Byarugaba introduced private ambulances in Uganda

Dr Hannington Byarugaba would have been your regular doctor from medical school at Makerere University except he had a dream; to be his own boss.

Whilst he sought employment after school like most of his colleagues, he only wanted to gain experience and raise capital to build his own business.

In 2007, he sold his first car which he had bought from saving his allowances at school and topped up with some little savings to open a small clinic in Wandegeya. As a part time employee at the time, he did not have enough time to run it fully.

Today, in addition to running a thriving medical practice, City Medicals Bukoto, he is the first Ugandan to own and run a multi-million private independent ambulance service (City Ambulance) with a fleet of five well equipped advanced life support ambulance vehicles and counting. He also has interests in real estate and employs about 55 people.

He told Clare Namanya, Darious Magara and Sebidde Kiryowa how hehas made it this far too soon.

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An ambulance attendant with City Ambulance evacuating a patient

Who is Hannington Byarugaba?

I was born in Kitabi, Bushenyi District to Augustine and Leodia Byarugaba in 1979. My father was a tea farmer and owned a shop that sold second hand clothes in Ishaka town, Bushenyi, while my mother was a house wife like many women of her time. I am the fifth of nine children.

I attended Kitabi Demonstration School and Mushanga Preparatory Seminary all in Bushenyi for primary education. I went to Kitabi Seminary still in Bushenyi for Ordinary level and St. Henry’s College Kitovu, Masaka, for Advanced level, completing in 1996 and 1998 respectively. I joined Medical School at Makerere University on a government scholarship and graduated with Bachelor of Medicine and Bachelors of Surgery degree in 2004.

Introduction to business

As children growing up in Bushenyi, there were many of us in my family but there were not enough resources to go around but my father worked tooth and nail to ensure that we went to good schools. Seeing how hard he had to work, this inspired the entrepreneurial spirit in me. I bore it in mind that if I ever had to do well for myself, I had to embrace entrepreneurship.

I tried that out while still at university. As government-sponsored students, we were entitled to an allowance of shs450, 000 per semester. I saved up mine to the tune of shs2m and sent for a car from Japan. A month later, my Toyota Sprinter arrived. I made a profit of sh2m from the sale of it. I continued doing this after my one-year internship at Mulago Hospital in Kampala following the completion of my degree.

During my internship, I earned sh600, 000 monthly most of which I spent paying school fees for my siblings who were still in school at the time.


The sophisticated equipment inside one of the ambulances


Joining formal employment

I then joined the Ministry of Health as a research officer. My salary, much of it per diem, amounted to sh1m. I saved none of it; all of it went towards my siblings’ tuition.

While at the ministry, I started moonlighting as a medical officer at Kadic Hospital in Bukoto.

My work with MOH lasted for one year. I applied for a job as an assistant medical coordinator with Medicins Sans Frontiers (MSF) translated as Doctors without Borders, a French medical non-governmental organisation. It dealt in emergency medical relief. I got the job. With MSF, I acquired extensive hands on experience with real medical emergencies.

We used to handle medical emergencies in northern Uganda during the LRA war. I treated several injured rebels and government soldiers alike. The local population presented to our medical facility with all kinds of emergencies ranging from trauma, severe malaria, seizures, obstetric and childhood emergencies.

It was also then that I started saving because most of my siblings were either through with or nearing completion of school at the time. I resurrected the dream of entrepreneurship. The most natural thing was to start a medical facility.

In 2008, I married Isabella, whom I had met in 2003 while at university. She has been by my side all throughout and as the story proceeds, I will use the word ‘we’ in reference to both of us.

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Part of the fleet of City Ambulance vehicles parked at the company call centre at Metroplex Mall, Nalya in Kampala


Starting JHB Health Services

In May 2007, I woke up one morning and told Isabella that I did not want to work for anyone anymore. I had a Toyota Corona, which I sold off at sh7.2m and topped up with sh3.6m from personal savings and benefits from MSFof sh5.2m.We began looking for an appropriate place to set up a clinic.

We secured space in Wandegeya near the Post Office; paid sh4.2m which was six months’worth of rent; sh250, 000 for the licence and started JHB Health Services.We spent sh1m on partitioning, bought two beds, drugs and saved the rest to help offset the workers’ salaries for the next four months since we were not sure that the clinic would have made enough to pay their salaries.

We did not even have a microscope because we could not afford it. It costs sh2m. So, we rented one at sh40, 000 a month.

However, I postponed the decision to resign from Kadic Hospital like I had earlier thought for two reasons; I wanted to earn more money and build a profile and experience. Secondly, I needed a fall-back position in case the clinic did not work. So, I hired a stand-in doctor to cover for me during the day while I worked in the evening.

Soon enough however, we realised that our clientele was not comfortable with our location in Wandegeya; the clinic was located between a garage and pork joint.

The environment was too polluted and there was insufficient parking space. When someone called and I told them that I was at the clinic in Wandegeya, they would suggest that I would rather see them from Kadic Hospital. That was counterproductive because it was stunting my clinic.

JHB Health Services moves house

At the time I stayed in Kiwatule. One day in December 2007, on my way home in a taxi; I saw a sign post in Bukoto near Nakumatt Supermarket indicating that the house was up to let. The owner wanted USD 900 per month and he wanted six months’ rent upfront in dollars.

We were broke because all the money had been spent on setting up the clinic. We knew that if we secured the place, we would be in position to serve a more upmarket clientele. For the first time, we borrowed from friends and relatives.

On January1, 2008, we moved to the new premises on Plot 1 Kiwana Close in Bukoto, where we are to date. We realised just how little equipment we had because the place was spacious.

Our situation was worse than we thought but the consolation was, with rent of the first six months cleared, that allowed us a grace period in which God willing, we would pick up.

After two to three months, we started seeing improvement. We started getting a more cosmopolitan clientele among them Pakistanis, Indians, Somalis and South Sudanese.

Our cash flow started stabilising. Lucky for us, there was no clinic along this whole stretch apart from Kadic Hospital.

Increase in clientele came with challenges; we needed specialists and equipment. At that time, we used to take all laboratory samples to another facility to be tested.

This arrangement reduced our profit margin since we had to spend on transport and pay for another laboratory.

It also became apparent that we needed to improve our record keeping and invest in buying more drugs.


An ambulance belonging to City Ambulances doing an air evacuation


City Medicals is born

To solve the issue of specialists, I agreed with some of my colleagues to come in on call because we could not afford to pay full time salaries.

We then started investing in laboratory equipment. We began by buying an Ultra Sound machine at sh10m from a friend who was closing his clinic. We paid for it over a period of six months with proceeds from the clinic. That same year I resigned from Kadic Hospital.

The more clients we got, the more gaps we found that had to be filled. The following year, we purchased a Haematology machine at sh17m which we paid in instalments for two years from retained earnings.

In 2010, we acquired an X-ray machine at sh30m, which we paid for over a year with proceeds from the clinic. Two years later, we acquired an ultra-modern ELISA machine. ELISA is an abbreviation for "enzyme-linked immunosorbent assay."ELISA tests are generally accurate tests.

They are considered highly sensitive and specific .The supplier came and inspected our facility to ensure we had the potential to pay back on hire purchase terms. We deposited sh30m and the machine was imported from France at a cost of $15, 000

This equipment in particular, we realised was a must have as it virtually does all tests among them -hormonal, fertility and cancer screening tests.

We changed the name from JBH Health Services to City Medicals because we wanted a catchier name. We started professionalising our operations like streamlining staff, which involved hiring bachelor’s degree nurses and laboratory technologists from Mulago Medical schools.

New opportunities support business growth

I knew we were on the right track when insurance companies started coming to us for partnerships. One by one, they came on board and right now, we are dealing with six of the main ones in the country.

The same year in which we bought the ELISA machine was around the time when companies started taking people to work abroad.

It was a requirement that the people who were taken to work abroad first undergo medical check-ups and since we had the required equipment, many of them were checked at City Medicals.

City Medicals ventures into unique innovative medical services

After careful study of market trends and clients’ needs, City Medicals specialized in travel medicine, international vaccination and pre-employment medical check-up.

The vaccines include:
 

•     Yellow Fever vaccine and yellow book certification
•     Cervical Cancer (HPV) vaccine
•     Rotavirus vaccine
•     Hepatitis A and B vaccine
•     Tetanus/Diphtheria vaccine
•     Injectable Polio for adult booster
•     Typhoid vaccine
•     Traveler’s Diarrhea/Cholera vaccine
•     Meningococcal Meningitis (quadravalent & conjugate C)
•     Rabies
•     Influenza (Flu)
•     Measles/Mumps/Rubella
•     Pneumococcal vaccine for both infants and adults
•     Varicella (chickenpox)
•     Snake venom anti-serum

Only officially designated medical facilities are authorized to administer the yellow fever vaccine which is required for travel to many countries. Every traveler receives an official vaccination certificate.

Under medical check-ups and occupational health services, we started to offer
 

• Pre-travel and pre-placement examinations for workers travelling abroa
• Medical examinations to determine fitness to work.
• Pre-term medical examination for schools 
• Routine Tetanus vaccination services for industrial workers prone to accidents  
• Hepatitis A and B vaccination for employees in high risk occupations (such as food handlers, garbage handlers, first aid attendants and laboratory attendants).
• Typhoid testing and vaccination for employees in high risk occupations (such as food handlers, garbage handlers, first aid attendants and laboratory attendants)
•  

Innovations spur business growth

In a bid to bring more programmess to help my clients while at the same time growing the clinic, I introduced a family scheme, both post and prepaid. Under the scheme, when a family member falls ill, they can get medical attention even if a parent or guardian is away.

Small medium enterprises started treating their workers with us and that too gave us a big boost.

Setting up City Ambulance

City Ambulance Ltd was born after the couple saw the suffering that the 2010 Bududa landslide victims went through.

Red Cross, which was the charity on the ground, was overwhelmed with a lot more ambulances needed to transport the casualties to hospitals. There were not enough vehicles and neither was there any private company to call to provide an ambulance service – everyone was stranded.

“This made me think that if there was an independent private ambulance provider many lives would have been saved,” Dr. Byarugaba says. “I started digesting the idea and discovered that there [was] no ambulance service, which was independent, not government or attached to charity or any hospital in Uganda” I got “Inspired to save life”, which has become City Ambulance motto.

But this was not the business one can dream of and start right away – it was much more complicated, requiring a lot of planning, understanding, consultations and hefty resources.

We planned for four years – mobilizing resources, reading all the available literature on how private ambulances work. I, also visited several countries including South Africa, India and United Arab Emirates which have such services.

In November 2014, City Ambulance started in earnest. It has five advanced ambulance vehicles worth Shs100m each; 12 fulltime employees and many part timers who are on call, including specialized doctors, nurses, paramedics, and drivers who are also trained as first aiders

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Dr. Byarugaba points to the Elisa machine that is used in medical checkups for patients that travel abroad

Services

Under City Ambulance, we offer eight products: Emergence medical rescue, planned patient transportation, events and conferences medical support, training in first aid, health and safety at work place, supply of first aid kits and other emergency medical equipment, medical air evacuation, medical escorts, and emergency medical consultancy.

Emergency medical rescue is the core activity which operates a 24/7 call centre. There has never been an ambulance call centre that runs 24/7 in Uganda.

It has an Ambulance toll-free line, 0800111044 that anyone with an emergence can call, and be guaranteed that someone will pick and dispatch an ambulance in the shortest time possible. The challenge is that our ambulance toll-free line is too long for anyone to memorize or even recall in case of emergency. We are still in talks with Uganda Communication Commission (UCC) to allocate for us a 3-digit number. More so, our tool-free line is reverse charged, meaning we pay for every call received; it is a huge cost for the Company.

The target response time is 10 minutes within Kampala and 15 minutes in parts closer, but outside Kampala.

The call centre is equipped with emergence medical dispatchers (EMDs), people trained to categorize calls – if it is a priority call meaning someone is in real danger, they will have to send an ambulance that has the capacity to handle such a case like a heart attack or uncontrollable bleeding.

Other calls are categorized as immediate and delayed. These are emergences but one is not in immediate danger such as a simple fracture or burns

Most important is that first aid is offered on phone by the EMD as the ambulance is on the way to pick the patient to take to hospital. Everything possible is done to ensure survival.

For example, the dispatcher will tell the attendant how to hold the patient, stop the bleeding or do a certain manoeuvre that would prevent further injury or deterioration of the patient’s condition.

They also liaise with the hospital where they would take the patient such that by the time the ambulance reaches the hospital, the receiving medical team is ready. You can promptly take the patient to Mulago but still spend an hour before the patient is touched.

Choice of the hospital depends mainly on the client because most of them are insured and know where to go. If the client has no preference we use our own discretion, according to the patient’s condition.

City Ambulance vehicles have GPS and navigation tracking system which tracks the ambulance from when the vehicle is dispatched, when it reaches the scene and up to the receiving hospital.

It helps us to know what happens during evacuation (so that) in case of anything, we dispatch another vehicle immediately, he says. We also relay live updates to the patient attendants and the receiving medical team all throughout the evacuation.

The company has also done a mapping system to determine where every health centre is, especially those with the capacity like the accident and emergence care unit, the intensive care unit where we can take the patients.

Under planned patients transfer, we transport patients from one location to another e.g. Home to hospital or vice versa, hospital to airport for the patients going for air evacuation, from hospital to other facilities that have certain services like computerised scans (CT Scan).

Isabella explains that this happens on appointment, where the company knows that at certain date and time they would be transporting a particular patient.

Under this product, we have introduced a new service – discharge through ambulance – where after hospital discharge; the patient is usually not strong enough or medically fit (for instance after surgery or in case of fractures) to move back home in a private vehicle, taxi or bodaboda. We transport such patients back home in our ambulances at a very affordable fee.

Under events and conferences medical support, we provide standby ambulance, medical team or mobile clinic depending on the nature of event. Any gathering with more than 300 people like sports activities, concerts, conferences, social events and weddings should have a standby ambulance.

“We have been at sports events like the Uganda Rugby union, MTN marathon, Aga Khan Convocation, Motorsport rally, to mention but a few.

The company has so far done six medical air evacuations out of Uganda since they started, using charter planes. It has also offered emergency medical consultancy to NGOs, private institutions and government departments that seek to acquire ambulances.

Market

The market reception of our service is “exciting” with a lot of Ugandans saying it is timely and much needed. The monthly average traffic for emergence service calls is about 50 to 60 calls at present. Events medical support demand has also peaked. Every week we cover an event–rugby, cricket, soccer, and the corporate leagues.

Yet all this is still less than 10% of our capacity. We are still hugely underutilized yet the operational costs are too high. We can handle up to 50 calls per day with our current fleet of ambulances.

Growing demand has also been experienced in first aid training and supplies. Industrial and manufacturing companies, corporations, private institutions, non-government organisations, government agencies, banks, schools, health facilities, individuals and households who demand training for nannies. We shall be running a fixed training schedule, where people can book either on our website or physically at our offices in Room G30, Ground floor at Metroplex Mall Naalya along the Northern bypass.

It cost us about sh1.5m to train a group of 10-15 people in first aid, health and safety at work place. Other training courses we undertook include; first aid training for nannies, fire fighting and safety, health and safety at work place, basic life support, advanced life support, advanced cardiac life support, advanced trauma and life support, automatic external defibrillator course, major incident management course.

Today, City Ambulance has in stock emergency medical equipment and supplies that include first aid kits, wheelchairs, stretchers, crutches, oxygen cylinders, fire extinguishers, splints, patient monitors, nebulizers, suction machines, portable ventilators, automatic external defibrillators, first aid drugs and other consumables among other items

It has not been a smooth ride. We have faced couple of challenges that include; huge start-up capital, high operational costs and lack of public awareness of our services.


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City Medicals, Dr. Byarugaba’s hospital in Bukoto Kampala


Investment

Initial investment came to about sh1b — with equipment, the fleet, and training, staffing and administrative structure. More than half of the investment went in the purchase of vehicles and equipment.

We still require more funding to purchase 100 ambulances for country wide coverage; we look forward to purchasing our own aircrafts for medical air evacuation.

We need a charity fund that can pay for or subsidize costs for people who cannot afford private ambulance but are in dire need of our services such as victims of motorcycle accidents, obstetric and childhood emergencies.

We charge sh120,000  to hire out or ambulances in Kampala while outside Kampala, each km is charged between sh2,000 and sh3,000 depending on the terrain and the condition of the patient.

We have transported patients as far as Juba in South Sudan, Nimule, Gulu, Kisoro, Fortportal, Mbarara, Kiboga,” says Dr. Byarugaba.

What makes him tick

Careful planning is very crucial. You may have the money, but you do not have the expertise. My start-up capital came from savings and part of the preparation was gathering enough information and understanding how private ambulance services work around the world.

While we run the business as a couple with my wife Isabella, as directors, we keep family issues out of it.  Family compromises decision making and principles – when starting up we were very clear on what we wanted.

I am a religious person

I am hard working

I do not stay out late partying that much.

I am very ambitious and I am always looking out for opportunities that can make a difference from the status quo.

Diamond tips

Stay focused on your idea but have an open mind because along the way, unexpected obstacles might pop up. These however might turn out to be opportunities.

Have passion and enjoy what you do because then, hard work becomes no work when you love what you do.

The start is not always about having money. Have the idea first; like I knew that I wanted a clinic first and then everything else will fall in line.

Have commitment and work hard. For example, I wake up by 5:00am

Uganda has many entrepreneurial opportunities. We just need to be creative and innovative

For the budding entrepreneurs, it is better to invest in areas you are schooled or experienced in. Business succeeds because of the expertise of the founders. If you are schooled in an area, you have a competitive edge. You are most likely to understand the products and marketing – that prior knowledge is important.

What others say

trueIsabella Byarugaba, wife and co-director

Nothing goes by me because everything is always up for discussion and as a couple we have learned to openly discuss business and table all the concerns and possibilities. He is so persistent and keeps motivating himself with various business books and audios of how to get rich, building wealth and leave a legacy; how to be highly efficient, to manage time and money and lately starting in the world of real estate.

I believe it is his values that will help him achieve more because he appreciates the fact that he has a lot more to learn and he wants the best for his children and family.

truePeter Ocama, medic

He is such a great and innovative director. In the beginning, I was very worried about where we would get clients from but now, hardly a year later; we are so overwhelmed with work.

I can only thank God for giving doctor such a unique idea. 

Having worked in Mulago Hospital’s accident and emergencies ward, I always appreciated that as a country, we needed more ambulances.

trueMoses Rukara, driver

Doctor and his wife are self-motivated; very good team players and are success-oriented. At times we wake up very late in the night together especially when there is an evacuation. They do not leave until it is done. It is just six months since we started the emergency medical services through ambulances but so far, it is impressive.