Health and Education Trust - www.thet.org .

• A self-help partnership relating for example to improvements to staff accommodation which might require staff to help in the renovation of their quarters.