Ensuring Neonatal Survival in an Under Resourced Environment (ENSURE)

The death rate of children in Uganda is extremely high.  I hope this is not a surprise to anybody, however have you ever considered how high it is?  Below is the comparison between the UK and Uganda.

	Uganda	UK
Neonatal mortality rate (per 1000)	26	3.2
<1 mortality rate (per 1000)	63	4.2
<5 mortality (per 1000)	99|	5

26/1000, thats 2.6% of newborn babies die.  Is that so bad?  Well in the UK the equivalent is 0.32%.  And this is the official statistics.  In Uganda the majority of births take place outside of a healthcare setting.  It is therefore likely that there are children who are not included in these statistics.  That means that in Uganda approximately 43,000 newborn babies die every year!!

One of the major causes of death in the neonatal period is birth asphyxia.  Birth asphyxia is when a child is born but fails to breathe.  It is suspected that birth asphyxia accounts for 900,000 deaths worldwide every year.

 

Due to this there has been a large effort to improve care at the time a baby is born.  One of the major ways of doing this is to ensure that when a woman delivers in healthcare centre where the birth attendant is skilled in resuscitation of the newborn.  As part of our time in Uganda we have been involved with a local NGO (non-governmental organisation) trying to provide training in the care of the newborn baby.  The course we have designed concentrates on ensuring all participants are able to provide effective resuscitation care to all newborns. 

Participants are also taught about a wide range of common problems affecting newborns in Uganda.  The course aims to build on knowledge they already have and to update it with current practice in Uganda and to give the health workers information that can be passed onto parents to improve preventative care in Uganda. 

We have delivered the course on 3 occasions and trained 37 midwives, nurses and doctors so far, who all showed excellent resuscitation skills following the course.  We have also trained 7 healthcare workers to deliver the course.  This should provide a lasting presence.  Over the next few months we hope to deliver the course of more occasions.

We have also trained a number of student nurses at Jinja Hospital itself, modifying the ENSURE course to a half-day version for training in resuscitation of the newborn and routine care of the newborn.

The feedback so far has been very positive, however participants have often commented that they do not have the ambu- bag and mask to perform resuscitation at the healthcare centres where they work. 

Jess and I are in the process of acquiring 10 of these sets to give to health centres, unfortunately this is only the tip of the iceberg.  If anyone out there has access to ambu- bags that are not being used, Jinja hospital would be very grateful to receive donations. Please contact us if you are in a position to help.

 Thank you.

The Ugandan Health Care System

Uganda has a population of approximately 33 million people who are served by a tiered health system.  This begins with Health care centres, that are graded from 1-4, with Healthcare Centre 1 or Village Health Teams (VHT) delivering the more basic care and Healthcare Centre 4 delivering more advanced care.  Following on from this are local hospitals, regional hospitals and then a single national hospital in Kampala (capital city of Uganda).  The approximate structure is shown in Fig. 1 below.

Figure 1; Healthcare Structure in Uganda

Healthcare Centre 4s (and a few Healthcare Centre 3s) have a doctor present, however Health care centres one and two are run primarily by nursing staff and some clinical officers.  The aim is a simple one – patients go to the nearest health centre and are given appropriate treatment if available or referred to the next level.  This system sounds sensible- patients get the correct level of care for their need or are referred to a centre that can provide the care.  However, as with any healthcare system, there are problems.  

- The first: the distances between centres.  This is completely reliant on the patient or carer being able to afford to travel and being willing to travel.  

- Secondly, the issue of knowing which level of care the patient needs.  This requires the healthcare worker to recognise the illness and severity and know which level is appropriate. It takes many years of good training to become proficient at this.  

- Lastly, there is the dreaded queue.  Patients may queue for a long period at one centre and then be told they need to go somewhere else and when they get there they join the back of the queue.  Some systems are in place to try to limit this, especially in emergencies, however they are not always effective. 

Other problems include the lack of staff and resources at all levels.  Most healthcare centre 2 and 3s have women giving birth but do not have the basic equipment needed to resuscitation a newborn infant.  This is in a country where children failing to breathe at birth is an everyday occurrence in most health centres and hospitals; the correct equipment would save lives on a daily basis.  The basic equipment is an ambu-bag and mask (add link).  It costs approximately £10 to purchase one of these at low resource price.

 

It is not just the health care centres where resources are limited.  Hospitals have the same problem and in a separate post I will detail some of the challenges I have experienced due to lack of resources.  But for now I will concentrate on lack of staff.  Having only 3 paediatric consultants in a regional referral hospital, with no middle grade (registrar equivalent) doctors and only 3 interns makes it impossible to provide a good level of care to patients. 

It is not just the Regional Referral hospitals that suffer from overstretched staff and resources.  The Ugandan Ministry of Health states that each National Hospital should cover a population of 10 million people, however there is only 1 National Hospital – Mulago in Kampala.  It covers a population of 33 million people.  To make this worse, Uganda’s population is increasing rapidly.  And here is the challenge!  Do you try to fill the holes in the current system to improve it today only for it to be outdated again tomorrow? Or do you plan for tomorrow and forget about the holes today?  There is no right answer and the truth is likely to lie somewhere in the middle.  This problem is not unique to Uganda and in fact you could say this situation is seen to lesser degrees in developed countries where medical care is becoming increasingly expensive and far outpacing any increased money governments have available to spend.

Becoming a Doctor in Uganda

The process of becoming a doctor in Uganda is very similar to that in the UK.  5 years at medical school followed by a period of being an intern doctor (Foundation doctor in the UK).  In the UK doctors spend 2 years completing their internship or Foundation training, but in Uganda this is only 1 year.  And here is where the similarities stop.  

In the UK almost ALL doctors would then undertake higher training whilst working in their area of interest.  In Uganda most doctors do not do this.  Most complete their 1 year as an intern and become a Medical Officer (MO) and then go and work in a Healthcare Centre or local hospital as a general doctor.  A big reason for this is that when undertaking higher training doctors are not paid.  They instead go to work most days in their area of interest, but need to find another means to support themselves.  Some are lucky enough to be sponsored, while others work at private clinics after their training job to make a small amount of money to survive.  Most of these doctors also have a family to support.  

The reality of the current Ugandan training structure is that not being paid whilst undergoing higher training significantly reduces the number of doctors taking this path, and thus significantly reduces the number of specialists, as well as reducing the level of expertise of all doctors.  

Hope this little bit of background helps to highlight some of the challenges faced by health workers in the Ugandan Healthcare System. It is possible for changes for to be made at ground level, but long lasting improvement is unlikely to occur without a change in overall structure.

More soon....

The differences

It’s been too long.  We hope you have missed us?  Apologies for the delay in updating the blog, work has got the better of us (like so many others)!

We promised to document the many differences in working as a paediatrician in Jinja and so will try to do so.  This is just a taster of the differences we feel are most important.

Always ask for help early!

When attending any resuscitation course in the UK one of the first things you are taught is to shout for help early.  In the resuscitation scenarios often the help isn’t available.  This makes for excellent preparation.  In the emergency department in Jinja, there is no crash bleep (or any bleep for that matter) to get people to come running.  There’s only you and the nurse (or student nurse). 

Intubation does not exist. The airway is managed with a bag and mask (mask singular – one size fits all).  The staff are not trained in neonatal or paediatric resuscitation, but they will help if you tell them what to do.

Cannulation

A task almost exclusively performed by nurses in Uganda.  And done to a level that puts me and every paediatrician I know to shame.  The nurses are able to cannulate in the most extreme and difficult situations. 

The hospital at night

Triage area- paediatric hospital

There are no doctors.  None.  The interns (doctors with less than one year experience following medical school) leave the hospital around 20.00 and return at approximately 09.00.  During that period clinical officers (people who have undertaken a 3 year diploma to learn to treat common local conditions) clerk the new arrivals whilst in-patients are cared for by the nurses.  In an emergency, the patient will be sent to ED and the nurse will be responsible for initiating treatment.  At times the same situation is true in the day.  This is what happens when a hospital which covers a population of 2.5 million has only 6 doctors: three consultants (one of whom is out of the region) and 3 intern doctors.  Just to put this in perspective, there are single children’s wards in the UK that have more doctors than this for 20 patients!

Neonatal Intensive care

A morning ward round at approximately 0900 in which all the in-patients and post-natal ward babies are seen.  No medical presence until the following morning.

Special care unit- incubators and oxygen concentrator

New admissions are seen and commenced on treatment that the nurse decides. If the nurse is unable to get iv access for that child, then no treatment is given until the doctor arrives the following morning. If there is a power cut (which happens frequently) there is no oxygen and incubators do not work.

A doctor trained in neonatal resuscitation does not attend deliveries and would not be easily contactable even they could attend, as the Children’s hospital is on a different site to the special care baby unit.

If a mother cannot afford to stay in hospital and cannot feed herself, then she does not produce breast milk the baby does not get any; this mother is also unable to buy formula.

Resuscitation area- special care unit

There is no phototherapy available in Jinja. Bilirubin levels are not checked, indeed blood tests are rarely taken at all. Treatment of jaundice involves holding the baby near the window and hoping for the best.

Clinic room (2 desks)

Clinics

Clinics have no maximum number and a ‘morning clinic’ will often run on until 3pm because of the volume of patients to be seen. The patients do not have a set appointment time- they simply attend on that day and wait until they can be seen, which is often several hours. The concept of ‘new patient’ or ‘follow up’ slots with allocated times is a distant dream here.  The time with each patient is limited and so consultations have to be kept very short and to the point.  Clinicians have to share clinic rooms as there is not enough space for each patient to be seen in a separate room and therefore patient confidentiality is not achievable.

More very soon....

Colin and Jess

How different is paediatrics in Uganda compared to the UK?

How different is paediatrics in Uganda compared with the UK?  That question has a very obvious answer.....or does it? 

It’s a question we had asked ourselves prior to coming and one that is actually much more difficult to answer than we first thought.  The differences are obvious.  The lack of doctors (approximately 400 medical students qualify to be doctors each year in Uganda compared with 7,500 in the UK).  We could do something very similar with nursing numbers.  We can talk about the fact a child can receive a maximum of 5 litres of oxygen or that compatible blood isn’t always available.  We could point out that investigations here are a luxury, not a necessity. We could even mention that the incubators and warmed using light bulbs (often broken or in need of replacement) and a complex system of moist napkins are used to control humidity. 

These are a few of the many differences, but there are lots of similarities.  It may seem odd that we could then say that paediatrics in Uganda and the UK are similar, but let us explain.   The most important first: it’s paediatrics.  Yes it’s a statement of fact, but it is important to realise that no matter where in the world you are, when children become unwell they present in the same ways.  Newborn children in Uganda still most commonly have problems with breathing and infection when first born.   Is the treatment different?  No!  Not at all- give them support to help them to breathe and treat the infection.  Of course, the antibiotics you use may differ slightly, but the problems, assessment and treatment are almost identical. 

A view of the main hospital

Moving on from newborns, let’s talk about children.  What are the most common reasons that children present to hospital in the UK?  Gastroenteritis, breathing concerns and fevers.  In Africa?  That’s right- gastroenteritis, breathing concerns and fevers.  How do you manage these conditions – appropriate fluids, oxygen/antibiotics/support and treat the cause of fever (usually antibiotics/antimalarials).  The availability of support differs, but the patients themselves are more alike than they are different.  There are diseases specific to tropical regions, the most prevalent of these being Malaria, but in general the children present with similar symptoms.  The big differences are that the children often present later (distance to nearest health advice) and with co-morbidities, most commonly malnutrition.

So, we have mentioned a few of the similarities of UK and Ugandan paediatrics and it is these underlying principles of paediatrics that, with some adjustment, have allowed us to work in Uganda.  However, we have still had to go back to school and learn tropical medicine. We will talk more in the next blog about the challenges we have faced, from understanding the Ugandan culture to improvising when the equipment we would usually use is not available. 

Happy Easter everyone!

Colin and Jess

How time flies!

Jess and I enjoying a relaxing afternoon

We have already been here 4 weeks.  In that time we have become accustomed to cold showers, washing our clothes by hand and going to the market every other day for our fresh food.  Whilst initially it took a lot of getting used to and we could see a lot of the negatives, time has now allowed us to see the many positives.  It makes a massive difference having food which you know has been picked that day and the price is remarkable!  A weekly vegetable shop for £3- every little helps!  Having restaurants that cater for the western diet (pizza, burgers and chips) has also helped us to have a small taste of home. The extremely friendly attitude of our hosts and the pleasant house in which we are staying has also helped. 

Getting used to the hospital was a challenge. Whilst we were aware of the high childhood mortality, seeing it first hand is something very different. Since starting work properly in Jinja on Monday 4^th March we have worked for many, many days in a row!  At least we don’t have to work nights!  Working has allowed us to understand how the hospital works and how patients are seen and treated.  The special care baby unit is placed at the main hospital and all other paediatric services are at the Children’s Hospital 15 mins walk away. This means that there is limited access to paediatric staff for the special care unit, due to the geographical area the doctors cover.

 Whilst working, we have identified areas which we feel we could help to improve and, following a meeting with Dr Namasopo Sophie (Lead Paediatric Consultant in Jinja), we have agreed on 8 areas we will try to address during our placement.  This has given us a clear plan for the next six months encompassing developing guidelines for common conditions, staff training and audit work, firstly, targeting the Emergency Department and Special Care Unit.

We have also been lucky enough to meet with Sarah Nalule (Project Manager of Health Child) to discuss a possible role we could undertake within their organisation.  We hope to further develop this link, in the hope that we could take the training we are planning for staff at Jinja Regional Referral Hospital and tailor it to other health workers who are working in Community Health Centres in and around Uganda.

White water rafting in Jinja

We have met several people who are working in Uganda for PONT, a project also funded by THET (the same organisation that funds Global Links Scheme).  We hope to meet up to see the work they are doing in Mbale, in the hope it may help us to avoid common pit falls, sharing knowledge and give us inspiration.

All of this has led to us having a very busy first month in Jinja.  In order to relax following our hectic introduction to Uganda, we went rafting this weekend.  Jinja has some of the best white water rafting in the world and it certainly did not disappoint.  It was a full day activity on a beautiful day which left us exhilarated, exhausted and unfortunately a little bit sunburnt! 

We have enjoyed our first month in Uganda, although it hasn’t always been plain sailing.  We are now looking forward to continuing our learning and working toward the goals we have agreed with Dr Sophie...

And of course to discovering all the beauty Uganda has to offer!

The River Nile at night

Colin and Jess.

Trusting local transport

Today (27th February) we undertook our first long distance journey in Uganda.  We travelled from Kampala to Jinja.  It was a 2 1/2 hour journey which was as terrifying as it was beautiful.  Looking forward you saw on-coming traffic, swerving in only to avoid on rushing cars momentarily before swerving back and onto the wrong side of the road.  However turning your eyes 90 degrees you we transported into the most beautiful and lush green surrounding you will ever see.  The trip was beautiful and we arrived safely.

On arrival in Jinja, we had a tour around the hospital which showed us the triage area, emergency department, and wards which were all extremely busy and filled with children who were so sick, they would be receiving the highest possible level of care in the UK.  We were introduced to a friendly and helpful staff and look forward to meeting and working with many others in the next few months.

Colin and Jess

Finally, our OOPE begins...

Arrived at 0100 on 25th February after a flight that was slightly delayed.

We were met at the airport by Noella who works for the Ugandan Paediatric association.  It had been a long journey but finally we were here!

We were taken to our accommodation which was next to Mulago hospital, the national referral hospital of Uganda.

Views over Kampala

Waiting at the accommodation at 0200 was the housekeeper who gave us a very warm welcome and showed us to our room which was extremely clean and came with everything you need (bed, mosquito net, toilet).

The first days- a tour of Kampala.  

Noella was our tour guide and was joined by Juliet, both of who were fantastic guides and showed us some amazing sights and views as well as helping us to negotiate the local market.  We were shown the martyrs shrine and learnt about the history of Uganda and the background to one of Uganda’s public holidays.  Following this we travelled to the cathedrals of Uganda and enjoyed great views across the city.

On day 2 we were shown around Mulago national referral hospital.  The paediatric unit has 60 admissions per day.  It has 6 paediatric wards as well as a outpatients department, a cancer centre and HIV centre.

The acute care unit (ED) is responsible for triaging infants and children according to ETAT and then commencing the necessary immediate management.

At the time of being shown round 4 patients were being treated as emergencies - all of whom had a reduced GCS and were several dehydrated and malnourished, before even considering the diagnosis that had brought them to hospital - it was not expected that any of these children would be admitted to PICU.  ACU had a small lab able to estimate haemoglobin and test for malaria.  The test for malaria could be turned around in 2 minutes!

PICU is a 7 bedded unit situated next to the emergency department that allows intensive observation. No ventilation is available, but bubble CPAP can be used.

I could write for hours on each ward we visited, but I will mention only 2 more.  

Firstly, the malnutrition unit: looks after those children who are severely malnourished.  These children often had single or multiple co-morbidities and were at risk of many infections.  It takes children here 3 months before they are in a position to go home, due to the poor condition of their underlying health. The challenges in fluid management and feeding are huge and it is only with expert care and parental education that so many make a recovery.

Secondly, the respiratory and cardiology ward had children sharing 2 to a cot, with no room between to ensure all children can be close enough to the oxygen supply. Each oxygen cylinder is divided between 4 children, so it is unclear whether any/all are receiving much benefit, particularly because there is no SATs monitoring. Therefore, the need for oxygen is all down to clinical signs.

It was a truly eye opening day. There was a huge amount to see and try to understand that is done so differently. This is only the beginning. In order to ever become useful here, I have a huge amount to learn.

That is the challenge of accepting a placement abroad.

Colin with "tour guides" Noella and Juliet

Colin and Jess