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....