Wednesday April 19 2017

Govt ambulance service stalls for two years after launch

A number of ambulances parked at

A number of ambulances parked at the National Ambulance Emergency Coordination centre at Mulago hospital which had been created to respond to emergencies when the Pope visited Uganda in 2015. PHOTO BY STEPHEN OTAGE. 

By ISAAC MUFUMBA

The Promise
On November 26, 2015, Dr Elioda Tumwesigye, the State Minister for Health, launched the first 10 ambulances, part of a fleet of 38 ambulances to be run by the government under what was meant to be the Uganda National Ambulance Service.

At the same function, Mr Tumwesigye flagged off 38 ambulances, which had been procured through a partnership that had brought together the Ministry of Health, the Uganda Police Force, the Army and Rubaga and Nsambya hospitals for purposes of providing emergency pre-hospital care during the November 27 to November 29 visit of Pope Francis to Uganda.

Prior to the launch of the service, a team of researchers had visited Uganda and carried out research on the state of emergency pre-hospital care.
In the “Current Patterns of Pre-hospital Trauma Care in Kampala, Uganda and the Feasibility of a Lay-First-Responder Training Program”, which was published in World Journal of Surgery in August 2009, it was projected that road traffic crashes will have by 2030 become the eighth leading cause of death and fourth leading cause of disability worldwide.

In noting that more than 90 per cent of the road traffic injury deaths occur in developing countries where up to 80 percent of the injury deaths in pre-hospital settings, the paper noted that injuries were by 1995 among the top six causes of death in at least 12 districts in which research had been carried out in Uganda.

The national referral hospital, Mulago, the paper pointed out had not formal pre-hospital emergency system and that many of the injured patients would arrive at Mulago and other hospitals around the country by any means, ““car, motorcycle, minibus taxi, police vehicle, or on foot”.

The onus of providing voluntary pre-hospital care for mostly road related emergencies was found to be on the shoulders the police, taxi drivers and local council officials.

In line with recommendations contained in the World Health Organization’s (WHO’s) Essential Trauma Care and Pre-hospital Care Guidelines, the researchers trained the police and other lay people in providing that much needed care.

The findings were followed by a visit to Israel between November 3 and November 8, 2015 of the Parliamentary Committee on Health led by the then Chairman of the Committee, Dr Kenneth Omona, and officials from the Ministry of Health led by the then Commissioner of Health Services in Charge of Planning, Dr. Francis Runumi. Dr Runumi also chaired the Task Force that was charged with designing the National Health Insurance Scheme.

The weeklong study visit which was organized by the Haifa based King David Medicine saw the legislators and government officials compare notes with the head of Israel’s ambulance service and disaster rescue agency.

The Israeli unit has over 45 branches across the country and has over 13,000 paramedics and trained volunteers who provided among others life support and are equipped with good ambulances, mobile intensive care units, motorbikes and all-terrain vehicles.

This visit, coupled with among other things findings of that research that the Ministry of Health and the University Hospitals of South Manchester and Health Education North West teamed up for work on the project “Healthy Uganda Building Capacity (HUBCAP)”, which led to the development of a primary trauma course, culminated into the formation and launch of the Uganda National Ambulance Service Project.

According to Dr Lukwago, the ambulances would after the Pope’s visit be transferred to Mulago where the service would start operating first within the Kampala Metropolitan Area before being rolled out to other parts of the country.

Under the initial plan unveiled in January 2014, government was meant to have purchased 100 ambulances at a cost of $157m. In an interview he had with the media at the time, this was meant to have been done over a five year period beginning with the financial year 2014/2015.

“The ambulances will be fitted with modern technology where surgery can take place and an emergency telephone number known to people in case of need. The ambulance would reach the survivors in 10 to 20 minutes depending on the location,” said Dr Mudanga.

The launch of the ambulance service was meant to have operationalised the Emergency Medical Service System (EMS) to provide first aid, pre-hospital care and transportation through an ambulance service and more specialized health care at designated emergency units based at Health centers across the country.

In order for that to be achieved dedicated medical workers, ambulance drivers and crews had to be recruited and trained. Modern ambulances equipped with modern medical and communication equipment was also meant to have been purchased; a toll free communication system with a different code other than the Police’s 999 should have been opened up and the referral system must have been made to work better.

Status
Apart from training of the initial batch of about 100 who had been meant as drivers and emergency staff, nothing else was really ever done to make it operational.

Even then the same staff were affected during a recent restructuring exercise that so a huge number of that category of staff, most of whom had been employed on contract terms. While a few contracts were cancelled, those that had expired were never renewed.

The referral systems are still a shambles and there is no specially designed communication system for health related emergencies. Modern well equipped ambulances have never been purchased and most of those which had earlier been dispatched to the various hospitals and health units are grounded for reasons ranging from lack of tyres, fuel or mechanical problems.

In other cases, the perpetual lack of operational funds at health units makes it practically for them to be serviced in time. Many of the ambulances are parked on grounds of having overshot their maintenance service limits.

Most of the health units across the country do not have intensive care units and where such units exist they are short of skilled personnel, a scenario which the Permanent Secretary, Dr Diane Atwine, says is being worked on.

“Right now the Health Service Commission is in the process of recruiting medical workers for most of the ICUs across the country,” she recently told Daily Monitor.

Emergency number purchase of modern ambulances to meet the requisite standards of care, establishment of a toll free communication system. Above all, it required ensuring that the country’s referral system is working. That too is not working.

Official Position
The establishment of an Ambulance service stands out prominently in the NRM’s 2016-2021.

“Instead of every health centre having an ambulance, which is normally abused by the in-charge of the health units, the National Ambulance System will have ambulances in strategic areas coordinated by a command Centre.

Health units in need of ambulance services will call the command centre which will in turn send an ambulance nearest to that health unit. The ambulances will always be on standby, ready to respond to emergency calls,” the manifesto reads in parts.

However, Dr Atwine says that it will be implemented in a manner different from what had originally been promised.

Instead of being placed in Mulago under the supervision of the Ministry of Health, she said, the project is to be placed under Kampala City Council Authority for work in Metropolitan Kampala. The existing ambulances were procured under a programme run by KCCA.

The rest of the country, she said, are to be serviced under a different project that is being mooted.
“We are instead working on a National Emergency Care strategy. That strategy is still being discussed, but it entails a lot more than the ambulance service,” she said.

Impact
Failure of the National Ambulance Service to come on stream means that the country’s handling of emergency cases remains rudimentary.

If the paper, “Current Patterns of Pre-hospital Trauma Care in Kampala, Uganda and the Feasibility of a Lay-First-Responder Training Program,” is anything to go by, most of the emergency cases do not arrive at hospitals in specifically designed vehicles to handle such cases.

“Less than 5% arrive by ambulance because few exist and these are mostly privately owned and prohibitively expensive. Furthermore, one in three patients arrive at Mulago beyond the first hour after the injury, the ‘‘golden hour,’’ during which expedient treatment would greatly increase survival,” the paper reads in parts.

While statistics related to cases of maternal and infant mortality arising out of lack of ambulances to transport expectant mothers from rural units to bigger units mostly in the urban centers are scanty, it is clear that lack of transport is a major contributor to morbidity levels.

Daily Monitor position

Whatever the form or substance that the government is suggesting, the fact that the country does need an ambulance service cannot be overemphasised.
Uganda badly needs a functional ambulance system, which is an extension of the health system.

Such a system should allow citizens who can neither afford Primary Health Care or those who are simply traumatized to access “treat and leave” or “treat and transfer” treatment. This will no doubt improve health systems and also help in the fight against infant and maternal mortality and morbidity. Government should have it high on its list of priorities.

imufumba@ug.nationmedia.com

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