Dec 12–13: Moving Up to General and Regional Referral Hospitals

Thursday, December 12, 2024

We hit a few speed bumps over two days of higher-level healthcare center visits.

We made an early morning exit from the Acacia Hotel in Mbarara to drive one hour to the Itojo General Hospital. A general hospital is essentially a district-level hospital and sits at level V, within VII levels, with the National Referral Hospital sitting at the highest level, level VII. Our first meeting with the Medical Superintendent and Hospital Secretary was brief, where we shared introductions and interests.  We learned that there were some additional administrative requirements that needed attending to prior to our interviews, so members of the team fulfilled those requirements over the next several hours.  For the other members of the team, there was time to observe the engaging health education awareness campaign painted across many of the hospital walls.

As we were waiting for administrative approval, we also had time to dive deep into a discussion with our Ugandan liaison on the greatest challenges in the Ugandan healthcare system. The most pressing need he cited, based on his years of experience at the Makerere University School of Public Health and within the overall system, is for more qualified staffing, particularly doctors and nurses, which is reliant on government funding. He shared many vivid examples, including one where a single midwife was managing an entire maternity ward.  A second need he shared, also most pressing, is for supplies of all kinds, again reliant on government funding.

At about 3:15pm approvals were received and we split into two teams and proceeded to interviews. 

One team interviewed the Medical Superintendent.  He provided background on the referrals from parish, sub-county and county healthcare centers (levels II, III and IV) to this district-level hospital, as well as a list of services the hospital provides, including in- and out-patient, lab services, maternity, pre- and post-natal, dental, radiology, stores (equipment storage), casualty (emergency), nutrition, and HIV/TB.  Pathology and chemotherapy are not provided here, as those services are provided at regional referral hospitals. Additionally, FNAC (fine needle aspiration) is not provided here, due to the need for specialized technique and supplies not provided for.

The Medical Superintendent elaborated further that this district-level healthcare center, when compared to a county-level healthcare center, delivers a higher level of services, with more surgical and more complicated cases. They have more blood than county-level centers, better lab services, more drugs, and have radiology (X-ray and ultrasound). They have ophthalmology, dentistry, orthopedic, ambulance as well as a higher-level physical plant. A mother will bypass a lower-level healthcare center and seek attention at a general hospital for the staffing and equipment, especially for complicated procedures (this center has a gynecologist and two surgeons). Therefore, for the system to push down services to lower levels, there is a need to not only provide improved staffing and equipment, but also an awareness campaign to instill confidence that quality care can be received at a lower level for more complicated, consequential issues.

After our enlightening meeting with the Medical Superintendent, we were provided a tour of the hospital, which provided members of the team the opportunity to meet staff and walk the impressive facility. 

An interview with lab technicians for members of our second team commenced in parallel with the first team’s meeting with the Medical Superintendent.  In that meeting it was shared that the facility does not perform cytology or FNAC, but only works with blood samples. The team shared the application and was provided strong feedback on design and functionality.

After our meetings we drove to dinner at a local hotel where we enjoyed many delightful rolexes, chicken and beef dishes, as well as seasoned chips.  The evening culminated with an hour drive to Kabale to stay at the White Horse Inn, late desserts of chocolate banana snow and chocolate crepe by the fire, and intermittent power and internet outages.

Friday, December 13, 2024

This is a short post about a long day, appropriately dated Friday the 13th. We left the White Horse Inn and arrived at the Kabale Regional Referral Hospital in the early morning. Over several hours we attempted to commence our interviews, but were unsuccessful, due to administrative issues.  We ultimately left the facility, without a meeting, and planned to return at a later date.

Learning

In addition to the key learnings into what distinguishes a general hospital, the greatest insights were into the importance of partnering with healthcare center administrative teams to achieve successful site visits.  These learnings include: 

·      Administrative requirements need to be performed in advance with additional contingency time

·      Formal approvals need to be received in advance with contingency time

·      Payment of required fees and confirmation of payments need to secured in advance with additional contingency time

·      Best to leverage liaison relationships with healthcare centers in order to expedite approval processes

·      Prioritize activities with healthcare centers in which a liaison relationships exist

·      If no liaison relationship exists, commit to advance, in-person development prior to a healthcare center visit in order to avoid fulfilling administrative requirements at time of visit

·      Carry addition funds in the event of unforeseen administrative fees

·      More broadly, understand that administrative approvals and fees are a core component of access, research and innovation adoption and build that into the plan

Put more simply, the preparatory work is as important as the work itself, and challenges can spring up even if you have dotted all the i’s and crossed all the t’s.  For as they say in Luganda: “Kyotanalya tokyesunga” or “Don’t get excited before you eat.”