Mulago’s referral system failure

New specialised women’s hospital sinks back to the old ways

Kampala, Uganda | FLAVIA NASSAKA | On Oct.16, a week after President Yoweri Museveni officially opened the new Mulago Specialised Maternal and Neonatal Hospital in Kampala on Oct.09, The Independent visited the facility. The expectation was to see an efficiently run facility with smiling health workers attending to patients in clean beds, using high end technology since the first days of free care had come to an end.

Instead, the scene was quite familiar for those who have visited any of the public health facilities or the main Mulago Hospital before it closed for repair.

Women lay desperately on the floor in an open space at the spacious reception area seemingly waiting for treatment. Yet more were pleading with security personnel at the gate to allow them entry.

The facility was opened on the idea that it will run by its own specialists and have its own new equipment. It was a turn-key project with the Arab contractors who built it under agreement to hand over a finished hospital with everything from equipment to hospital beds and health workers fully trained to work there. But now, it appears, the dream hospital is fast reverting to the old Mulago ways.

It was impossible to imagine this was the new hospital that was opened with strict referral rules to only handle cases that require super-specialised care that could not be handled by lower facilities. So what has gone wrong?

Nothing but minor glitches, according to Dr. Diana Atwiine; who is the Permanent Secretary of the Ministry of Health.

When asked about this at a media briefing, she said:  “What has been stopping Mulago from handling referrals are these small glitches but we are now slowly identifying and solving them. This overcrowding because of headaches, malaria will soon stop,” she said, “Our specialists are busy treating malaria. Some get frustrated that they aren’t practicing their specialties and end up leaving the country.”

But for Kyamureesire Rutaagi, the issues of the New Mulago Hospital extend beyond the glitches the public sees. The former lecturer at Makerere University Business School says Mulago has a management problem. The management expert says if this is not fixed; the touted referral system might remain a dream even with the entire necessary infrastructure in place.

“what Mulago needs is a manager,” Rutaagi says.

He explains that managing the referral system requires basic resources to implement such as human resources and the right technologies to deliver services with efficiency. He says these should be supplemented by efficient planning, quick decision making, and supervision.

“Doctors are not trained in management,” he says, “As much as it’s important for one to have medical knowledge, managerial skills are key to be able to plan and ensure policies are implemented.”

Some doctors, it appears, would agree.

Dr. Richard Idro, a pediatrician at Mulago Hospital says the challenge for health workers is that they cannot just send away dying people and that people know they will find all the expertise they need at the national referral.

“They are better off waiting in queues at Mulago with hope than not getting anything at lower facilities”, he says,” no patient will want to queue when they know they can get the same service at Kiswa or any other lower facility.”

Idro says there appears to be no alternative and the overcrowding of the new facility should communicate to healthcare managers in the country that the people do not trust that they can find care at the lower facilities.

He says Mulago should be creating conditions where patients know that if you go there without a referral note you will not access care, but he adds that “the country is ages behind in terms of implementing policies such as the referral system”.

“One needs to look at how medical records are stored” he says, “It has become worse now. People come with exercise books, we write and they take them back. We now don’t have any medical records as hospitals; so you can imagine the sort of conversation you will have if a doctor from a higher facility contacted you about a patient.”