Shock treatment for VIPs at Mulago

By Ronald Musoke

So why do some doctors there say the hospital is getting better?

At around 11 O’clock on Oct. 7, the most vivid scene that symbolises Mulago Hospital’s current pitiable state unfolded as a high profile delegation visited one of the two maternity wards on the fifth floor of this 51-year old facility.

A youthful doctor, wearing a white lab coat and unbothered by the curious eyes of the visitors, cautiously squats beside a patient lying on a thin mat on the dirty-looking plain terrazzo ward floor. The patient is a mother who had her baby the day before by a Caesarean-section operation and the doctor is checking on how she is recovering.

In her frail state, she lies on a mat covered with thin bed sheets. She was brought here straight from the operating table. Due to over-crowding in the ward, she had no alternative but to settle for the cold floor.

Lying right next to her; on another mat, on the same floor is another mother who went through the same medical procedure.

The two mothers appear weak but we are told the hospital has no alternative but to discharge them immediately.

The doctors say more mothers being delivered using the same procedure will be brought in and space is of the essence, so the idea is to give space to those who are in a more critical condition.

I am tugging along as several MPs, officials from the Ministry of Health, the World Health Organisation (WHO), and United Nations Population Fund (UNFPA), tour the ward and witness the young doctor in action.

Led by the new Minister of Health, Dr Ruhakana Rugunda, the group is at the hospital to launch a three-week National Hospital Ward Round Campaign which is intended to make policy makers appreciate what frontline health workers go through every day as they go about delivering services in Uganda’s hospitals.  It is all part of events to commemorate Uganda’s 51st Independence Day anniversary.

The focus of the nationwide ward round; the first of its kind, is on laboratory services, HIV/AIDS, Tuberculosis, Malaria, maternal/child health and non-communicable diseases.

Every inch of the ward seems to be covered by mothers;  those who are in labour and struggling to push, those who are on the waiting list for the C-Section, those who delivered naturally, and those who over the previous 24 hours were operated upon. They are all here, not too far from one another.

The VIP visitors are, therefore, surprised when the calm and youthful-looking doctor taking the group around announces that the day is quite unusual because “Mondays are normally busy”.

The doctor’s name is Yosam Nsubuga. He explains that usually on Mondays, mothers would have come in from many health facilities both from within Kampala and around the country.  His explanation leaves many in the group wondering what a really `busy’ Monday on this ward looks like.

Dr Baterana Byarugaba, its executive director says Mulago Hospital which is Uganda’s biggest referral hospital, handles about 6,000 out-patients every day in addition to 3,000 in-patients, and it delivers between 80—120 mothers every day.

“This is the greatest number a hospital can deliver anywhere in the world,” Byarugaba says, as the tone in his voice gives away his frustration, “In 2012, 35,000 mothers were delivered and 7,500 of these were by caesarean section [at Mulago].”

Byarugaba says, although Mulago is the ‘Supreme Court’ of Medicine in Uganda, the hospital can only do so much. It faces enormous challenges regarding delivery of mothers and far from being a national “referral” hospital, Mulago has since turned into a first centre of call; a reality that compounds the poor state of its services and reflects that breakdown of Uganda’s healthcare system.

The MPs and ministry technocrats have been here for just a few minutes but they can barely hide their frustration.

One of the female MPs cannot bear the high-pitched screams of a mother in labour who is just a few metres away.  She moves outside the ward. From this scene alone, you can clearly see what the hapless nurses and midwives endure on a daily basis.

The WHO’s acceptable standard ratio is one midwife for every two mothers in labour. At Mulago, one midwife handles more than twice the recommended number, Dr Byamugisha who heads the Obstetric and Gnaecology department says.

“At times it can be one midwife for up to six mothers yet the labour period is the most critical when care is most needed by the mothers.”

The hospital requires between 65-75 midwives but it has about 40 at the moment.

Although Mulago was built in 1962 when Uganda had a population of about seven million people, no new hospital of its size has been built since then although the country’s population has since shot up to about 34 million people. Instead, there have been no substantial expansion or additions to old facilities.

Unwelcome patients

Back then, each of the two maternity wards could have accommodated about eight patients on any given day, today, the same wards host four times more patients.

As we move from one maternity ward to another, Dr Christine Biryabarema, an Obstetrician tells The Independent in a soft low voice that Mulago is congested because it is working on many cases that it is not supposed to handle. She says because the hospital cannot turn away any patient, they have to help everyone who finds their way into the facility.

Then she delves into another issue that is slowly turning the facility into something else, the number of caregivers who are outstretching the meager resources of the hospital such as water, electricity and toilets.

“Sometimes they crowd all the corridors that you can’t find space to walk,” she says.

We have just gone past a group of around 100 caregivers, mostly women, although there are a few men and children. She says she suspects some homeless people have turned Mulago into a lodging facility.

Dr. Margaret Mugherera, the president of the World Medical Association says for one to understand what Uganda’s health challenges are, Mulago is the place to be but to get a good picture, this should not be a one day event.

“We need six months to understand what health workers go through,” Mugherera says, “Uganda has a health worker crisis.”

Indeed as we move from one ward to the next, Alice Alaso, the FDC Secretary General, and Woman MP for Serere District labels the exercise a public relations stint.

“This visit will not change anything because the problems in Mulago are well known; overcrowding and motivation [of health workers],” Alaso says, adding that “No amount of research or visits will change these problems.”

She asks: “After we have done the ward rounds, will it change anything?” To her, Mulago and the other hospitals around Uganda are suffering because the political will to effect the needed changes is still lacking.

She says recruitment and retention of health workers should be given more focus to reduce the attrition rates at Mulago and other facilities around Uganda.

She is frustrated that people in government keep talking about the same problems every year while expecting different results.

But Ruhakana Rugunda, the minister of Health attempts to calm Alaso down saying the government is in control and is committed to improving the situation.

He then reels off a few positives in the public health arena.

Rugunda, who is a public health specialist and pediatrician, says he has been impressed with what he has seen at Mulago, notably, the new Trauma Centre, the refurbished laboratory which was recently upgraded to Grade IV.

Mulago is now able to manufacture its own oxygen, he notes, the Cancer Institute and the renal unit are one of the very best in the region. But he also decries the shortage of midwives and congestion brought about by the caregivers.

Rugunda says Mulago’s staff numbers will be re-inforced with effect from 2014 with 400 health workers, including 350 nurses and 50 mid wives.

“Mulago must function,” he says.

Asuman Lukwago, the health ministry Permanent Secretary adds that the ministry is aware of the crisis and “with effect from January; Mulago’s staff woes will end”.

In the long term, Mulago will be remodeled and upgraded, thanks to a US$ 80 million loan from the African Development Bank and work will start in January next year. This project which was launched in January, 2012 will include a 320-bed women’s hospital aimed at decongesting Mulago.

To further reduce the congestion at the facility, the government will soon build two new hospitals in Kawempe and Makindye Divisions to add onto the one built at Naguru, in Nakawa Division.

Dr Fred Okuku from the Uganda Cancer Institute has been at Mulago for the last one decade and he has seen the worst and best of the facility.

He says what he sees today is progress at Mulago.

“It is definitely happening although at a slower pace but things are happening,” he says. But for first time visitors to the hospital, like most of the VIPs on this Ward Round, it is difficult to see the progress Dr Okuku sees.