Addressing the medical equipment situation in the country

Ms Justine Kaboggoza, 48, welcomes her son back from his first O-Level final exam. It means a lot, celebrating this milestone because she had never imagined Samuel Ssonko would live this long.
Ssonko, 16, a student of Mamtaz Senior Secondary School in Kawempe Division, Kampala, had a difficult childhood. Ms Kaboggoza says when he started crawling at seven months, Ssonko would breathe heavily and tire very fast.
Ms Kaboggoza, a lay reader at Ebenezer Church of Uganda Parish in Kawempe, then, took him to Kawolo hospital where a doctor told her Ssonko had a hole in his heart. The doctor, however, told her it was a small hole that would close as he grew older. But at five years, the problem persisted. Ssonko could only watch as his friends enjoyed their childhood.
She then sought help from the Uganda Heart Institute (UHI) where she was told he needed a heart operation which could not be done at the facility. Through correspondences with their counterparts at UHI, doctors at the National Heart Institute in India diagnosed Ssonko with Tetralogy of Fallot, a congenital heart defect which is understood to involve four anatomical abnormalities of the heart, and said the operation would cost close to Shs60m. For years to come, Ms Kaboggoza toiled to raise the money, and on many occasions lost hope. Ssonko was lucky and finally had his operation three years ago.
Ms Kaboggoza’s case is an example of many Ugandans who go through a lot of hardships trying to access medical care right from health centres to the referral hospitals. The lack of medical equipment, or the inability to maintain the available ones, and the shortage of skilled manpower to operate the machines is a problem the country has grappled with for long.

Health system that was compromised
A 2012 report by Human Rights Network Uganda, an NGO, says Uganda was widely acknowledged during the post-independence era (1962-1971) as one of the countries in Africa with the best health indices and a vibrant health care system which functioned at all four tiers i.e. primary, secondary, tertiary and quaternary health care.
“This once functional and efficient health care system was short-lived due to decades of civil unrest and political instability that led to the collapse of the system,” the report says in part, adding that although the general, regional and national referral hospitals have continued to make major contributions to essential clinical care in Uganda, there are still numerous challenges they face.
Dr Francis Runumi, the commissioner for planning in the Ministry of Health, says the issue of equipment in health facilities is a matter they have been addressing in the rehabilitation and reequipping of hospitals.
“From almost every loan we get, [and also from] Treasury allocation for hospitals, we look at the equipment situation through statistics from our management information systems. We look out for what kind of equipment we have in every facility, what age and [its] functionality,” he says. “This helps us know when to replace and when to provide because the equipment we require is a lot.”
Though it is difficult to establish the exact number, many Ugandans are referred abroad annually for treatment.
Mr George Ntambi, the director Action for Disadvantaged People, a local NGO that has helped connect more than 50 people to India hospitals for operations since 2008, says the most common illnesses for referrals abroad are heart, kidney and brain conditions.
“We usually have a bulk of people who apply for our help and we assist in linking them to hospitals in India. We also fund raise for them because the operations are costly, for example, a heart operation can cost from $8,000 (about Shs20m), minus air tickets, depending on the type of operation,” says Ntambi, adding that some patients pass on while they are trying to look for funds.
This is perhaps why Kaboggoza says Ssonko’s ability to live up to 11 years, when he finally had the operation, was a miracle. “Doctors would come to our room with students for them to see him. They said it was just a matter of time before blood would start oozing out of every hole in his body – his nose, ears, eyes and so on,” she says.
Uganda’s population is estimated to grow by more than 3 per cent per year, which is among the highest growth rates in the world. This means more people for the government to plan for in terms of health care.
Serere Health Centre IV is lucky to be a facility that will soon be upgraded to a hospital.
Dr Francis Odeke, the Serere District health officer (DHO) – the person directly responsible for the management of medical equipment at district level – says it is a high bulk facility with patients coming in from other districts. He says they have two medical officers who perform operations daily.

Some progress made, more to be done
“Our health centre IV is fairly equipped. We have equipment in the theatre like the anaesthetic machines, the resuscitator…and in the OPD [out patients department] we have those used on a daily basis like the BP machines, stadiometer etc,” Dr Odeke says.
“Our lab has state-of-the-art equipment that was donated by Baylor Uganda. We also have a 3D ultrasound scanner, but it’s unfortunate we don’t have anyone operating it yet because it was a donation.”
He, however, says they still need a lot more equipment at the facility that is operating like a district hospital.
“There are things that are lacking, for example ECG machines which show how the heart is functioning, and an X-ray machine because we refer all X-ray cases, either chest X-ray or those with fractures, to Soroti Regional Referral Hospital,” he says. By policy, Health Centre IVs are not entitled to an X-ray machine.
It is about 27km from Serere to Soroti and the journey is difficult because the transport system is poor and the roads are not good. Dr Odeke says at times patients have to go by public means due to lack of fuel in the ambulance. The fare to Serere costs Shs6,000. He says despite having most of the basic equipment, some of them are outdated. “We have some machines that are obsolete like the electric BP machine [and] the baby incubator which were brought in 2000. Maintenance is very poor and because of that, we get problems [in using them],” he says.
Dr Runumi says they include the equipping component as part of the loans they extend to some hospitals that have been targeted for rehabilitation. “[For] those lower level facilities, we have a set of standard equipment we provide them. When they get broken, we get reports from the districts and we plan and provide that equipment,” he says.
Dr Runumi, however, says as far as they are concerned, equipment is not the problem in most of the facilities as they are equipped with what they require.
“The major problem is human resource, the health workers to use the equipment. It is a challenge that has taken long to address because first and foremost, they [health workers] need a conducive working environment. That means enough work space, accommodation, the equipment we are talking about and above all, a good pay,” he says, adding that since they are not paid very well, the health workers look for alternative sources to make ends meet.
“Even if you address the infrastructure, the equipment, the medicines and drugs situations, still the actual qualified people are the ones to make those things useful. So it’s not the infrastructure, infrastructure is just support.”
In September, The Observer reported that every year Uganda loses more than 250 medical workers to work mainly in South Africa, Botswana and the United Arab Emirates.

The problem of remuneration
In a country where health professionals earn between Shs400,000 for midwives and Shs700,000 for medical doctors per month, working abroad, where remuneration is four times higher, is incredibly enticing.
In 2012, government announced an increment in salaries of medical doctors working in health centres IVs from Shs1.2m to Shs2.5m after a standoff between the Executive and lawmakers over a request by the Ministry of Health for Shs260b to motivate and recruit more health workers.
But as the government continues making baby steps in increasing the diagnostic and treatment capabilities of the referral hospitals, more and more Ugandans get desperate by the day.
And while people like Ms Kaboggoza are lucky enough to raise funds through well-wishers and are able to watch their children live, for others, being told a condition cannot be handled in Uganda is as good as a death sentence.

Hospital donations should be handled carefully

The World Health Organisation’s donation guidelines require “all donated medical equipment have a useful life of at least two years” and should include manuals.
To prevent Ugandan health facilities from being used as dumping grounds, Dr Francis Runumi, the commissioner for planning in the Ministry of Health says they coordinate donations of medical equipment.
“Whenever they [donors] have equipment, we have a technical committee, the National Technology Committee, which deals with equipment,” he says.
“This one looks at each donation that has been proposed and we look at the kind of machinery being brought and its functionality. They have the standards they use to gauge which equipment should be allowed into the country and which one should be rejected.”
“In most cases you find equipment which is donated is not so useful and can even become hazardous to the population, they are rejected.”
“But those we find are extremely useful, the National Advisory Committee on Medical Equipment (NACME) gives approval certificates and whoever is given the approval then proceeds. And in some cases, the donations which require taxes, the Ministry of Health pays the taxes.”
However, Dr Jacinto Amandua, the commissioner of clinical services at the Ministry of Health, says they do not have a regulatory framework for regulating devices at the moment.
“The National Advisory Committee on Medical Equipment isn’t legal in the current statute,” he says. This means donors are not legally required to come through the Ministry of Health, although the policy recommends it.
He says ensuring medical equipment entering the country is usable and safe is the biggest challenge they have.

How to get the health system back onto its feet

1. Get new machines in
The congestion of Mulago National Referral Hospital has partially been blamed on the inability of the regional referral hospitals to handle some cases.
Dr Francis Runumi, the commissioner for planning in the Ministry of Health says they are going to budget for high-tech machines for the referral hospitals. He says the machines have been identified and will beef up the diagnostic capability of cancer and heart problems at the regional referral hospitals.
“As the work they do is for referral purposes, it is not a machine you can place at a health centre. Even if you place it there, somebody runs the blood through, but when the results come out, they need somebody at the level of a consultant to interpret and make use of them.”
According to the National Medical Equipment Policy 2009, equipment can pose a risk to patients and staff, particularly if used improperly. It says appropriate daily, periodic and corrective maintenance of medical equipment is key to achieving safe and cost-effective management of the machines.

2. Maintain the equipment
Dr Runumi says they have managed to secure some money for regional equipment maintenance workshops and have these workshops at regional referral hospitals. “These organise at regional level how to repair broken-down equipment. They are actually the same who advise us on which new units to provide additional new equipment,” he says.
Asked how effectively the system is working, the Serere DHO says: “It depends; some equipment takes a short while to be worked on while others take from months to years [to be repaired] because they lack spares and they [workshop people] also complain that they don’t have enough finance. And spares for some of these old types of machines are no more, they are no longer in the market.”
Dr Odeke adds: “Even for simple fridges, we have to take them back to UNEPI [Uganda National Expanded Programme on Immunisation] in Entebbe where they are worked upon. Those ones can at least afford to buy spares for those fridges. But at the regional referral, most of our equipment we take stay there and don’t come back.”

3. Have suppliers provide support
He, however, thinks things can be handled better: “For example, machines that are obsolete, the next ones they buy should be ones that are common and have spares and the suppliers should be given a period of about five to 10 years to maintain it. So that when it gets spoilt within that liability period, they should be able to come back and repair it.”
In 2012, the government equipped fully the Uganda Heart Institute’s (UHI) cardiac catheterisation unit--a specialised medical setting in which doctors can visualise heart structures, diagnose the precise nature of cardiac diseases, and perform minimally-invasive, corrective heart procedures.
The presence of such equipment has attracted high-profile specialists to carry out complex operations like neurosurgery and open heart surgery in Uganda.

4. Train Ugandan doctors
Dr Runumi says the permanent solution is not in attracting more of these visiting specialists, but in training Ugandan doctors from abroad so that they can use these gadgets and handle the big numbers that are being sent to hospitals abroad.
“We have put aside close to $2m (about Shs5.3b) for the next three to four years to train super-specialists within and outside the country. The programme is just rolling out and we anticipate within the next four years we should have not less than 150 specialists and consultants who can start helping the issue of referral cases, the ones we find in hospitals in India, Italy, Germany, where we refer our patients in general,” Dr Runumi says.

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