What went wrong in Uganda’s war against Covid-19?

Monday July 19 2021
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Mortuary staff at Mbale Regional Referral Hospital carry the remains of a person who succumbed to Covid-19 last month. Many Covid-19 patients died in regional referral hospitals due to a shortage of ICU beds and oxygen. PHOTO/ LEONARD MUKOOLI

By Frederic Musisi

Uganda’s Covid-19 response in its early days received global plaudits when few cases were registered as the regime enforced stringent lockdown measures and ramped up testing and contact tracing. 

Government later borrowed heavily to resuscitate an ailing economy and health system. Despite, the second wave, which came with a potent, sting put a strain on the health sector and only a second lockdown could halt the rising number of deaths. How did the country’s fight against this deadly pandemic flounder? writes Frederic Musisi.

Petellina Akol, 65, breathed her last on July 2, 2021 at Soroti Regional Referral Hospital (RRH). The post-mortem report indicates that she died of respiratory failure, which occurs when one’s blood doesn’t have enough oxygen, a complication, which was worsened by Covid-19.

Desperate relatives had earlier on transported Akol for a distance of 50km from her home in Ojie Village, Kumi District, to Soroti Regional Referral Hospital, which serves eight other districts in Teso Sub-region. 

The hospital, which was elevated to regional referral status in 1996, has undergone years of neglect and chronic underfunding.

Much earlier, in 2020 when the country registered its first case of Covid-19 on March 21, followed by a few community cases, the government imposed a lockdown to buy ample time to plan, procure, install vital equipment and equip public health facilities to prepare for a surge in cases at the time, and possibly a second wave.  

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By the time President Museveni imposed a second lockdown on June 18, 2021, Soroti Regional Referral Hospital was teeming with Covid-19 patients—registering a daily average of 100 patients, majority requiring oxygen, which was not readily available.

“The second wave has been tough---patients filled up here in a short time, and in need of oxygen which was difficult to come by,” recalled Dr John Wilson Etolu, the Covid-19 case management team leader, for Teso.

He added: “We didn’t prepare adequately both on the population side, and on the health infrastructure. First, there was the politics, when people thought Covid was a political disease used to curtail opposition; when we’re recording few cases and deaths. Even after the political season, the caseload did not peak as some of us feared, so once the curve went down, we lowered the guard. On infrastructure, we didn’t do well to stock things like oxygen.”

“Experience from elsewhere shows countries went through more than one wave. Whatever has happened we should learn a big lesson and sufficiently prepare,” Dr Etolu cautioned.

When Akol was admitted to the Covid-19 treatment unit in the last week of June, the referral hospital was grappling with a surge in patient numbers and deaths too. The hospital’s oxygen plant with capacity to refill five cylinders in three hours was way too slow to save critically ill patients.

The reckoning
The second wave further barreled deep into communities, including in the countryside since March, according to the Health ministry.

But how exactly did we get here? 
In a year, which coincided with party internal elections, a section of the population warned that to be able to combat the spread of the pandemic, the general polls in 2021 should be postponed.

But during high-octane campaigns to elect party flagbearers and later parliamentary and presidential campaigns, large crowds gathered to listen to politicians without observing safety measures.

There are fears that by the end of the general election polling on January 14, 2021, the virus had found fertile grounds to spread across pockets of the country.

When the second wave struck, it was different from the first wave. The pandemic had a greater sting with the highly transmissible variants such as Delta, sending critically ill-patients to require intensive care unit beds or high dependency unit rooms.

Between late May and the first three weeks of June, the country registered the highest number of cases in a single day— 1,259 or 17 per cent positivity rate —deeply exposing the fragilities of the health system long ignored by the government. 
With numbers of the sick surging, government hospital services began to come under strain. 

As the stench of death permeated across the city, funeral service vans parked across Mulago’s mortuary.  The piercing sound of ambulances blaring horns across Kampala’s haunted streets became the symbol of the second wave.

The first lockdown last year was supposed to provide government with enough time to borrow enough funds and equip hospitals. It was also meant to allow health institutions to train specialised nurses to provide care to critically-ill Covid-19 patients.

Asked whether the country could have been better prepared, the Health minister, Dr Jane Ruth Aceng, said in an interview last Thursday that now is not the time to talk about that.

“The overwhelming number of critical cases were not predicted; you could not detect whether the virus will affect the young or old,” Dr Aceng said. “Preparation was done but like in all other countries, systems get overwhelmed,” she added.

The upper-crust who could afford the astronomical bills of private hospitals lined up to find a bed for their ailing patients. 
Oxygen, one of the key components in treating acute Covid-19 cases, became scarce and commoditised, which became too costly for the average citizen.

 A video captured at Mulago national referral hospital showed caretakers fighting for oxygen cylinders that had just been refilled. At various regional referral hospitals (RRHs), fatigued caretakers could be seen ferrying cylinders from refilling stations to treatment wards. According to a Daily Monitor investigation, the situation got dire, especially at night when several health workers were resting.

Dr Aceng said all RRHs got additional oxygen cylinders. “During the first lockdown President Museveni directed that we prepare for the worst-case scenario but the pandemic changed.”

In its March 2020 - June 2021 Covid-19 Preparedness and Response Plan, the Health ministry detailed eight key pillars, namely, leadership, stewardship, coordination and oversight; surveillance and laboratory; case management; strategic information, research and innovation; risk communication and social mobilisation; community engagement and social protection initiatives; logistics; continuity of essential health services, to combat the pandemic.

Money meets ineptitude
During the same period, a Finance ministry semi-annual budget monitoring report yet to be made public, ostensibly due to fear of a backlash from the tender beneficiaries, a copy of which has been seen by this newspaper, details that the Health ministry received both budget and off budget support from various funders, including World Bank, Global Fund and GAVI, to the tune of Shs750b, of which Shs617b or 82 per cent had been spent by March 31, 2021.

The report also offers some insights into how things went wrong. Of the Shs750b, Shs22b was spent on procurement of face masks and Shs594m on distributing them, Shs35b on procurement of ICU beds and accessories, Shs29b on procurement of test kits and reagents, and Shs22b as allowances for health workers.

Among others, Shs11.6b used to procure fuel and lubricants from Vivo Energy, Shs11b for procurement of assorted personal protective equipment, Shs11b for procurement of 37 ambulances, Shs8b spent on civil works and buying tents, and Shs8.5b was transferred to RRHs for patient management and hardship allowances.

During the first lockdown, the Health ministry promised to, among others, improve ICU bed capacity across the country, purchase more ambulances, install oxygen plants, purchase regulators, humidifier bottles, and cannula defibrillators, suction and infusion pumps, nebulizers, mobile x-rays, oxygen concentrators, weighing scales, portable ultrasounds, patient trolleys, and ventilators.

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An LDU personnel chases after a man during the first lockdown in Kampala last year. PHOTO/ALEX ESAGALA

In various addresses, President Museveni implored the ministry to procure 42,000 beds for Covid-19 patient care, of which 3,793 beds have been so far made available. These include 3,100 standard beds; 600 at Mulago, 900 in RRHs, 1,300 beds at Namboole, 120 at Bombo military barracks, and 180 beds at the seven Health ministry certified private facilities treating Covid-19. Another 474 high dependency beds, and 218 ICU beds were also procured. However, there is still a deficit of 38,207 beds. 

In April 2020, the Health ministry acquired 20 sleeper tents with a capacity to accommodate 100 patients, each at Shs163m or a combined Shs3.8b. Lumious Uganda Ltd, which was handed the contract, was supposed to install tents at Mandela National Stadium, Namboole, to create a large patient holding point.

The Health ministry Permanent Secretary, Dr Diana Atwine, explained in an interview last December that the stadium management stopped them from puncturing the stadium turf. The tents were later dispatched to various RRHs.

Two tents were installed at Soroti RRH but have barely been used.  The first tent, officials explained, required a concrete floor to be constructed and lacked a stable electricity supply while the second tent installed on a lawn also lacked a constant power supply. When the hospital Covid-19 treatment unit was overwhelmed with numbers, management improvised space 1.4km away at the Soroti School of Comprehensive Nursing.

Last year, the Health ministry handed out two tenders; Shs26.9b to Elsmeed EA Ltd for the delivery, installation, and commissioning of ICU equipment in 17 hospitals across the country, and a second tender worth Shs10.5b to Joint Medical Stores (JMS).

Status of equipment
A doctor, speaking anonymously, told this newspaper that some of the equipment delivered “had issues.” After delivery of five ICU beds and the associated equipment at the hospital, it dawned on management that they did not have intensivists—certified physicians who provide special care for critically ill patients in ICU.

Dr Etolu acknowledged the problem and revealed that they have now sent 12 staff for training at Mulago as intensivists, who are expected to return later this month.

After the Health ministry delivered ICU equipment to Soroti RRH, it came to the notice of management that the entire hospital complex comprises decrepit structures that could not accommodate heavy equipment.  Dr Etolu revealed that they are now re-modelling a new structure to accommodate ICU equipment.

On the day we visited, we found several supplies dispatched by the Health ministry, including beds and mattresses, outside the Covid-19 treatment unit as there is no space to accommodate them, while officials were trying to prepare the two tents dispatched last year. There is also a shortage of front line staff; given the risks involved and delayed payment of risk allowances. 

“Putting up an ICU unit has its specific dimensions and it’s not just about buildings but also about staff. You find that a patient in ICU needs about four nurses, which luxury we don’t have here,” Dr Etolu said. “It’s true we received equipment from MoH but we were able to use some; we couldn’t find space for others.”

Haphazard planning?
But how did things go wrong when Uganda appeared to be making strides in the fight against Covid-19 compared to neighbouring states earlier on in the year? Why did those in charge not rely on the first lockdown as the saving grace to fully equip hospitals in time?

At Mbale and Moroto RRHs, officials revealed that the scarcity of oxygen was the most frustrating problem as Covid-19 patients died.

Dr Emmanuel Tugaineyo, the Mbale RRH director, told Daily Monitor: “Our Oxygen plants’ output-refilling—is about 24 cylinders in 24 hours, but during the peak of the second wave, we found that we required between 30 and 40 cylinders for Covid-treatment, not mentioning other departments where oxygen was needed badly. So, the Health ministry had to deliver oxygen from Kampala.”

Two frontline health workers in Mbale, speaking anonymously, talked about the “low morale”—after going months without being paid their risk allowance, a pattern across several RRHs around the country.

While Dr Tugaineyo said all outstanding allowances have been cleared until the end of June, the health workers we talked to denied receiving such payments. At Moroto RRH, the toxic work environment spiralled into the Covid-19 treatment unit, putting patients at risk. One health worker indicated that there was “selective promotion” of those working on the frontline to benefit from risk allowances. This, as the hospital grappled with a staff shortage—four staff against an average patient capacity of 60 at the peak of last month— and oxygen scarcity.

“Handling the second wave caught us slightly unaware…at the beginning of the year things seemed pretty normal but starting May we started detecting a surge in numbers through mass-testing although we have now stabilised,” said Dr Moses Okwir, the Covid-19 focal person for Karamoja Sub-region.

Officials at Soroti, Moroto, and Mbale RRHs respectively, told Daily Monitor that they often had to rely on oxygen supplies dispatched by the Health ministry from Kampala to complement their in-built oxygen plants.

Procured equipment
The finance monitoring report further details that as of January 31, 2021, 1,497 out of 1,553 (96.4 per cent) pieces of equipment procured had been delivered to the respective recipient facilities, and 85 per cent of the installations done by both Elsmeed and JMS.  These included blood gas analyzers, defibrillators, suction and infusion pumps, nebulisers, mobile x-rays, oxygen concentrators, weighing scales, portable ultrasounds, patient trolleys, ventilators, and ICU beds.

By January and February 2021, the report shows that laboratory equipment such as blood gas analysers supplied by Elsmeed Ltd was not working, while equipment delivered at Soroti, and Lacor hospital in Gulu did not work at all, and one delivered to Gulu RRH worked for less than 48 hours.

The equipment had flaws related to sensors, temperature failures, and frozen screens, among others issues. However, the Health ministry told those conducting an audit that the issues had been fixed in March 2021, except at Soroti RRH. 

At Soroti RRH, doctors lamented about the lack of a stable power supply, which affected functionality of blood gas analysers. This intermittent power supply, despite the country’s hydro-generation capacity, killed dozens of patients in ICU, including at Mulago Covid-19 unit.

While JMS delivered 99 per cent of its equipment—388 pieces of ICU equipment, including 28 per cent ventilators, 25 per cent patient monitors, 24 per cent oxygen therapy apparatus, while the rest (22 per cent) ICU beds—the report indicates their equipment was inferior compared to that supplied by Elsmeed EA Ltd.

In a statement to this newspaper, the JMS executive director, Dr Bildard Baguma, said his company supplied high quality equipment in line with the specifications shared by the Health ministry, in addition to guaranteeing a three-year manufacturer’s warranty.

The country’s Covid-19 death-toll had by mid-July inched towards 2,164 but all is not entirely despair as more than 61,304 patients have recovered of the total caseload of 88,194. 

One hopes that in case the third wave strikes, the country will have learnt from its past mistakes and be better prepared. 
 

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