Health centres redundant, turned into residences

By Vision Reporter

BUDADIRI health centre (HC) IV in Busilani sub-county in Sironko district is the area’s Mulago Hospital, because it is where every sick person prefers to go.

BUDADIRI health centre (HC) IV in Busilani sub-county in Sironko district is the area’s Mulago Hospital, because it is where every sick person prefers to go.

However, knowing that any country’s health system is measured by maternal mortality, operational shortcomings have affected the centre’s ability to provide quality reproductive health and emergency obstetric care.

The health centre where the late Dr. Samson Kisekka, Uganda’s first Vice-President under the NRM regime, once served, now simply carries the name of a formerly powerful facility because financial constraints have forced it to shut its doors to many mothers.

“Our doctor left last year. For over six months we have not had a resident doctor and the centre is manned by a clinical officer, whose capacity is limited when it comes to some emergencies that require caesarean births,” says Judith Nakirijja, a midwife.

“Once in a while the district director of health services steps in when emergencies, which regrettably, are an everyday occurrence, happen.

Unfortunately he is only able to help on week days when he is not committed elsewhere.

Like now, he is attending a workshop. In such instances, at night and on weekends, we refer patients to Mbale Hospital, which is about 30km from the health centre,” Nakirijja adds.

With an average of 12 deliveries a day, the health centre also faces a shortage of staff. “We are only four midwives, yet we get many complications like botched abortions, severe bleeding that calls for transfusion, ruptured uteruses, ecclampsia and obstructed labour that calls for caesarean births. We are forced to refer even when we know that it will impact on the outcome.

“Well, we hardly register any deaths but we often lose the babies because they get distressed. Otherwise, the facility is still functional with running water and electricity, save for the constant drug and blood shortages,” Nakirijja discloses.

“We have a perennial lack of antibiotics,” Nakirijja explains.” Sometimes mothers have to buy them. We also do not have an ambulance but have a double cabin pick up that helps with referrals, although it is grounded due to lack of fuel.”

Budadiri HC IV is but an example of an untapped facility that is ideally the most important as far as bringing services closer to the communities is concerned.

According to the Ministry of Health’s 2007-2015 road map for accelerating the reduction of maternal and neonatal mortality and morbidity in Uganda, the programmes that make up the national minimum healthcare package consist of promotion, prevention and curative services, structured from the village facilities to the national referral hospital.

HC IIIs serve sub-counties and are first level where maternity, in-patient and laboratory services are provided, while the HC IVs provide emergency surgery and blood transfusion in addition to the services provided by the former.

However, most HC IIIs have no running water or lighting for the maternity units, while most HC IVs lack functional operating theatres, with inadequately skilled medical officers who are unable to perform emergency obstetric and newborn care, hence unable to perform caesarean operations or carry out blood transfusion. A report from the field visits in January, February, March and April this year by Parliament’s sessional committee on social services on performance of the health sector in 16 districts countrywide, notes that although Government has managed to construct some new HC II, III and IVs with a view of extending services nearer to the people and easing pressure in major hospitals, emphasis should be redirected to renovation of existing facilities.

Regarding operationalising HC IVs, the Government needs to consider supporting a few districts at a time. The selected districts should be facilitated to redesign their poorly- constructed theatres, to ensure that they are well-equipped with the basic equipment that they require,” it adds.

The MPs observed that the effectiveness of lower health units was heavily dependent on the functionality of the referral system.

“The Ministry of Health should provide HC IIIs and IVs with functional ambulances and push for a special budget for fuel and maintenance. This will help extend services to communities and ensure timely emergency evacuation.

“In addition, the few units with access to electricity and water are finding it difficult to pay the exorbitant tariffs, while some HC IIs have been converted into residential homes and others have been rented out because they are no longer functional,” it says.

Uganda’s maternal mortality stands at 435 deaths for every 100,000 live births, meaning that with fully functional health units and comprehensive emergency obstetric care, many more mothers can be saved. Unfortunately, despite the fact that 15% of all pregnancies are emergencies according to the World Health Organisation (WHO), because they develop life-threatening complications and require timely obstetric care, 97% of the facilities expected to provide these services in Uganda are not able to do so.

But according to the 2007-2015 road map, the country is facing a severe shortage of such life saving interventions. Quoting the 2004 Emergency Obstetric Care (EmOC) needs assessment, the national need for EmOC is 23.9%, whereas it should be 100% if all women with complications are to be treated.

The document says only 11.7% of women give birth in fully functional health facilities, while only 14% go to fully-functional EmOC facilities.

Co-authored by Dr. Anthony Mbonye, the assistant commissioner for reproductive health, the assessment study also notes that 77.5% of districts lacked specific signal functions for emergency obstetric care. “Only 31.5% of HC IVs and 42% of district hospitals had oxytocics in stock, while most health units including referral hospitals had stock outs of antibiotics,” Mbonye remarks.

According to the study on functionality of HC IVs in 2005/06, only 17% provided blood transfusion services, although 81% had complete theatres, 75% were equipped and 34% functional.

“Despite the fact that there was infrastructure, uninstalled equipment, unreliable power supply, lack of water and facilities for blood transfusion undermined their functionability,” it says.

Nonetheless, Mbonye says: “We have improved. We have been training health personnel in handling emergency obstetric cases, we have established maternal death audits and ensured effective emergency obstetric care.’

Mbonye adds that the ministry’s guidelines recommend that if a mother presents an emergency, she should receive international standards of care.
“They should be checked for blood pressure, given post abortion care, administered with necessary drugs and fluids or otherwise. This is the practise the world over,” he says. “Most of our problems (80%) are caused by funding constraints. But we can still do a lot, even with so little,” he says.

He, however, regrets that many mothers delay and get to the health facilities when there is so little that can be done to help them.

There are four forms of delay, Mbonye explains, the first one being deciding when to seek healthcare at individual or household level. There are also delays in reaching health facilities because of poor transport and communication, the delay to see a health worker because of long queues and staff absenteeism, as well as the delay caused by the facilities’ inability to offer emergency care because of shortcomings like lack of blood or a non-functional theatres.

“It is advisable that mothers consider all pregnancies as emergencies and seek medical attention early, so that there is time to refer in case of delays. I’m urging that men get on board to support their wives and ease delays at individual level which ‘aggravate the other delays,” he says.

Dr Olive Ssentumbwe, the national professional officer for population and reproductive health at the WHO, advises mothers to get antenatal care, ensure skilled deliveries and seek postnatal care.

“If a midwife is properly trained, she is able to provide interventions at all these stages if complications arise, or to know when to refer a woman to an emergency facility,” Ssentumbwe says. “Unfortunately, many of our health units still lack skilled workers who can help save the lives of new-born babies, even as studies have shown that most mothers die with their babies.”

Ssentumbwe also notes that although there are efforts by the Government to employ skilled midwives and nurses in all health units, some still have nursing aids.

“The majority of the nursing aids cannot, for instance, handle mothers who require an emergency. Besides, our health units still lack professionals who can monitor and detect high blood pressure in a mother and treat it immediately.

“Another skill that is lacking is the use of the Vacuum to extract or pull out the baby from a mother’s womb. (This is done when the baby gets stuck during delivery). ”
Ssentumbwe observes that if a mother has a retained placenta after delivery or abortion, the situation presents the need for someone who can do a manual vacuum aspiration to remove it.
The Government needs to train health workers at HC IIIs in some skills traditionally meant for only doctors, such administering drugs through the vessels and muscles (injections and drips) to bleeding mothers she says.

She adds that mothers could be dying due to bleeding resulting from delays during referrals. While some of these skills can be provided by nurses and midwives, some are advanced, thus the need to recruit more doctors. Emergency care is also affected by the limited quantities of blood in blood banks.

She further notes: “The national C-section rate is 2.7% as opposed to the minimum 5% meaning that many women who could be benefiting from this intervention are missing out. This low unmet need for C-sections implies increased neonatal morbidity and mortality since some of these indications for this procedure are fatal.”

Maternal mortality at 435 deaths per 100,000 live births translates into 6,000 deaths every year. Worse still, for every woman who dies, six survive with chronic health problems.

Critics argue that poor funding has kept the figures high. The Maputo Protocol saw African leaders pledging 15% of their national budgets by 2010 towards reproductive health. However, Uganda is still at 8.2%. In addition, the amount of resources committed to maternal and newborn health at districts and sub-county levels is very small and difficult to track.

WHO calls for an increase in the availability, accessibility and utilisation of skilled care during pregnancy, childbirth and postnatal period at all levels of the health delivery system, if tremendous results are to be seen. Over 80% of pregnant women receive antenatal care, with only 42% accessing skilled services. About 60% deliver at home partly because of perceived poor quality of antenatal and delivery services at health centres, poor attitude of health workers and lack of basic supplies at health centres and hospitals.
“We get many emergencies when the traditional birthing attendants go wrong. And they often go wrong,” says Maimuna Nabutono, a midwife in Sironko. “And when they do, mothers are required to buy the basic necessities such as gloves, razor blades, cold ligature, syringes and needles, cotton wool, sanitary pads and soap, which they had dodged with the traditional attendants. The absence of these items during delivery increases chances of infection, which is common with emergency cases.”

It is also estimated that there are 297,000 unsafe abortions conducted in Uganda annually, with the practise contributing an estimated 26% of maternal deaths and much higher proportions of reproductive ill health. According to the 2007 Guttmacher Institute report on unintended pregnancy and induced abortion in Uganda, 1,200 deaths and 23% of severe complications are recorded annually.

But while post-abortion care services are supposed to be provided in HC IIIs and HC IVs, most of the health facilities are ill-equipped to provide it. HC IIIs and IVs are also provided with two and four midwives respectively, but these are inadequate. And this is in addition to the fact that many positions are not filled.

“Besides, there is inequitable distribution of personnel among districts or even between urban and rural areas with over 80% of doctors and 60 % of midwives in towns,” says Dr Wasswa Ssalongo, a consultant gynecologist/obstetrician at Mbarara Hospital.

“There has been a mismatch between construction of new health facilities and the capacity to make them functional in terms of human resources, medical equipment and operational budgets. Many health facilities are in an appalling state, lacking water and lighting,” Wasswa says.

A recent countrywide survey by the parliamentary social services committee established that in most HCIVs the theatres are either non existent or non-functional due to lack of equipment, staff or staff housing, hence intended basic surgery, e.g. caesarian section are not carried out on those in need.

“Women have to trek long distances looking for these services,” says Dr. Chris Baryomunsi, vice chairperson of the committee.

Besides, the referral systems should be from the community to health centres and then to the hospital, with adequate support for appropriate care at each level, according to the ministry’s policy.

But there is a lack of, or in cases where they are available, rundown ambulances in communities, affecting women who need to deliver in hospital. This is further challenged by poor transport and communication networks.

“Roads in the rural areas are poor, while the communication system that has been established for referrals does not function efficiently.

In cases where radio communication equipment has been installed and ambulances provided, their maintenance and operation has been a challenge for districts.

“As a result, relatives of the women are asked to fuel the ambulances, yet most of them are too poor to afford the cost,” Baryomunsi says. “The health facilities also face chronic shortages of essential equipment and supplies.”

Health centres redundant, turned into residences