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Health Center in Rural Uganda is defying the odds by standing out

Daily Monitor, Uganda

December 29, 2015
It is a rather chilly morning deep in the hills of Rubanda west, Kabale Districtwhen we enter the maternity ward of Muko HC IV. With most mothers sitting outside, the ward is largely empty except for four women, one of whom is nursing a baby.

Novense Ekyarituha looks nervously at the visitors in the ward, completely unaware of her important place as the second woman to have had an emergency caesarean section delivery at the renovated health centre theatre.

“I was in labour for one and a half days and on December 11, at around 1pm, the midwife said that the baby was tired,” says the 18-year-old first time mother. Foetal distress is a condition that occurs when the labour stage lasts too long. Ekyarituha’s mother-in-law, Margaret Mugabirwe, says that unknown to her, the girl had taken local herbs to speed up the labour.

“Instead, these herbs were causing complications. When my daughter confessed to the midwife, Dr Alex Mulindwa, a medical officer at the facility gave us two options; either a C-section would be performed at the health centre or he would give us a referral to Kabale Hospital.” Kabale Regional Referral Hospital is 30km from Muko. Ekyarituha’s parents decided that the operation should take place at the facility and it was a success.

Making the facility functional

Dr Mulindwa says before he was deployed at the facility, the last C-section delivery had been carried out three years ago.

Since then, there had been staffing challenges, with no doctors, theatre assistant, an anaesthetists, or theatre attendants, to man the dilapidated operating theatre. “I was recruited a year ago, and it was only two months ago that an anaesthetist was employed. With him in place, we decided it was time to start operations. I review the patient, prepare the instruments and perform the operations,” Dr Mulindwa says.

Theatre assistants help with surgical procedures such as cleaning the instruments to be used, under the supervision of a surgeon. The facility also has a pick-up ambulance which began working four months ago. “Sometimes the cost of fuel is a challenge and the patients have to contribute some money,” Dr Mulindwa adds.

Previously, the patients’ relatives and medical staff had to hire private cars at Shs100,000-200,000 to take a patient to Kabale Hospital. For a mother with postpartum bleeding, sometimes this process would drag in the end leading to loss of lives.

According to Dr Patrick Tusiime, district health officer (DHO), Kabale, there are seven HC IVs in the district and they are being rehabilitated. “We are trying to make it possible for them to offer comprehensive emergency obstetrical care. We are happy that Muko has taken the lead. The facility was lucky to get Dr Mulindwa who has put together a hardworking team.”

The district was able to recruit a principal anaesthetic officer who had just retired from Kabale Hospital. Dr Tusiime is optimistic that other staff will be recruited because there is support from the Ministry of Health and other organisations, both local and international, which have provided much-needed medical equipment to the operating theatres.”

Work in progress

Besides the renovations done by the government, Worldwide Healing Hands (WHH), a nonprofit organisation dedicated to improving healthcare for women and children, sent a team of medical professionals to train health care workers and provide services at Muko health centre. They also donated blood pressure monitors”

With functionality restored and a minimum of staff available, Muko health centre IV can now carry out emergency obstetric conditions.“We work on patients up to a certain point where we can safely refer them,” Dr Mulindwa says. “For example, we can stabilise a woman with postpartum bleeding and then transport her to Kabale Hospital for blood transfusion.”

The medical officer says the facility has the personnel and equipment to store blood but does not have the capacity to transport it from the centre. With improving services, women are convinced that the health centre services are almost the same as those offered at Kabale hospital, and more of them are attending antenatal services with 45 women delivering at the facility in a month.

Pressing challenges

The maternity block is still small for the rural population of 100,000 that the health facility serves. Dr Mulindwa talks of getting nightmares about operated patients contracting sepsis. With only one medical officer and three midwives, the health centre has major staffing challenges. This reality reduces the quality of the work they do, even as the quantity of patients visiting the facility is increasing.

Accommodation is also a challenge.Sometimes, an operation is delayed for an hour because the anaesthetist lives a few miles away.

Electricity is also another challenge. The facility is not connected to the national grid and as such they spend Shs200,000 per month on generator fuel because the theatre needs to be on standby for emergency operations.

WRA Uganda and Amref Health Africa provided solar suitcases to ease the burden. Hilda Kihembo, a midwife, says, “Previously, we would place phones, with torches flashing, in our mouths as we concentrated on stitching up the new mothers.”

“We are given a primary health care fund of approximately Shs1m per month, which has to cater for day-to-day running expenses, such as paying utility bills, carrying out outreaches, allowances, and supervision of lower health centres,” says Dr Mulindwa. He adds that the facility has the capacity to deal with four C-section deliveries in succession if they are supplied with oxygen, monitors and equipment needed to resuscitate newborn babies.

Way forward

Dr Tusiime says by the end of December 2015, three other health centre IVs under his jurisdiction - Hamurwa, Mparo, and Rubaya – will be able to perform emergency C-sections. “Staff have to be motivated to work and the district gives an additional Shs500,000 every month to health centres as top-up allowances. The district is also looking into the possibility of engaging private investors to build staff houses for medical personnel at a subsidized rate.” To improve healthcare in the villages, Dr Tusiime says the Ministry of Health has trained village health teams to identify pregnant women and encourage them to visit the health centres.

Pioneer C-section mother

The distance from Muko HC IV to Mulambo parish in Nkumba Sub-county is about 6km. After 1km, our car could not go further because a section of the road had collapsed. We walked the rest of the way, up numerous hills, along village paths, through a light forest, and across a stream.

This is the journey Anna Tushemerirwe, 19, took when she was in labour on November 23. “I always went to the health centre for my antenatal treatment,” says the shy girl. We are sitting in the front room of her three-roomed mud and wattle home, built on a steep slope. She is cradling her baby, who is barely covered, despite the chilly weather. “When I went into labour, I walked to the facility with my mother-in-law and we stayed there for a night and a day before Dr Mulindwa told me I had a contracted pelvis and I needed to have a C-section.”

Tushemerirwe was the first C-section delivery Muko HC IV has performed in the recent past. “The midwife showed me how to clean the wound, but I remained at the health centre for a week until the surface of the wound healed.”

Outside the house, Tushemerirwe’s neighbours have gathered to listen in to the conversation and they agree that it is better for a woman to give birth at the health centre, rather than at home to avoid complications.

Returning functionality to health centres

In 2013 a citizen led campaign codenamed Act Now To Save Mothers coordinated by White Ribbon Alliance for Safe Motherhood Uganda (WRA Uganda) was flagged off in Kabale, Lira and Mityana districts. The goal was for government to uphold its commitment to ensure that comprehensive emergency obstetric and newborn care increases in health centre IVs from 17 per cent to 50 per cent and that basic emergency obstetric and newborn care services are available in all health centres. Twenty two health centres were assessed in Kabale District, and the findings showed there were no medical doctors at seven health centre IVs.

Kabale residents used the findings to engage their district and national leaders through dialogue meetings and petitioning Parliament to change the state of health affairs.

As a result of this campaign, seven medical doctors, including Dr Mulindwa were recruited to work at the health centre IVs. Since then, strides have been taken in the right direction. Dr Mulindwa also says Muko HC rarely gets drug shortages, as far as emergency obstetrical care is concerned.“I thank the National Medical Stores for that, though in the general wing, we get a few shortages at the end of the drug supply cycle.”

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