HOIMA REGIONAL REFERRAL HOSPITAL HAS ONE MIDWIFE FOR A POPULATION OF HALF A MILLION

A nurse works on a patient lying on the floor in Hoima hospital

Hoima Regional Referral Hospital is suffering an acute shortage of medical personnel following the retirement of some staff and migration of others overseas. This hospital is the referral facility for a population of around 500,000 people living in the area.

The hospital is run by 8 doctors out of the 35 indicated in the establishment. The laboratory has one personnel at the level of a technologist. The hospital has 34 nurses out of the required 56. The X-Ray department is run by one staff.

Hoima hospital has 97 staff out of the 197 required to run the hospital leaving a gap of 107 personnel. Consequently, the hospital has been working under threat from the patients’ attendants whose anger is aroused by the death of their dear ones or neighbours in hospital due to poor quality of service delivery.

Most of the doctors have left their posts in search for greener pastures abroad, leaving only one who is the superintendent and doubles also as the only surgeon. However, this doctor has retired leaving a vacuum in the ward, which is yet to be filled, according to a source at the hospital.

According to the Ministry of Health, Hoima Hospital is supposed to have 10 consultants, but has only one obstetrician and gynecologist.

In addition, the hospital also lacks adequate operating theatres. It has only one general theatre that serving the orthopedic, dental, maternity, and surgical wards, with only one operating bed instead of three. Moreover, the hospital has been operating without a surgeon since 2009.

“There is no other option other than doing what we can and leaving what we can’t. What do we do when things are beyond our reach?” a staff lamented.

There is only one senior midwife in Maternity department. Maternity ward has 15 beds but can receive sometimes 30, making others sleep on the floor. There is one nurse in labour ward, one in maternity ward. When three mothers go into labour at the same time, there is only one midwife to attend to them.

“Sometimes a mother who is delivering calls the midwife attending to another who is in labour pain and she (the midwife) is forced to leave her to go and receive the baby,” one of the nurses said.

When contacted, the Hospital Director, Dr. Francis Mulwanyi, said: “Efficiency has reduced. We have no surgeon at all. This means that all patients with complicated cases have to be referred to Mulago National Referral Hospital.” (Dr. Mulwanyi should have said effectiveness: they are not achieving any result as far as quality of care is concerned)

He added that patients in all wards have to wait for long since there is no ward with enough staff and that the X-Ray department is run by one staff.

The deputy Resident District Commissioner, Mr Abdul-Swamadu Wantimba said he has informed the Minister In-charge of the Presidency, Ms Beatrice Wabudeya, about the situation.

DON'T GROPE AROUND: HERE ARE INTERVENTIONS THAT HAVE PROVEN IMPACT ON MATERNAL HEALTH

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Large-scale successes in reducing maternal mortality

What interventions reduce maternal deaths?

In the following analysis, find a breakdown of what interventions should be prioritized if mothers are to be saved at birth.

One illustrative case study in Millions Saved: Proven Successes in Public Health is devoted to the reduction of maternal mortality in Sri Lanka. Since 1950, Sri Lanka has reduced maternal deaths "from between 500 and 600 maternal deaths per 100,000 live births in 1950 to 60 per 100,000”. Levine (2007) attributes this decline to four major factors:

1. Universal access to a strong and functional health system.
2. Training and recruiting more midwives.
3. Strengthening the HMIS and using it to make decisions.
4. Implementing quality improvements to vulnerable groups.

Evidence on other specific interventions

Training traditional birth attendants

There is very little strong evidence that training TBAs is an effective program for reducing maternal mortality. The available evidence suggests that TBA training increases knowledge among TBAs and may reduce infant mortality, but does not have impact on maternal mortality.

There are a number of reasons why training TBAs may fail to reduce maternal mortality. These include:

1. Lack of medical services to which to refer women with major complications.
2. Barriers to learning due to lack of formal education among TBAs.
3. TBAs training are insufficient to give them skills to perform life-saving interventions.

In view of this, the World Health Organization recommends that every birth must be attended by a skilled birth attendant—a doctor, midwife, or nurse who has received formal education in the management of pregnancy and childbirth.

Skilled birth attendants

The World Health Organization advocates for expanded use of skilled birth attendants to reduce maternal mortality. Challenges to expanding the use of skilled attendants include:

1.    The inadequate supply of midwives and doctors,

2.    Lack of health facilities to which to refer complicated cases,

3.    And reluctance among women to use such services

Antenatal care

Antenatal care is comprised of a number of interventions administered to women during pregnancy, including screening tests, immunizations, and treatment for identified complications. A 2001 evaluation of the effectiveness of antenatal care in preventing maternal deaths was sparse.

The World Health Organization has suggested some reasons why antenatal care may fail to improve maternal outcomes. These reasons include:

1. Difficulty in predicting birth complications during pregnancy.
2. Lack of communication between antenatal and delivery care personnel.
3. Poor quality of antenatal services.

Community mobilization

A recent review of community-level interventions to reduce maternal mortality found one randomized controlled study that did not focus on training of traditional birth attendants or antenatal care models (see above). The study, conducted in Nepal, examined the effect of "facilitator-led women's groups to improve perinatal care practices”.

It attributed a large, statistically significant reduction of maternal mortality to this community-based intervention.

Clean delivery kits (Mama Kit)

According to the World Health Organization, 15% of maternal deaths are due to infection. Programs that provide clean delivery kits hope to reduce infections among mothers delivering at home and in health centers, as well as among their infants. Kits include such items as soap for washing of hands and vagina, clean razors and cord ties for cutting the umbilical cord, plastic sheets for creating a clean delivery surface, and a pictorial instruction sheet for directing mothers and their attendants on how to use the items in the kit.

A study in Tanzania found significant reductions in infections among women who used the kits and were taught World Health Organization recommended hygienic procedures, and an even larger reduction among their infants.

To recap, four interventions: skilled birth attendance, family planning, clean birth kits, and innovative community mobilization within a strong and functional health system are the essential for safe motherhood.

A CUT ABOVE THE REST: RESEARCHERS SHOW THAT CIRCUMCISION PREVENTS CANCER OF THE CERVIX

Women in the developing world looking for protection from cervical cancer have another reinforcement to add to their arsenal: male circumcision. The Johns Hopkins Bloomberg School of Public Health researchers have finished a multiyear study that shows the efficacy of male circumcision as a means of reducing the rate of HPV infection among women. Human papillomavirus (HPV) can cause genital warts and cervical cancer. In the developing world, where 85 percent of infections occur, the situation is dire: WHO estimates that about 33 percent of East African women are harboring HPV. Cervical cancer is the leading cause of cancer death among women in Uganda, where the study took place.

Women partnered to circumcised men have a 25 to 30 percent reduction over time in the number of HPV infections. Though encouraged by the finding, the researchers caution that couples should still practice other forms of safe sex. “Don’t think of this as a magic bullet,” she says. “It’s part of a program of protection.” In the study, 5,000 uncircumcised HIV-negative men enrolled, together with their HIV-negative female partners.

Everyone was tested for infections at the beginning, middle, and end of the study. Circumcised males had lower rates of HPV infection, likely because the procedure makes carrying the disease more difficult, says Wawer. And, as suspected, so did their female partners. The parallel effect occurred because male circumcision both reduced the number of new male infections and increased the proportion of men with HPV at the time of enrollment that subsequently cleared the virus.

“We hypothesize that the foreskin mucosa is an important site for infection,” notes Wawer. “Without this focal site, there is higher clearance at other sites along the male genital tract and less reinfection of other sites by the virus when it is no longer shed by [cells within] the foreskin mucosa.” Since fewer men were infected, fewer transmitted HPV to their partners. A bonus: Wawer says that about 40 percent of women in the study reported being more sexually satisfied after the man’s circumcision, mainly because of better hygiene.

She and her colleagues have been studying a broad range of HIV-related matters since the late 1980s in the Rakai region of Uganda, where they founded the Rakai Health Sciences Program. The researchers made headlines several years ago with a study showing that circumcision dramatically reduced men’s chances of contracting HIV from infected female partners.

CONTINUUM OF CARE: WHERE TO SAVE MOTHERS; HOW TO SAVE MOTHERS

POLITICS, POLICY, PROBLEMS AND THE TAXI OF UGANDA: WHAT CAN PUBLIC HEALTH SPECIALISTS LEARN?

Streams model

There are many different models to explain the policy process. One of them is the multiple streams model of policy-making  by J.W. Kingdon (1984). Kingdon’s model, which focuses more on the flow and timing of policy action than on its component steps, is useful in understanding the complexities and realities of policy-making. In this model, particular attention is paid to three streams: the problem stream, the policy stream, and the political stream, which move independently through the policy system.

This model explains why some issues and problems become prominent in the policy agenda and are eventually translated into concrete policies, while others never achieve that prominence. Kingdon’s starting point is the "garbage can model" of policy-making, developed in 1972 by Cohen, March, and Olsen. This model contradicts the rational approach to decision-making, claiming that policies are not the product of rational actions, because policy actors rarely evaluate many alternatives for action and because they do not compare them systematically.

Kingdon’s model underlines the existence of three distinct, but complementary, processes, or streams, in policy-making. It is the coupling of these streams that allows, at a given time and in a given context, for a particular issue to be turned into a policy (opening a “policy window”). These three streams are:

1.      The stream of problems. The rationale behind this stream is that a given situation has to be identified and explicitly formulated as a problem for it to bear the slightest chance of being transformed into a policy. A situation that is not defined as a problem, and for which alternatives are never envisaged or proposed, will never be converted into a policy. The feeling that a current or foreseen situation is wrong and that something should, and can, be done to improve it is a prerequisite for turning an issue into a policy. Moreover, it is necessary to be able to demonstrate that the problems mentioned can actually be attributed to causes within human control and thus that action can be taken to change the situation.

Take the issue of walk to work demonstration and analyze whether Dr. Besigye has defined food and fuel prices as a problem whose solution is within government control.

Can you think of how any public health problem can be turn into a “hot political potato”?

2.      The stream of policies. The second stream used to explain how an issue rises or falls on an agenda has to do with the stream of policies. This stream is concerned with the formulation of policy alternatives and proposals. New policies will never be shaped if there are no ideas or policy proposals on which they can be based and developed. An important aspect of the streams model developed by Kingdon is linked to the idea that such proposals and solutions, which must be technically feasible, are not initially built to resolve given problems; rather they float in search of problems to which they can be tied. A variety of actors can participate in the elaboration of such solutions and alternatives, and in the drafting of proposals for policy reform.

3.      The stream of politics. Although they take place independently of the other two streams, political events, such as an impending election or a change in government, can lead a given topic and policy to be included or excluded from the agenda. Indeed, the dynamic and special needs created by a political event may change the agenda. In the political stream, consensus is usually obtained as a result of bargaining rather than persuasion. The question is, “how will this benefit me?”

Thus, more attention is paid to assessing the costs and benefits of a policy proposal to the politicians and stakeholders than to underlining its technical and operational importance and relevance.

Look at the way Reproductive Health Uganda has lately strategically been advocating for family planning as economic development issue rather than a birth control issue (where the heartbeat of the president lies!). Why did they change their name from family planning Uganda to Reproductive Health Uganda?

As mentioned above, these three streams are separate and independent; problem recognition, the formulation of policy proposals, and political events each has its own dynamic and pace. As such, no stream is decisive to the overall policy process, though all streams are important. It is when they meet and coincide (thus, opening a policy window) that an issue is transformed from a mere topic and/or problem into a concrete policy, that is, a compelling problem is linked to a plausible solution that meets the test of political feasibility.

For example, supporters of a given policy reform take advantage of a political context that favours and seeks new ideas and approaches, claiming that their proposal for reform is also a solution to a previous problem. In this instance, there is a complete linkage between the three streams, which increases the chances for an issue to become a policy.

However, it is not always necessary for all three streams to meet simultaneously for a policy to develop. In some cases, partial couplings, the convergence of two of the streams, are sufficient, though the whole policy-making process is more uncertain. Kingdon argues that policy entrepreneurs play a key role in connecting the streams, and that there are different types of couplings. Couplings can be more or less ‘tight’ or “loose”, depending on the degree to which streams, though independent, depend on each other for an issue to develop into a concrete policy.

Contrary to other models, the streams model does not picture the policy-making process as one that involves steps and stages. Rather, it views the policy process as the result of the intersection of at least two independent streams at one time. In this model, there is no chronological sequence or priority among the streams. Streams act and react according to their own logic, until a window of opportunity is opened and two or more streams coincide and become a policy.

The major strength of this model is that it recognises that the policy process is fluid and non-linear, and that it involves a vast number of actors and forces. It also explains how a given issue becomes a specific policy—or not.

Major Ssebagala once, being interviewed on WBS TV said, in response to why the City Bus project failed aborted, “major stakeholders could not allow me; they run the taxi business!”

This was a major eye-opener to policy formulation in Uganda. Please react to this article.