annual report 2016
Mothers and Children First
1,000 DayS
annual report 2016
Graphic design and layout Heads Collective Publistampa Arti Grafiche Photography Cover photo Matteo de Mayda Inside photos Luigi Baldelli p.16 Nicola Berti p. 8– February 18, June 11; p. 9 – July 7, pp. 18, 20, 22, 24, 41, 52-53 Matteo de Mayda pp. 4, 10-11, 29, 31, 32, 34, 37, 38, 40, 42, 43, 62, 66 Matteo Danesin p. 9 – November 5 Davide Lanzilao pp. 8, 9 – May 7 Sara Minelli p. 9 – November 7 Images not credited are from the Doctors with Africa CUAMM archive. Editorial staff Andrea Atzori Andrea Borgato Dante Carraro Chiara Cavagna Chiara Di Benedetto Andrea Iannetti Fabio Manenti Giovanni Putoto Bettina Simoncini Jacopo Soranzo Anna Talami Samuele Zamuner Mario Zangrando Printed by Grafica Veneta Via Malcanton, 1 Trebaseleghe (PD) Printed June 2017 Supplement no. 1 to èAfrica magazine no. 3/2017 – authorization Court of Padua Prints log n. 1633 of 19.01.19999
Thanks to: Grafica Veneta for the complimentary printing of this
report
Angola Avenida Murtala Mohamed Largo do Hotel Palm Beach Rua das Casas Novas N° 9 IL 23 - Ilha do Cabo C.P. 16624 Luanda t. 00244.923351224 angola@cuamm.org Focal point: Joaquim Tomàs Ethiopia Sub city Bole Kebele 03/05 House nr. 4040 P.O. Box 12777 Addis Ababa t. 00251.116612712 t. 00251.116620360 f. 00251.116620847 ethiopia@cuamm.org Country manager: Matteo Bottecchia Mozambique Av. Patrice Lumumba 424 Bairro Central Maputo t. 00258.21302660 f. 00258.21312924 mozambico@cuamm.org Country manager: Michela Romanelli Sierra Leone 22, Wilkinson Road Freetown t. 00232.76653457 sierraleone@cuamm.org Country manager: Giovanna De Meneghi South Sudan c/o Juba Raha Hotel Juba g.gelfi@cuamm.org Country manager: Giorgia Guelfi Tanzania New Bagamoyo Road plot nr. 14 Regent Estate P.O. Box 23447 Dar Es Salaam t. 00255.222775227 f. 00255.222775928 tanzania@cuamm.org Country manager: Matteo Capuzzo Uganda Gaba Road “Kansanga” Plot nr. 3297 P.O. Box 7214 Kampala t. 00256.414.267508 t. 00256.414.267585 f. 00256.414.267543 uganda@cuamm.org Country manager: Peter Lochoro
CONTENTS
04 INTRODUCTION
32 NUTRITION
05 THE PATH “WITH” AFRICA
35 INFECTIOUS DISEASES
06 ABOUT US
38 TRAINING
08 POSTCARDS FROM 2016
40 MONITORING, EVALUATION, AND RESEARCH
10 AFRICA REPORT 12 NUMBERS, FACES, AND STORIES 14 ANGOLA 16 ETHIOPIA 18 MOZAMBIQUE 20 SIERRA LEONE
43 FOCUS ON HOSPITALS 50 HUMAN RESOURCE MANAGEMENT 52 COMMUNICATION 52 EVENTS 53 SUPPORT GROUPS
22 SOUTH SUDAN
54 EDUCATION AND AWARENESS RAISING
24 TANZANIA
55 ORGANIZATION
26 UGANDA
57 BUDGET
28 MATERNAL AND CHILD HEALTH
04
Doctors with Africa CUAMM
Annual Report 2016
THE PATH “WITH” AFRICA
Don Dante Carraro Director of Doctors with Africa CUAMM
The year 2016 was a great journey for us with many really special, important moments: Saturday, May 7, Rome, Sala Nervi, general audience with the Pope; Saturday, November 5, Padua, Teatro Geox, Annual meeting of Doctors with Africa CUAMM attended by the President of the Republic Sergio Mattarella, the Secretary of State Cardinal Pietro Parolin, and many other authorities and institutions, where we announced the results of the Mothers and Children First program and took on a new challenge: the First 1,000 Days. We are still feeling the intensity of these events, the comfortable atmosphere, the gestures and words of encouragement that spur us forward.
faces, and their smiles became unforgettable memories. They are our greatest treasure. We have been supported on our path by an assortment of friends, groups, associations, young and old people, and private companies and foundations, as well as the Episcopal Conference, Italian Cooperation, United Nations agencies, and the European Union.
Pope Francis inspired us with his powerful words, “You are doctors “with” Africa, not “for” Africa. And that is so important! You are asked to engage the people of Africa in the process of growth, taking the path together, sharing tragedies and joy, pain and enthusiasm.” We want to put into action our being “with” Africa, taking on these challenges with local churches and governments, with an approach based on reciprocal responsibility as they work alongside us in managing services and training personnel. We are proud to say that we own nothing in these lands. In the seven countries where we operate, including the 19 hospitals we support, there has never been a “CUAMM hospital.” We go to support what is already there to help it grow and leave it when it can continue on its own. We want to note that our commitment in Africa is in support of the most vulnerable groups, mothers and children, especially those who are malnourished. Too often their lives are considered the community’s “discards.” Too many young women die bringing their children into the world, and many newborns do not survive the first week or month of life. Motherhood needs to be supported, safeguarded, and protected, both through support during birth and complications that can be fatal, and through a growing number of well-trained midwives, as well as engaging and educating mothers and fathers to make them more aware of their choices. We are at the furthest outposts of the health system, the “red” zones, so-called because only red dirt roads go here. This is on the outskirts of geography and existence, and this is our life, exhausting and exhilarating. This is where we want to be; it is here where we want to do our part. In Africa, there is no need for “super-clinics” for fees, but rather “field hospitals” accessible to the poor. More than 90% of the African population suffers and dies from “diseases of poverty,” and that is what we want to defeat. This is also how we win against terrorism and insecurity; we should fear poverty more than different religions. This Annual Report details the geographical and issue priorities of our work. In 2016, we met many people and helped thousands of mothers to give birth and children to come into the world. All these human beings became part of us, and their stories, their
But we are the ones who really make the difference, each one of us, with our passion, dedication and unflagging daily work for, and with, Africa. This is the strength of what we believe in that change the world. And it really does change it! Maybe we won’t turn the world completely around, but we can effect change with what we believe and what we do! Some things have already changed in Africa and we are reporting them here. This goes beyond the attended births and children treated to include the local human resources trained — doctors, nurses, and midwives. It also includes the social, economic, and development effects that are triggered and their impact on migration and safety against extremism. In Italy, we have seen the growing involvement of many young people, groups, specialization schools and universities, with more meetings, first trips, internships, training programs, and, most importantly, awareness of health within the global dimension, where human and financial resources must be used carefully because they are inherently limited. As President Mattarella said in his speech, quoting an old African proverb: “When we dream alone it is only a dream, but when many dream together it is the beginning of a new reality.”
Sergio Mattarella, President of the Republic, and Don Dante Carraro, Director of Doctors with Africa CUAMM
05
ABOUT US www.doctorswithafrica.org/who-we-are/
mission
AREAS OF FOCUS
Doctors with Africa CUAMM was the first NGO working in the international health field to be recognized in Italy and is the largest Italian organization for the promotion and protection of health in Africa. We work with a long-term development perspective. In Italy and in Africa, we engage our human resources in training and in researching and disseminating scientific knowledge, affirming the fundamental human right to health. Learn more at doctorswithafrica.org
“The priority issues define which health issues are addressed with which actions (what)”. Strategic Plan 2016–2030 p. 21
MATERNAL AND CHILD HEALTH
STRENGTHENING HEALTH SYSTEMS
Care for mothers and children is at the heart of what we do, providing and distributing effective services in the community, peripheral health centers, and in hospitals. For instance, the “Mothers and Children First” program involved four countries (Angola, Ethiopia, Tanzania, Uganda) and ended in 2016 with results surpassing expectations. In all the countries where we work we strive to raise awareness about the importance of pre- and postnatal visits and make sure pregnant women have free access to safe, attended births in health centers and hospitals through an effective ambulance and transport system. Together, we aim for continuity and quality of care for infants and children.
Doctors with Africa CUAMM affirms that strengthening health systems is our key strategy to meet health needs and fulfill the right to health of poor groups in Africa. Strategic Plan 2016–2030 p. 16
06
Doctors with Africa CUAMM
Annual Report 2016
NUTRITION
We focus on nutrition education for both women during pregnancy and for children in the delicate early stage of their lives. We support the period of exclusive breastfeeding up to six months, and we monitor children’s growth at birth and during their early months. We also focus on fighting acute and chronic malnutrition.
INFECTIOUS DISEASES
We support local health services to raise awareness among families and communities about major diseases. We provide support and quality treatment for malaria and tuberculosis in particular — so-called diseases of poverty — which can be fatal if not treated. We implement actions to fight HIV/AIDS, for which we have treatments that are effective, but difficult to provide over patients’ entire life spans. .
TRAINING
We support several schools and universities that train qualified health workers (midwives and nurses) and universities (doctors and specialists) with teachers and training material. We also provide ongoing training working side by side with health personnel in the hospitals, health centers, and public health departments.
MONITORING, EVALUATION, AND RESEARCH
We always want to understand what impact our actions have, which is why we collect and analyze the data available and work to improve quality when needed. We also conduct full operational studies on specific aspects to guide and improve our strategy and modes of action.
WHERE WE WORK
SNAPSHOT 2016 Doctors with Africa CUAMM is currently active in 7 countries with:
19
hospitals
SIERRA LEONE
SOUTH SUDAN
3 hospitals (Lunsar, PCMH Freetown, Pujehun CMI) 59 CUAMM staff members
4 hospitals (Cueibet, Lui, Rumbek, Yirol) 1 school for midwives (Lui) 102 CUAMM staff members 1,023 human resources in “extraordinary management”
45
districts (with projects for public health, maternal and child care, combating AIDS, tuberculosis, and malaria, and training programs)
3
schools for nurses and midwives (Lui, Matany, Wolisso)
1
university (Beira)
1,628
staff members, including
421
Qualified professionals
ETHIOPIA 2 hospitals (Turmi, Wolisso) 1 school for nurses and midwives (Wolisso) 50 CUAMM staff members
UGANDA 2 hospitals (Aber, Matany) 1 school for nurses and midwives (Matany) 69 CUAMM staff members
TANZANIA 3 hospitals (Mikumi, Songambele, Tosamaganga) 58 CUAMM staff members
ANGOLA 1 hospital (Chiulo) 37 CUAMM staff members
MOZAMBIQUE 4 hospitals (Beira, Montepuez, Palma, Pemba) 1 university (Beira) 46 CUAMM staff members About us
Key
Hospitals Schools Universities
07
Postcards from 2016
February 18
May 7
June 11
February 18, Sierra Leone A project is underway to support Princess Christian Maternity Hospital in Freetown, the largest hospital in Sierra Leone qualified to manage obstetric emergencies. The project is dedicated to Don Luigi Mazzucato.
08
Doctors with Africa CUAMM
May 7, Vatican City Pope Francis’s special audience for Doctors with Africa CUAMM. The Paul VI Hall in the Vatican held more than 9,000 participants who came from throughout Italy.
Annual Report 2016
June 11, Mozambique In Beira, the first 32 new doctors have graduated from the Catholic University of Mozambique, with which CUAMM worked in training programs, and hospital and research internships by granting scholarships to students lacking financial resources.
July 7, South Sudan The world’s youngest country is celebrating five years of independence. Despite the fragile situation, CUAMM has stayed in the country to defend the right to health for all.
July 7
November 5
November 7
Davide Lanzilao
December 2
November 5, Padua Over 2,500 people took part in CUAMM’s Annual Meeting. The results of the program “Mothers and Children First” were presented along with the new challenge that CUAMM will take on for the next five years, attended by the President of the Italian Republic, Sergio Mattarella, and the Secretary of State of the Vatican, Pietro Parolin. Postcards from 2016
November 7, Vatican City Leaving no one behind. Private sector actors, NGOs, civil society, and cooperation agencies gathered in a meeting organized by CUAMM with the aim of promoting public-private partnerships and innovation on issues of maternal and child health in developing countries.
December 2, Padua Evaluation of international health cooperation projects. At the University of Padua, CUAMM organized a conference and a round table with the leading Italian NGOs about evaluating international health cooperation project.
Watch videos on Doctors with Africa CUAMM's YouTube channel to re-experience 2016's gatherings, excitement, and events: www.youtube.com/mediciconlafrica
09
AFRICA REPORT DOCTORS WITH AFRICA CUAMM’S WORK IN AFRICA IS AT THE CENTER OF WHAT WE DO. SINCE 1950, WE HAVE STROVE TO CREATE RESPECT FOR THE BASIC HUMAN RIGHT TO HEALTH AND MAKE HEALTH SERVICES AVAILABLE TO ALL, ESPECIALLY THE POOREST AND MOST MARGINALIZED GROUPS. WE DEVELOP LONG-TERM HEALTH SERVICE PROJECTS: IN HOSPITALS, IN SMALL HEALTH CENTERS, VILLAGES, AND UNIVERSITIES. CUAMM WORKS TOGETHER WITH AFRICA TO WORK, BUILD, AND GROW WITH ITS PEOPLE.
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Doctors with Africa CUAMM
Annual Report 2016
Report Africa
11
NUMBERS, FACES, AND STORIES SCOPE AND COMPARISON
Numbers can tell us many truths, but they can become too abstract without proper interpretation and contextualization. Let’s compare the statistics of some countries where we work with those of Italy. These comparisons can give us a frame of reference to help us understand what the people we help need and remind us there is a face and a story behind every number. The countries where Doctors with Africa CUAMM works are highly diverse, including in geography. Their areas range from Sierra Leone’s 72,000 km² to Angola’s 1,200,000 km². Italy has an area of 300,000 km², a quarter of that of Angola, less than half that of Mozambique; but in Italy has more than twice the population of either of these two countries. Working on the furthest outposts means moving across these vast, sparsely populated lands to support hospitals and health centers in the remotest areas and getting to villages that aid has trouble reaching. Moving personnel, medicine, and materials is often part of what makes it complex. While in some parts of Ethiopia, it takes an hour and a half to get across 100 km — not much different than in Western countries — but covering the same distance in South Sudan takes more than three hours, which becomes endless during the rainy season (which can lasts up to six months) and in the areas most affected by insecurity and instability due to factional fighting. Health numbers are the hardest to compare, and they are the statistics most recurrent in this report. The lyrics of “La Strada per l’Africa,” a performance made to address the issue of unequal health, inspired by the stories of Doctors with Africa CUAMM workers. A piece of one song: “83: life expectancy in Italy, 50: if you’re born in Sierra Leone. When we lose a friend at 50 years old, we say that he died young and his life was cut short. And that’s true. Or at least that’s true in our world. Because, in another world, dying at 50 years old is the norm. 44: the average age of the population in Italy, 16 in Uganda, 17 in Mozambique, 19 South Sudan. Imagine two cafés: one whose regulars are quiet fifty-year-olds and another with a bunch of kids. We’re getting older and older, and they’re getting younger and younger.
Leone. The pain of those 4 out of 100,000 is no different than that of those 1,360. But the numbers tell of two different worlds. In one, these are terrible, but extremely rare events, and in the other, a tragedy on a massive scale”. This report seeks to provide an account of the results achieved by the many people who work every day to strengthen the health systems of the countries where we are active. For instance, what does it mean that CUAMM made 40,027 attended births possible in Uganda in 2016? It means that CUAMM helped achieve a number of attended births very close to those in the region of Veneto, according to Italian Ministry of Health data. In Ethiopia, we made 12,718 attended births possible, roughly equivalent to those the Marche in Italy. And so forth: Mozambique is like Tuscany, South Sudan like Liguria. Similarly, we can look at Italian statistics to help us understand hospital data. The San Pietro Fatebenefratelli Hospital is one of Rome’s leading hospitals and attends about 4,400 births per year (source: CedAP). The Princess Christian Maternity Hospital is the largest maternity hospital in Freetown, Sierra Leone’s capital, and had 5,718 births in 2016. The hospital in Wolisso, Ethiopia, counted 3,687, almost the same number as that in the Gemelli Clinic, also in Rome. How many doctors are there to attend the births as well as everything else? In Italy, 1 for every 253 inhabitants; in Sierra Leone, 1 for every 41,600 inhabitants; in Angola, 1 for every 7,000; in Uganda, 1 for every 8,300; in Mozambique, 1 for every 18,100; in Tanzania, 1 for every 33,000; and in Ethiopia, 1 for every 40,000. The situation in South Sudan is so unstable that it is impossible to gather any statistics. For Doctors with Africa CUAMM, this is what it means to work at the furthest outposts with passion and tenacity to strengthen all levels of the African health system.
35 out of 1,000, the mortality rate in Italy, 157 out of a thousand in Angola. 3.5 compared to 157. The news for mothers is no better. Four mothers out of 100,000 die in childbirth in Italy, 480 out of a hundred thousand in Mozambique, 789 in South Sudan, 1,360 in Sierra
12
Doctors with Africa CUAMM
Annual Report 2016
Report Africa
AREA
AVERAGE AGE OF THE POPULATION
Angola
1,247,000 km²
Ethiopia
1,104,300 km²
Uganda
15.9
Tanzania
947,300 km²
Angola
16.3
Mozambique
799,380 km²
Mozambique
17.3
South Sudan
644,330 km²
Tanzania
17.6
Ethiopia
18.6
Italy
301,338 km²
South Sudan
Uganda Sierra Leone
241,550 km² 72,300 km²
Sierra Leone
18.9 19.3
Italy
44.3 10
0
20
30
40
50
MORTALITY OF CHILDREN UNDER 5 YEARS
MATERNAL MORTALITY Per 100,000 live births
Per 1,000 live births
Italy
Italy
4
Uganda
343
Tanzania
Ethiopia
353
Uganda
Tanzania
3,5 48 54
Ethiopia
398
59
Angola
477
Mozambique
Mozambique
480
South Sudan
South Sudan Sierra Leone
1,360 300
600
900
92
Sierra Leone
789
0
79
1,200
120
Angola
1,500
157 0
50
100
NEONATAL MORTALITY
DENSITY OF PHYSICIANS
Italy
Italy 1:253
Per 1,000 live births
200
Per 1,000 population
1
Tanzania
150
Angola 1:7,000
Uganda 1:8,300
Mozambique 1:18,100
Tanzania 1:33,000
35
Uganda
37
Ethiopia
41
Mozambique
Ethiopia 1:40,000
56
South Sudan
60
Sierra Leone
Sierra Leone 1:41,600
87
Angola
96 0
20
40
60
80
100
13
ANGOLA
SNAPSHOT 2016
www.doctorswithafrica.org/angola
CUAMM staff members
37
43
health facilities supported
¤1,216,690
invested in projects
IN 2016
OUR HISTORY
Though Angola is a middle-income country, the collapse of oil prices has had a profound social and health impact. This is evident in the worsening living conditions that helped the spread of the largest yellow fever epidemic of the last thirty years, concentrated especially in Luanda and was only eradicated through international aid. Angola is even in last place in under-five mortality rankings. CUAMM worked in Cunene, one of its most marginalized provinces, focusing on maternal and child health and nutrition. In Luanda’s most peripheral, degraded areas, CUAMM has also been involved in an important study on the correlation between tuberculosis and chronic diseases, such as diabetes and hypertension.
1997 With the country in the midst of civil war, CUAMM implemented its first emergency actions in the province of Uige.
14
Annual Report 2016
Doctors with Africa CUAMM
Country profile
2004 CUAMM supported the health system through the difficult process from emergency to development, with projects in Luanda and the provinces of Uige and Cunene. 2012 Start of the Mothers and Children First program to ensure access to safe birth and newborn care in four African countries. 2014 Start of an innovative project in Luanda to improve the diagnosis of diabetes, hypertension, and tuberculosis.
Report Africa
Luanda Capital 25 million Population 1,247,000 km² Area 16.3 years Average age of the population 51/54 years Life expectancy (m/f) 6.2 Average number of children per woman 150 out of 188 countries Human Development Index
477 per 100,000 live births Maternal mortality
156.9 per 1,000 live births Mortality of children under 5 years
96 per 1,000 live births Neonatal mortality
WHERE WE WORK
LUANDA PROVINCE 6 centers for tuberculosis diagnosis and treatment 7,246 tuberculosis patients tested for diabetes and hypertension
DEMOCRATIC REPUBLIC OF THE CONGO
CUNENE PROVINCE Luanda
Municipality of Ombadja 1 hospital Chiulo 36 health centers 306,550 population served
Atlantic Ocean
ZAMBIA Cunene
CHIULO
Municipality of Ombadja
NAMIBIA 0
150
300 km
RESULTS ACHIEVED MATERNAL AND CHILD HEALTH NUTRITION
18,965
antenatal visits
72
transfers for obstetric emergencies
3,098
attended births
14,816
visits for children under 5 years
129,945
vaccinations
279
children treated for severe acute malnutrition
Angola
INFECTIOUS DISEASES
4,660
CONTINUING TRAINING
15
160
CHRONIC DISEASES
379
1,352
patients treated for malaria
7,679
patients treated for tuberculosis
health workers trained on monitoring and screening tuberculosis patients tuberculosis patients diagnosed with diabetes
474
patients in antiretroviral treatment nurses and midwives
7
doctors
tuberculosis patients diagnosed with hypertension 15
ETHIOPIA
SNAPSHOT 2016
www.doctorswithafrica.org/ethiopia
CUAMM staff members
50 30
health facilities supported
¤2,361,179
invested in projects
In 2016
OUR HISTORY
The process of strengthening the health system involved both hospitals and actions scattered throughout the area. The project at Wolisso Hospital was especially important, where support for the nursing and midwifery school was provided to respond to the shortage of qualified workers endemic in the country. CUAMM brought its support to cross-border areas where ethnic minorities live, where there is the most pressure from migrants in transit in the country. In South Omo, we worked on maternal-child health by linking it with measures to prevent cervical cancer, HIV/ AIDS, tuberculosis, and hepatitis B. We also worked to support refugees and residents in Gambella at the borders with South Sudan.
1980 The first CUAMM doctor was sent to the Gambo leper colony.
16
Annual Report 2016
Doctors with Africa CUAMM
Country profile
1997 CUAMM signed an agreement with the Ethiopian Bishops’ Conference, leading to the construction of St. Luke’s Hospital of Wolisso with an attached school for midwives and nurses. 2012 Started the “Mothers and Children First” program to ensure access to safe birth and newborn care in four African countries. 2014 Started project in South Omo, a remote and poorly-served area, working to strengthen the health system and improve maternal and child health.
Report Africa
Addis Ababa Capital 99.4 million Population 1,104,300 km² Area 18.2 years Average age of the population 63/67 years Life expectancy (m/f) 4.6 Average number of children per woman 174th out of 188 countries Human Development Index
353 per 100,000 live births Maternal mortality
59 per 1,000 live births Mortality of children under 5 years
41.4 per 1,000 live births Neonatal mortality
WHERE WE WORK
SOUTH WEST SHOA ZONE
ERITREA YEMEN
1 hospital Wolisso St. Luke Hospital 1 school for nurses and midwives 4 districts 20 health centers 1,198,149 population served
SUDAN GIBUTI
Gulf of Aden
South West Shoa Zone
Addis Ababa
Gambella
WOLISSO
SOUTH OMO 1 hospital Turmi 3 districts 8 health centers 181,697 population served
SOUTH SUDAN
South Omo
Indian Ocean
TURMI HC SOMALIA KENYA
0
150
300 km
RESULTS ACHIEVED MATERNAL AND CHILD HEALTH NUTRITION
16,845
pre-natal visits
832
transfers for obstetric emergencies
12,718
attended births
11,337
visits for children under 5 years
10,887
vaccinations
431
children treated for severe acute malnutrition
Ethiopia
INFECTIOUS DISEASES
322
1,026
1,516
CONTINUOUS TRAINING
259
241
32
SURGERY SERVICES
3,328
patients treated for malaria community agents
patients treated for tuberculosis nurses and midwives
major surgeries, including 582 orthopedic surgeries
patients in antiretroviral treatment doctors
5,035
40
midwives graduated from the midwifery school
minor surgeries, including 178 orthopedic surgeries
239
others
2,667
physiotherapy sessions 17
MOZAMBIQUE
SNAPSHOT 2016
www.doctorswithafrica.org/mozambique
CUAMM staff members
46 12
health facilities supported
¤1,943,363
invested in projects
In 2016
OUR HISTORY
A declining economic situation slowed down this country, which had been showing some progress. The economic crisis became tied to the political crisis, which led to the return of a ruling class and a social class, causing tensions and conflict. CUAMM addressed urgent problems, including maternal mortality and surgery, in the country’s poorest provinces, such as Cabo Delgado where we created new neonatology units in the hospitals of Pemba and Montepuez. In Beira, we furthered our efforts to fight HIV/AIDS, especially among adolescents, and continued to support the neonatology unit of the Central Hospital as well as research and teaching at the Catholic University.
1978 CUAMM’s work began with health cooperation, at first in the postwar emergency period, and later in the development phase of health service.
Country profile
2002 CUAMM came to Beira, providing technical support to hospitals and health centers. 2004 Started the collaboration with the Catholic University of Mozambique in Beira. 2013 CUAMM’s support extended to the district of Palma, one of the country’s most remote areas. 2014 Started projects in the province of Cabo Delgado.
18
Doctors with Africa CUAMM
Annual Report 2016
Report Africa
Maputo Capital 27.9 million Population 799,380 km² Area 17.1 years Average age of the population 56/59 years Life expectancy (m/f) 5.6 Average number of children per woman 181st out of 188 countries Human development index
480 per 100,000 live births Maternal mortality
79 per 1,000 live births ortality of children under 5 years
56.7 per 1,000 live births Neonatal mortality
WHERE WE WORK TANZANIA PALMA Cabo Delgado
ZAMBIA
MALAWI
PEMBA
MONTEPUEZ Nampula
3 hospitals Montepuez, Palma, Pemba 2 health centers 6 districts 966,700 population served
Tete Quelimane Sofala
ZIMBABWE BEIRA
PROVINCE OF CABO DELGADO
Indian Ocean
PROVINCE OF SOFALA 1 hospital Beira Central Hospital 1 university Catholic University of Mozambique 6 health centers 462,000 population served
SOUTH AFRICA Maputo
SWAZILAND 0
150
300 km
LESOTHO RESULTS ACHIEVED MATERNAL AND CHILD HEALTH
7,132
antenatal visits
attended births
28,842
23,388
1,361
INFECTIOUS DISEASES
54,529
20,085
555
601
CONTINUOUS TRAINING
61
200
32
7
Mozambique
adolescents educated on HIV/ AIDS awareness
community agents
adolescents tested for HIV
nurses
visits for children under 5 years
adolescents with positive test results
students graduated from the University of Beira
vaccinations
children returned to treatment
teachers sent for short teaching programs
19
SIERRA LEONE
SNAPSHOT 2016
www.doctorswithafrica.org/sierra-leone
CUAMM staff members
59
80
health facilities supported
¤2,064,464
invested in projects
In 2016
OUR HISTORY
Sierra Leone is trying to recover after Ebola, which crippled the entire country and its health care system. During the epidemic, CUAMM never left and indeed achieved significant results in Pujehun, fighting the epidemic and improving maternal and child health services. This prompted the government to ask us to act in the capital city of Freedom to support the country’s main maternity ward, the only hospital for obstetric emergencies serving over a million and a half people. Our work continued at the hospital of Lunsar as well, a private facility where CUAMM, since March, has been ensuring free births, including for C-sections for all mothers.
2012 CUAMM started working in the Pujehun district of Sierra Leone.
20
Annual Report 2016
Doctors with Africa CUAMM
Country profile
2014 Sierra Leone was the hardest hit country in the worst Ebola epidemic in history. CUAMM stayed in Pujehun and ensured the presence of an expatriate staff and the continuity of essential services. 2015 Started supporting the hospital in Lunsar which had been forced to close during the epidemic.
Freetown Capital 6.5 million Population 72,300 km² Area 19 years Average age of the population 49/51 years Life expectancy (m/f) 4.83 Average number of children per woman 179th out of 188 countries Human development index
Report Africa
1,360 per 100,000 live births Maternal mortality
120.4 per 1,000 live births Mortality of children under 5 years
87.1 per 1,000 live births Neonatal mortality
WHERE WE WORK
PORT LOKO DISTRICT 1 hospital St. John of God Hospital – Lunsar 630,145 population served
GUINEA
Makeni Port Loko District
LUNSAR
PUJEHUN DISTRICT
FREETOWN
Freetown Western Area
1 hospital Pujehun CMI 77 health centers 354,776 population served
Bo
Atlantic Ocean
Bonthe
FREETOWN WESTERN AREA
Pujehun District
PUJEHUN
LIBERIA
1 hospital Princess Christian Maternity Hospital Freetown 1,540,921 population served 0
40
80 km
RESULTS ACHIEVED MATERNAL AND CHILD HEALTH
50,129
NUTRITION
337
antenatal visits
893
transfers for obstetric emergencies
attended births
20,708
1,982
5,710
14
21
31
80
visits for children under 5 years
vaccinations
children treated for severe acute malnutrition
INFECTIOUS DISEASES
2,993
CONTINUOUS TRAINING
75
Sierra Leone
patients treated for malaria
nurses
midwives
lab technicians
doctors
others
21
SOUTH SUDAN
SNAPSHOT 2016
www.doctorswithafrica.org/south-sudan
CUAMM staff members
102
1,023
government personnel managed by CUAMM
IN 2016
OUR HISTORY
South Sudan is a fragile state and one of the poorest countries in the world, where war, epidemic, and famine feed into on another. CUAMM worked to strengthen the health system and make communities more resilient and better equipped to respond to their many needs. Despite the severe crisis, CUAMM continued to provide services to the area, transportation for emergencies and support to over 80 facilities, including hospitals and peripheral centers, with a special effort to bolster treatment of acute malnutrition in 13 of these centers and in hospitals. In 2016 we also brought humanitarian aid to areas affected by instability, such as the Mundri East County, where the Lui Hospital became a safe haven for displaced people.
2006 Start of remodeling and reopening of the Yirol Hospital.
22
Annual Report 2016
Doctors with Africa CUAMM
83
health facilities supported
¤6,752,996 invested in projects
Country profile
2008 Our action extended to the Lui Hospital. 2013 Conflict in the country faced CUAMM with a severe humanitarian emergency. 2014 CUAMM provided assistance to displaced persons, opened a school for midwives in Lui and starting the project in Cueibet.
Juba Capital 12.3 million Population 644,330 km² Area 18.9 years Average age of the population 56/59 years Life expectancy (m/f) 5.2 Average number of children per woman 181st out of 188 countries Human Development Index
Report Africa
789 per 100,000 live births Maternal mortality
92.5 per 1,000 live births Mortality of children under 5 years
60.3 per 1,000 live births Neonatal mortality
WHERE WE WORK
FORMER LAKES STATE
Rumbek Centre 1 hospital Rumbek 13 health centers 222,658 population served
Cueibet 1 hospital Cueibet 170,268 population served
Rumbek North 7 health centers 62,465 population served
Rumbek East 18 health centers 178,328 population served
Wulu 11 health centers 58,435 population served Yirol West 1 hospital Yirol 10 health centers 149,110 population served
CIAD
Former Western Equatoria State Mundri East 1 hospital Lui 1 school for midwives 20 health centers 60,948 population served
SUDAN
Nyal
ETHIOPIA
Former Lakes State
CENTRAL AFRICAN REPUBLIC
CUEIBET RUMBEK Former Western Equatoria State
YIROL
LUI
DEMOCRATIC REPUBLIC OF THE CONGO
Juba
KENYA UGANDA
0
187,5
375 km
RESULTS ACHIEVED MATERNAL AND CHILD HEALTH
35,961
NUTRITION
592
antenatal visits
165
transfers for obstetric emergencies (Yirol)
10,522
attended births
214,892
visits for children under 5 years
269,914
vaccinations
children treated for severe acute malnutrition
INFECTIOUS DISEASES
184,206
40
379
CONTINUING TRAINING
72
75
20
patients treated for malaria
community agents
patients treated for tuberculosis
nurses and midwives
patients in antiretroviral treatment doctors
20
midwives in the three-year course
HUMANITARIAN 8,410 RESPONSE displaced people assisted at the Lui Hospital and in the county of Mundri East
South Sudan
23
TANZANIA
SNAPSHOT 2016
www.doctorswithafrica.org/tanzania
CUAMM staff members
58
108
health facilities supported
¤3,572,884
invested in projects
In 2016
OUR HISTORY
The Tanzanian health system is in a paradoxical situation: access to services has substantially improved, yet it fails to always ensure quality services. There is a growing gap between different parts of the country, which is why CUAMM’s action focuses primarily on the most disadvantaged regions, such as those of the north, working to provide maternal and child health services, combat HIV/AIDS (introducing “test and treat” programs) and noncommunicable diseases, such as diabetes and hypertension. Malnutrition is still a particularly great challenge, to fight it we have implemented prevention measures, promoting adequate, sustainable eating habits and providing medical responses for severe cases.
1968 Started actions to strengthen the health care system.
24
Annual Report 2016
Doctors with Africa CUAMM
Country profile
1977 CUAMM received a mandate to implement the first health cooperation program under the technical cooperation agreement between Italy and Tanzania. 1990 Hospital inaugurated in Iringa. 2012 Started the “Mothers and Children First” program to ensure access to safe birth and newborn care in four African countries. 2014 Started the project in the regions of Iringa and Njombe to treat child malnutrition.
Report Africa
Dodoma Capital 53.5 million Population 947,300 km² Area 17.6 years Average age of the population 60/64 years Life expectancy (m/f) 5.5 Average number of children per woman 151st out of 188 countries Human development index
398 per 1,000 live births Maternal mortality
48.7 per 1,000 live births Mortality of children under 5 years
35.2 per 1,000 live births Neonatal mortality
WHERE WE WORK
REGION OF SHINYANGA
REGION OF SIMIYU
REGION OF MOROGORO
2 health centers 2 districts 495,808 population served
1 hospital Songambele 12 health centers 3 districts 1,080,941 population served
1 hospital Mikumi 6 health centers 1 district (Kilosa) 438,175 population served
UGANDA RWANDA
IRINGA REGION
BURUNDI
SONGAMBELE Region of Shinyanga
1 hospital Tosamaganga 8 health centers 5 districts 687,460 population served
Dodoma
REPUBLIC OF THE CONGO
Iringa Region
TOSAMAGANGA
NJOMBE REGION
150
Indian Ocean
REGION OF RUVUMA
Region of Ruvuma
49 health centers 6 districts 702,097 population served
300 km
MIKUMI Region of Morogoro
Njombe Region
ZAMBIA
0
KENIA
Region of Simiyu
MOZAMBIQUE
28 health centers 6 districts 1,376,891 population served
MALAWI
RESULTS ACHIEVED MATERNAL AND CHILD HEALTH NUTRITION
12,833
antenatal visits
168
10,282
transfers for obstetric emergencies
attended births
7,090
visits for children under 5 years
17,178
vaccinations
1,113
children treated for severe acute malnutrition
Tanzania
INFECTIOUS DISEASES
687
288
6,404
CONTINUOUS TRAINING
1,602
128
82
patients treated for malaria
community agents trained, focused on treating severe acute malnutrition
patients treated for tuberculosis
nurses and midwives
patients in antiretroviral treatment doctors
58
local residents
25
UGANDA
SNAPSHOT 2016
www.doctorswithafrica.org/uganda
CUAMM staff members
69
155
health facilities supported
¤1,864,846
invested in projects
IN 2016
OUR HISTORY
Uganda is facing internal and external challenges. The internal ones are in the areas of the country growing at a slower, more difficult pace. CUAMM worked in the Karamoja and Oyam districts to ensure prevention, particularly of HIV/AIDS and tuberculosis, antenatal visits, and an effective transport system for emergencies and attended births. The external challenges have to do with refugees from South Sudan coming into West Nile’s already troubled situation. Here CUAMM brought support, especially increasing efforts to treat acute malnutrition and ensure safe motherhood.
1958 The first CUAMM doctor was sent to the Angal Hospital.
Country profile
1979 CUAMM received a mandate to implement the bilateral cooperation between Italy and Uganda in the health field. The first CUAMM doctors started working in the national health system. 1990s CUAMM worked on rebuilding the Aber Hospital and rehabilitating the hospitals of Maracha, Angal, Aber, and Matany. CUAMM has supported 11 hospitals over the years. 2012 Start of the Mothers and Children First program to ensure access to safe birth and newborn care in four African countries.
26
Doctors with Africa CUAMM
Annual Report 2016
Report Africa
Kampala Capital 39 million Population 241,550 km² Area 15.9 years Average age of the population 60/64 years Life expectancy (m/f) 5.9 average number of children per woman 163rd out of 188 countries Human Development Index
343 per 100,000 live births Maternal mortality
54.6 per 1,000 live births Mortality of children under 5 years
37.7 per 1,000 live births live births, neonatal mortality
WHERE WE WORK
WEST NILE REGION Arua district 3 health centers 39,060 population served
SOUTH SUDAN
KARAMOJA REGION
West Nile
OYAM DISTRICT
Karamoja
DEMOCRATIC REPUBLIC OF THE CONGO
Oyam District
MATANY
ABER
1 hospital Aber 29 health centers 388,019 population served
Kampala
KENYA
1 hospital Matany 1 school for nurses and midwives Matany 7 districts 121 health centers 1,497,485 population served
Lake Victoria
RWANDA
TANZANIA
0
80
160 km
RESULTS ACHIEVED MATERNAL AND CHILD HEALTH NUTRITION
26,796
antenatal visits
1,574
12,565
transfers for obstetric emergencies
transfers for normal births
40,027
348,446
10
114
attended births
visits for children under 5 years
10,302
children treated for severe acute malnutrition
Uganda
INFECTIOUS DISEASES
14,489
658
3,367
CONTINUING TRAINING
4,004
55
130
patients treated for malaria
community agents
patients treated for tuberculosis
nurses
patients in antiretroviral treatment midwives
lab technicians
doctors
27
MATERNAL AND CHILD HEALTH
MOTHERS AND CHILDREN FIRST Maternal and child health is a priority action area for Doctors with Africa CUAMM. In sub-Saharan Africa, too many mothers still die from treatable diseases. Distances from hospitals, facilities, and insufficient staff mix with a shortage of information to put at risk the lives of the most fragile and vulnerable groups. In 2016, the “Mothers and Children First” program came to a close after five years. In four districts of four African countries, we have acted to support the local staff so that a growing number of women could have access to safe, assisted childbirth. The hospitals involved included Chiulo (Angola), Wolisso (Ethiopia), Tosamaganga (Tanzania) and Aber (Uganda). 115 health professionals took turns ensuring quality
hospital services, staff training, awareness and education for women. The program was underpinned by actions to lower barriers to access health services. Prime among these were lowering the cost of Cesarean sections, making transfusions available and establishing a transport system to facilitate the transfer to health centers and hospitals. CUAMM worked closely with the Catholic Church, which owns the hospitals, and public authorities, which own the health centers and are first and foremost responsible for the health of their citizens to provide quality care and access for all.
Attended births IN 4 COUNTRIES/ DISTRICTS IN 2012–2016 32,763
35,000 30,000
31,063
28,725
25,000
15,000
7,072
7,636
28
8,148
2013
2012
Hospital births
20,577
14,486
13,165
10,000 5,000
22,122
20,237
20,000
23,558
22,784
Attended births in peripheral centers
Doctors with Africa CUAMM
8,279
2014
2015
9,205
2016
Total attended births
Annual Report 2016
Report Africa
RESULTS ACHIEVED We set ourselves the goal of increasing the number of attended births to reach 32,000 a year by the end of the project for a total of 125,000 attended births in five years. On November 5, 2016, with the President of the Italian Republic in attendance, as the first phase of the program coming to a close, we were at last able to report our results, which surpassed our expectations:
NEARLY 135,000 Attended births OBJECTIVES REACHED AND EXCEEDED. We are renewing and expanding our efforts for the next five years. With the “Mothers and Children First 1,000 Days” program, we plan to direct our care to mothers and children from the beginning of pregnancy up to 2 years of age, with special attention to the issue of nutrition.
OTHER DIFFICULT SETTINGS CUAMM’s action extended beyond these four countries to Mozambique, Sierra Leone, and South Sudan, in their most peripheral, disadvantaged areas, i.e. the “furthest outposts.” A program for improving newborn care has been launched in Mozambique, in the Cabo Delgado province. A new neonatal unit was built and opened in the Pemba provincial hospital, as well as in the Montepuez Hospital and Ocua Health Center. Maternity support was provided in the Palma Hospital with 1,031 attended births and 103 C-sections. In the Pujehun district of Sierra Leone, 364 C-sections for major complications were performed at the hospital. Over 700 births with complications were referred from throughout the district through an effective ambulance service that manages to reach the most remote places and navigate the difficult roads and rivers typical of the area. In South Sudan, despite the country’s problems, we continued to support hospitals in Cueibet, Lui, and Yirol to provide continuity of care and assistance. This was particularly important for Lui, where insecurity and guerrillas obstructed
Maternal and Child health
all activity and movement in the territory for several months. Comparable maternal health centers were also created in other hospitals, including: Turmi in Ethiopia, Beira in Mozambique, Lunsar in Sierra Leone, Rumbek in South Sudan, Mikumi and Songambele in Tanzania, and Matany in Uganda.
7 COUNTRIES OF OPERATION 19 HOSPITALS 126,197 Attended births 31,476 IN HOSPITALS
REBUILDING AFTER EBOLA The greatest challenge faced in 2016 was in Sierra Leone. After the impressive results that CUAMM achieved during the Ebola epidemic, the Ministry of Health requested our action to improve the quality of services to Sierra Leone’s major hospitals. Princess Christian Maternity Hospital in Freetown, the capital city, has 120 beds only in obstetrics and assisted about 6,000 births before the epidemic. CUAMM started a targeted project in March, acting on infrastructure, rehabilitating the water system and the reorganization of the spaces and workflows of some departments, such as operating rooms, and waste disposal. Our doctors’ constant presence, working side by side with the personnel and many students in training, helped reconfigure protocols for diagnosis and treatment of complications in pregnancy. As a result, maternal mortality from direct causes fell from 3.2% in the first half of year to 1.5% in the second.
29
ATTENDED BIRTHS IN DISTRICTS WHERE WE OPERATE*
* The data refers to attended births only in the districts where Doctors with Africa CUAMM operates on all three levels of the health system (community, peripheral health centers, and hospitals) for which we can calculate the coverage rate more exactly.
COUNTRY
region
DISTRICT
EXPECTED BIRTHS
ATTENDED BIRTHS IN HOSPITALS AND HEALTH CENTERS
COVERAGE IN PERCENTAGES
ANGOLA
Cunene
Ombadja
14,910
3,098
21%
ETHIOPIA
South Omo
Dassenech
2,314
1,190
51%
Male
1,420
1,361
96%
Omorate
2,560
778
30%
Goro
2,079
1,457
70%
Wolisso urban and rural
8,695
4,114
47%
Wonchi
4,237
2,653
63%
Palma
2,673
1,031
39%
Pujehun
16,934
11,851
70%
Cueibet
9,573
894
9%
Wulu
3,297
425
13%
Rumbek Center
12,483
1,790
14%
Rumbek East
9,986
2,825
28%
Rumbek North
3,529
956
27%
Yirol West
8,389
2,960
35%
Fomer Western Equatoria State
Lui
2,498
672
27%
TANZANIA
Iringa
Iringa District Council
9,198
8,566
93%
UGANDA
Karamoja
Abim
5,895
3,218
55%
Amudat
5,580
2,045
37%
Kaabong
8,405
4,676
56%
Kotido
9,370
5,471
58%
Moroto
5,260
2,209
42%
Nakapiripirit
8,315
3,657
44%
Napak
7,162
4,676
65%
Oyam
19,740
14,075
71%
86,648
46%
South West Shoa Zone
MOZAMBIQUE
Cabo Delgado
SIERRA LEONE SOUTH SUDAN
Former Lakes States
Lango
TOTALS 30
Doctors with Africa CUAMM
Annual Report 2016
Report Africa
THE CHILD IN ROOM #1 February was one of the hardest months. The newborn cots covered every square inch of space, and I found it hard to tell the new arrivals from the ones I’d treated the day before. But I remember a small premature baby in his first days of life, which weighed just over one kilo (two pounds). I never got him confused with the others. I looked for him every day in his room, Room #1, to see if he was still there, if he was still alive. He was so little it was hard for him to eat and he was fed with a feeding tube. He’d gone through an infection and many dramatic blood sugar swings. Then one morning I didn’t find him there.
Maternal and Child health
Chiara Boscardin Resident in Pediatrics at Beira, Mozambique, from Ciao Mamma Vado in Africa, TV series in 5 episodes
I looked for him, a bit worried, and asked a nurse who sent me to the “kangaroo room” where premature babies who had finally been stabilized are kept in physical contact with their mothers. He was there, happy and swallowed up in the enormous chest of his smiling mother. He grew over the following days, wrapped in his mother’s warmth, started to breastfeed and became bigger and stronger. I didn’t see him go home, but on the morning that I found his empty bed, it was a celebration for me.
31
NUTRITION
ENSURING GOOD NUTRITION
FIGHTING ACUTE MALNUTRITION
The importance of good nutrition, especially during pregnancy and early childhood, is a top priority within the Agenda 2030 for sustainable development, signed by 193 UN member states. CUAMM addresses the issue of nutrition by supporting national programs and policies, facilitating practical nutrition education for pregnant women in the communities, dispensaries, and health centers, raising awareness among mothers about the advantages of exclusive breastfeeding up to six months, and monitoring children’s growth during the early years. We also handle acute and chronic malnutrition cases, still widespread in Africa, particularly during droughts and subsequent famines. Worldwide, malnutrition contributes to 45% of all deaths of children less than five years of age (Lancet 2013) because it is a factor that aggravates and complicates all illnesses. Every health intervention, both in hospital and health centers, must address this difficult situation.
Acute malnutrition results from rapid weight loss or the inability to gain weight. It only occurs when a person has insufficient access to food, such as in cases of famine or economic difficulties. It may be moderate or severe, in which case, the child risks dying. CUAMM supports nutritional units for the intensive care of severe, acute and complicated malnutrition in several hospitals in the countries where it operates. In Karamoja, the Uganda region that includes seven districts, as well as in different regions of Tanzania, CUAMM has supported a treatment program in hospitals and health centers, addressing both severe acute and moderate malnutrition.
32
Report Africa
Doctors with Africa CUAMM
Annual Report 2016
TREATMENTS FOR ACUTE MALNUTRITION IN HOSPITALS COUNTRY
HOSPITAL
PATIENTS PATIENTS HEALING DISCHARGED RECOVERED INDEX
DECEASED PATIENTS
MORTALITY INDEX
NUMBER OF DROPOUT DROPOUTS RATE
ANGOLA
Chiulo
178
154
86.5%
16
9.0%
8
4.5%
ETHIOPIA
Wolisso
431
272
63.1%
26
6.0%
133
30.9%
sierra leone
Pujehun CMI
337
160
47.5%
31
9.2%
146
43.3%
SOUTH SUDAN
Cueibet
324
273
84.3%
8
2.5%
43
13.3%
Lui
80
21
26.3%
8
10.0%
51
63.8%
Yirol
190
135
71.1%
5
2.6%
50
26.3%
tanzania
Tosamaganga 306
229
74.8%
25
8.2%
52
17%
uganda
Matany
142
69
48.6%
9
6.3%
64
45.1%
1,988
1,313
66%
128
6.4%
547
27.5%
TOTAL TREATED INTERVENTIONS TO COMBAT ACUTE MALNUTRITION IN THE COMMUNITY REGION COUNTRY
REGION
PATIENTS PATIENTS HEALING DISCHARGED RECOVERED INDEX
DECEASED PATIENTS
MORTALITY INDEX
NUMBER OF DROPOUT DROPOUTS RATE
tanzania
Ruvuma e Simyu
848
642
75.7%
43
5.1%
163
19.2%
uganda
Karamoja
9,147
5,841
63.9%
146
1.6%
3,160
34.5%
9,995
6,483
64.8% 189
1.9%
3,323
33.2%
TOTAL TREATED
READ THE DATA The mortality index is generally below 10%, which indicates a good standard of care. The data for Lui Hospital in South Sudan reflects the area’s state of insecurity, which causes patients to reach the hospital too late or in a critical condition when it is already difficult to intervene effectively. The most Nutrition
serious problem is still the high dropout rate, tied to economic and cultural problems the families may have in staying in the hospital for the twenty or more days needed to re-establish a child’s adequate nutritional status.
33
FIGHTING CHRONIC MALNUTRITION
in tanzania Specific actions to fight chronic malnutrition are underway in Iringa and Njombe regions in Tanzania. Our accomplishments in 2016: 672 community agents involved, 32,256 educational sessions, 1,415 cases of SAM treated, 60 health professionals trained for effective antenatal and postnatal visits, and 78,392 children monitored for growth.
Chronic malnutrition means stunted growth, a low height/age ratio. It is caused by a constant shortage of food and the restricted use of potential resources, starting in the early days of a fetus’s life. It causes permanent deficits for the child in terms of physical, psychological, and intellectual growth, compromising the rest of his or her life. Though there is, unfortunately, no real treatment, CUAMM’s targeted programs include educational projects for mothers and providing supplements to pregnant women and children, which can reduce the impact and damage of stunting. One of our main actions is treating anemia in pregnancy, providing folic acid and other minerals like iodine, preventing malaria in pregnancy, supporting good nutrition for the mother, exclusive breastfeeding, and treating intestinal parasitosis in children.
THERE IS NO FOOD One of the first words I learned in the local language when I came to Ethiopia was llelem which means “There isn’t any. It’s all gone.” I hear it very often in the hospital when the medicine supplies run out or the feeding tubes for malnourished children run out or there is no more treatment milk. These months are the part of the year furthest from the last harvest, there is a scarcity of food and until the crops are sown, there will be no
34
Doctors with Africa CUAMM
Eleonora Urso Pediatrician at the Wolisso Hospital, Ethiopia
more food. And so I see people eat less and less around me and the number of children treated for malnutrition grows. When you look closely at their parents, you realize how thin they are too. In our world, when you’re out of something, you just got and buy it. Here, it’s not like that. When something is gone, you have to learn to do without it.
Annual Report 2016
Report Africa
An ambitious program was also started in 2016 in two other regions of Tanzania, Symiu, and Ruvuma; the aim is to combine actions aimed at combating chronic malnutrition with those to identify and treat acute malnutrition. 930 community agents were trained for this purpose. Starting in 2017, we plan to measure the results of nutrition education and screening will begin in an area with a population over 2 million.
INFECTIOUS DISEASES
INSIDIOUS ENEMIES
FIGHTING MALARIA
In recent years, international cooperation has helped achieve significant results in the fight against major infectious diseases, including malaria, tuberculosis and HIV/AIDS. In Africa, there are now fewer people infected, fewer deaths, and more patients in treatment. Nonetheless, much of the African population continues to suffer, disproportionately compared to other continents, from preventable premature death and disability caused mostly by major epidemic diseases. These diseases affect poor people and groups and those vulnerable to poverty, especially pregnant women, children, adolescents, and adults living in disadvantaged social conditions who have problems accessing, using, and adhering to prevention and treatment services.
In every hospital, dozens and dozens of cases of malaria are treated every day, especially in children under five years of age. In 2016 to Aber, Uganda, there was an outbreak of malaria which required the hospitalization of 4,900 patients with a mortality rate of 2.5%. South Sudan and Sierra Leone also have high incidence rates of malaria. In Yirol, 47,600 cases of malaria were treated, with 33 deaths among hospital patients; in Pujehun, 1,479 children were treated.
FIGHTING TUBERCULOSIS
TUBERCULOSIS AND DIABETES
There are slightly fewer tuberculosis patients, but diagnosis is still difficult, especially in children, even with new technology like GeneXpert, which can detect tuberculosis and possible resistance to rifampicin, indicating possible “multidrug resistance�.
DIAGNOSES IN HOSPITALS IN 2016 Wolisso
Matany
Patients diagnosed with tuberculosis
1,026
412
Patients tested with GeneXpert for MDR-TB
974
883
Patients tested with GeneXpert positive for tuberculosis
90
291
Patients who tested as rifampin-resistant (MDR)
2
11
Ethiopia
Infectious Diseases
Uganda
In Luanda, Angola, we conducted a study in several health centers that showed a greater prevalence of cases of tuberculosis in patients with diabetes. We tested the blood sugar level of all patients who had been diagnosed with tuberculosis. In 2016, 7,246 patients with tuberculosis were tested, and, of these, 379, 5.2%, were diagnosed as diabetic. This was one of our first in-depth studies on the topic of non-
infectious chronic diseases, which will be a focus over the next few years, though they are already treated in the hospitals where we work.
35
FIGHTING HIV/AIDS In 2016, we adopted a new strategy in many countries to limit the HIV/AIDS pandemic through a “test and treat” approach. Previously, patients who were infected treated only if they had T4 lymphocyte counts, our immune systems’ infection-fighting agents, below a certain number. Only pregnant women who were HIV-positive started treatment in all cases. With the test and treat approach, all infected patients start treatment, regardless of their lymphocyte count. The aim is to stop the spread of the virus by reducing the likelihood that each individual HIV-positive patient can pass on the virus.
RESULTS FROM ANTI-RETROVIRAL CLINICS THAT WE OVERSAW DIRECTLY COUNTRY
ANTIRETROVIRAL CLINICS
TESTED FOR HIV*
POSITIVE FOR HIV
% POSITIVE
NEW PATIENTS WHO TOTAL PATIENTS STARTED TREATMENT IN ART IN 2016 TREATMENT
ANGOLA
Chiulo
1,305
117
9.0%
86
474
Ethiopia
Wolisso
10,539
121
1.1%
60
1,516
MOZAMBIQUE
Beira
20,085
555
2.8%
SOUTH sudan
Lui
2,096
38
1.81%
38
76
Yirol
1,060
358
33.77%
304
379
Bugisi
20,493
818
3.99%
552
2,145
Mwamapalala **
470
22
4.68%
35
629
Ngokolo **
326
8
2.45%
8
119
Songambele **
214
20
9.35%
0
0
Tosamaganga
3,042
252
8.28%
553
3,511
Aber
23,741
755
3.2%
82
2,558
Matany
4,394
240
5.5%
113
809
87,765
3,304
3.76%
1,831
12,216
tanzania
uganda
TOTAL
Data about the total number of patients receiving antiretroviral treatment (ART) also includes patients who were waiting for treatment and started it when the test and treat approach was implemented.
36
Doctors with Africa CUAMM
Annual Report 2016
Report Africa
* Includes individuals who tested voluntarily, patients, and women during antenatal visits. ** Data refers only to the last quarter (October-December 2016).
IN MOZAMBIQUE Though these actions were part of the hospital and peripheral clinic actions, in some instances we have specific projects targeted at groups or settings with a high incidence of HIV/ AIDS. For example, our work in Mozambique and specifically in Beira is targeted at adolescents, a group particularly at risk of contracting the virus in high prevalence settings. Prevalence in Beira is estimated at 16.3%. The project involved establishing youth centers in some urban areas; dedicated clinics were organized in schools and in some health centers to encourage voluntary testing and educate young people
about safe behavior to avoid contracting the disease. In 2016, 20,085 adolescents were tested and 555 were positive. Only 278 of these started treatment. Ensuring that treatment is continued is still difficult in urban settings where patients may not come back to the center to continue treatment because they feel well and consider it unnecessary, or due to economic reasons and the resulting isolation and social problems. In 2016, awareness raising and information campaigns helped 601 children return to treatment after having stopped.
I STARTED FEELING BETTER For me, tuberculosis meant taking a lot of drugs for a long time and not improving, then starting again and still feeling sick. I ended up getting tired of it and I stopped taking them, but the cough came back, along with other problems. They made me collect a lot of samples of spit in those little bottles, “It’s for the GeneXpert,” they told me, and I didn’t understand. Then I started a new treatment. It lasted two years and there are so many pills that I can hardly Infectious Diseases
Beira
GIRLS
BOYS
Adolescents given counseling
34,595
19,925
Tested for HIV
13,175
6,910
Positive for HIV
420
135
% positive
3.2%
2.0%
Mozambique
Lino Lowakin, Treated at Matany Hospital, Uganda
remember how many...13, yeah, 13 a day...and an injection a day for the first six months, except Sundays. Tuberculosis also meant finding the doctors and nurses of the Matany Hospital who treated me and helped me with food and transportation. There were a lot of hard times, but then I started feeling better, gaining weight back... and I even started my job selling tobacco again.
37
TRAINING
THE CRITICAL ROLE OF TRAINING Training health personnel is essential for improving and strengthening the quality of care and ability to provide health services. In addition to what Doctors with Africa CUAMM accomplishes working every day alongside local personnel and local authorities, we run professional development courses, and we have supported field stays, involving some 7,573 people, including community agents, nurses, obstetricians, doctors, and paramedics.
A DRIVE TO LEARN Our work in Wolisso is a constant spur to improve, recognizing and treating tropical diseases, as well as the diseases more familiar to us; engaging with our colleagues to find best solutions; and working to transfer knowledge. Some changes in recent months have made me really happy. For example, being able to teach health officers (hospital health workers without degrees) 38
Doctors with Africa CUAMM
The focus of the training is on maternal and child health, integrated treatment of newborn and childhood diseases, treating acute and chronic malnutrition, and the information and data gathering systems. In addition, training was provided for managerial and administrative positions, starting with those in management roles in the hospitals, including Chiulo, Wolisso, Tosamaganga, Aber, Pujehun, Freetown, Yirol, Cueibet, and Lui. In Lui Hospital, because of the serious weakness of the diocesan that owns the facility and because of the situation in the country, CUAMM was asked to take complete charge of the hospital’s management. This responsibility will be shared with local figures who will later fill this management role.
Marta Lunardi, internist at St. Luke’s Hospital in Wolisso, Ethiopia
to do an ultrasound scan. Now they are able to use this low-cost diagnostic tool in ordinary and urgent situations, without requiring the presence of a doctor. Sometimes, they see things during an ultrasound that I didn’t notice, which makes for smiles and lively discussions. I see their self-esteem rise along with the drive to learn more.
Annual Report 2016
Report Africa
TRAINING WITH SHORT COURSES OR RESIDENCES COUNTRY
COMMUNITY AGENTS
NURSES
MIDWIVES
GENERAL DOCTORS
OTHERS
TOTAL BY COUNTRY
ANGOLA
82
85
75
7
0
249
Ethiopia
259
165
76
32
239
771
mozambiQUE
61
200
0
0
0
261
sierra leone
0
75
14
31
80
200
South Sudan
72
53
22
20
0
167
tanzania
1,602
113
15
82
58
1,870
uganda
4,004
32
111
14
25
4,186
Total
6,080
723
313
186
402
7,704
BY CATEGORY
PROFESSIONAL AND UNIVERSITY TRAINING In 2016, we continued our support of several schools and universities for professional and university training, graduating the following professional figures:
COUNTRY
FACILITY
NURSES GRADUATED
MIDWIVES GRADUATED
STUDENTS AT THE MIDWIFERY SCHOOL
STUDENTS AT THE NURSE SCHOOL
DOCTORS GRADUATED
Ethiopia
School for nurses and midwives in Wolisso
-
40
62
16
-
mozambiQUE
Faculty of Medicine, University of Beira
-
-
-
-
32
South Sudan
Nursing school in Lui
-
-
20
-
-
uganda
School for nurses and midwives in Matany
23
19
54
55
-
23
59
136
71
32
Total
BY CATEGORY Training
39
MONITORING, EVALUATION, AND RESEARCH
MONITORING OUR PROJECTS, MEASURING OUR SYSTEMS
CONFERENCE Evaluation of international health cooperation projects.
For international cooperation to be a truly significant tool for change, programs and projects must be managed scientifically and transparently to ensure that benefits reach those who need them. Data, scientific evidence, impact measurements, tools, and methods are needed to evaluate the work done. This is why CUAMM’s monitoring and assessment go beyond those required for individual projects. The impact we want to measure is about strengthening health systems and not just individual project indicators, though necessary to provide donors with transparency and accountability. That is why the hospitals we support are evaluated for their overall performance and why we spend a section focusing on each one. This is also true for public health. Whenever possible, the districts and areas of intervention are evaluated in terms of overall impact.
40
Doctors with Africa CUAMM
Annual Report 2016
Cooperation must be closely linked to evaluation. This was the focus of the conference organized by Doctors with Africa CUAMM with the Global Health Center of the Region of Tuscany, held on December 2 at the University of Padua. The European Commission, the Ministry of Foreign Affairs, and the Italian Cooperation Agency participated as
Report Africa
experts in the field evaluating health and cooperation projects. Representatives of major Italian NGOs met at a round table for discussion. This was the second occasion of the event, which we plan to make annual. The goal is to spread a full-fledged “culture of evaluation” to build increasingly effective interventions for high quality cooperation.
OPERATIONAL RESEARCH IN THE FIELD Within Doctors with Africa CUAMM’s diverse areas of intervention, both geographically and by issue, we perform operational research with different methods and focuses to expand our knowledge, the quality and effectiveness of our services. In 2016, CUAMM had 19 publications in international scientific journals, four posters and four oral presentations in four Italian and international conferences, and one conference on evaluation and monitoring organized in Padua. These numbers show the progress we made this year in terms our scientific production and presence. Our relationships with our research partners are further evidence of this growth; in 2016, we started collaborations in international cooperation with academic centers such as the Karolinska Institutet in Stockholm, and the University of Bergen in Norway. We simultaneously strengthened our existing relationships, such as with the University of Padua – five studies were published that we had done jointly the university’s Department for Women and Child Health; with the University of Bari, with five joint publications; and with the Bruno Kessler Foundation in Trento. We are particularly proud that our work with the Kessler Foundation has forged a positive cycle, pairing this center of excellence in computational epidemiology with our NGO and its field-based operational approach. We did two joint studies with an interdisciplinary approach in 2016, both on Ebola. The research underpinning one of these won the prestigious Aspen Award 2016 for its scientific quality and its practical application to a major health and social problem.
2016 RESULTS 5
main issue areas
19
studies published
8
posters and presentations at international congresses
30
Italian, African, and international partners working together to build quality healthcare
Issue areas:
MATERNAL AND CHILD HEALTH INFECTIOUS DISEASES
UNIVERSAL HEALTH COVERAGE AND EQUITY NUTRITION
CHRONIC DISEASES
Every year, Doctors with Africa CUAMM brings together in a single publication scientific articles, abstracts, and posters that it has presented at international congresses. The collections can be downloaded free of cost at www.doctorswithafrica.org.
41
42
Doctors with Africa CUAMM
Annual Report 2016
Report Africa
FOCUS ON THE HOSPITALS
2016 SNAPSHOT 19
hospitals managed by Doctors with Africa CUAMM
1
Angola
2
Ethiopia In 2016, Doctors with Africa CUAMM was involved in managing 19 hospitals: one in Angola, two in Ethiopia, four in Mozambique, three in Sierra Leone, four in South Sudan, three in Tanzania, and two in Uganda. As is true throughout Africa, hospitals are the main facilities providing healthcare in these countries, especially complex services like surgery. This means it is important for CUAMM to evaluate our work as we see access to care as a basic right of every human being, especially important for the poorest parts of a population. We can measure the volume of health services provided by a hospital using an aggregate indicator called Standard Unit for Output (SUO), which takes as the unit of measurement a visit to an outpatient clinic and provides a relative weight in terms of cost for other major hospital services (admissions, births, vaccinations, and pre- and post-natal visits).
Focus on the Hospitals
The use of this indicator allows hospital managers and boards of directors to plan rationally, make evidence-based decisions aligned with the institution’s mission, and explain choices with successful or unsuccessful results. We can use this measurement system as the basis for four indicators:
- PRODUCTIVITY
To measure the total volume of a hospital’s activity;
- EQUITY
To evaluate if services are accessible to everyone, especially to the most vulnerable groups;
- STAFF EFFICIENCY
To evaluate the management of human resources;
4
Mozambique
3
Sierra Leone
4
South Sudan
3
Tanzania
2
Uganda
The formula for calculating the SUO shows the relative significance of a hospital’s different services: SUO-op = (15xadmissions) + (1x outpatient visits) + (5xbirths) + (0.2xvaccinations) + (0.5xpre-postnatal visits)
- MANAGEMENT EFFICIENCY To evaluate financial resource optimization.
43
PRODUCTIVITY Overall performance is evaluated by averaging the results of the eight hospitals, which are the only ones for which continuous data are available for the last five years. The trend is towards progressive improvement, though there was an insignificant drop in 2015 (-1.4%). In 2015, activity at South Sudan’s hospitals decreased due to extreme insecurity in the country, as well as in Chiulo Hospital (Angola) because of the drop in oil prices and resulting economic crisis. There was significant growth in 2016 (+9.9%), mainly from the increase in pediatric admissions in Aber (Uganda), where a major malaria epidemic doubled admissions, and in Wolisso (Ethiopia) due to a measles epidemic.
The Yirol Hospital (South Sudan) also showed a significant increase in 2016 after a slight reduction in 2016, possibly due to the relative stabilization of security in the area. The total volume of activity is different for each hospital and does not correspond to the number of beds, though there was a general growth trend in six of the eight hospitals monitored. A slight drop was seen in the hospitals of Matany (Uganda) and Mikumi (Tanzania). In Uganda, the drop can be explained by more activity in the peripheral units reduced admissions for less complicated cases and those treated sooner. At the Mikumi Hospital, the drop is probably due to excessively high user fees that discourage access. Overall performance is evaluated by averaging the results of the eight.
TOTAL AVERAGE VOLUME (SUO) IN 8 HOSPITALS
Average
200,000
191,225
190,000 180,000
174,529
176,519
168,380
170,000
174,144
160,000 150,000 140,000 2012
2013
EQUITY The cost of the service charged to patients is calculated based on the ratio of revenues from the users and the total cost. It has been essentially stable in the last five years, never going above 30%, and benefited from the relative cost stabilization in the last two years. The Mikumi Hospital has the largest percentage (58%). Doctors with Africa CUAMM is moving forward within its complex relationship with the hospital’s management. Increased costs for services paid the patients often do not seem justified and discourage access to those who cannot afford it.
2014
2015
2016
The average for the hospitals for which we have continuous data for all the years — Aber, Matany, Mikumi, Tosamaganga, and Wolisso — seemed to settle around 31% in 2016. It should be noted that the rise in costs paid by patients is to the detriment of equity and is caused by growing, widespread difficulty in procuring financial resources to fund hospitals, both in these countries and internationally. There is also pressure from the diocesan hospitals, such as in Aber and Wolisso, to become “independent” from donor resources, though underestimating the serious risk of reducing access to the poorest groups with the least ability to afford the service costs.
% OF THE SERVICE COST PAID BY PATIENT
Average
30%
25%
25%
25%
28%
27%
22%
20% 15% 10% 5% 0% 2012 44
Doctors with Africa CUAMM
2013 Annual Report 2016
2014 Report Africa
2015
2016
STAFF EFFICIENCY In terms of staff efficiency (the ratio between the total SUO and qualified staff), we saw a noticeable drop in 2015 due to the reduced volume of activity at the Yirol Hospital (South Sudan). A considerable recovery was seen in 2016 with a 5% rise due to a widespread increase in admissions. The epidemics in Ethiopia and Uganda were handled without new staff, which led to an increase in relative efficiency.
UNITS DISPENSED BY ONE HEALTH WORKER Average
4,000 3,500
3,195
3,390
3,575 2,762
3,000
2,908
2,500 2,000 1,500 1,000 500 0 2012
2013
MANAGEMENT EFFICIENCY As for the service cost per SUO (ratio between total cost and total SUO), we see a growth trend starting in 2012. This trend was affected by the rise in prices caused by the international economic crisis and resulting adjustment of labor cost, rising in all countries. Though there was a slight drop in 2015, in six hospitals, the service cost per SUO rose by 7% in 2016 over the previous year. This is a sign that costs are continuing to rise despite the increase in activity. However, this is an average statistic that pertains to different countries, meaning that they have both different
2014
2015
2016
production costs and different inflation rates, with a variable local currency exchange rate to the euro. As such, these statistics cannot be considered comprehensive and should be taken with caution.
COST PER UNIT PROVIDED BY THE SERVICE
Average
5€
4.4 €
4.5 €
3.8 €
4€ 3.5 €
4.5 € 4.2 €
3.5 €
3€ 2.5 € 2€ 2012
Focus on the Hospitals
2013
2014
2015
2016
45
QUALITY OF HOSPITAL SERVICES In limited resource settings, such as in the parts of subSaharan Africa where Doctors with Africa CUAMM works, hospital performance needs to be monitored in terms of accessibility, equity, and efficiency, as well as to evaluate the quality of services for the people; providing low cost services is not enough in itself as they may be of inadequate quality. Though it is difficult to measure a hospital’s performance in general — and it is even harder to measure the quality of its services — we introduced some indicators in 2012 to evaluate the quality of obstetric assistance.
RATE OF STILLBIRTHS PER 1,000 LIVE BIRTHS This indicator pertains to the specific way that the birth is managed during labor and expulsion. The statistic helps define how correctly and timely services were delivered and do not consider stillbirths that were already certain before labor. In 2016, there was a general reduction in the average number, due primarily to the results of the two most recent hospitals where we work, Lunsar and Palma, which are also the hospitals that had
caused the rise in the rate the year before. This result, however, is uncertain because of the difficulty in collecting reliable data. It could be due to CUAMM’s support in improving quality. On the other hand, cases like Princess Christian Maternity Hospital in Sierra Leone could be emblematic. The hospital in Freetown has the highest rate, with 50 stillbirths for every 1,000 live births. CUAMM started working here only in May. The explanation for this seemingly high rate could be due to inaccurate or incomplete recordkeeping, especially in the months before we were involved.
Maximum
80
Minimum
79
70 60
59
60
50
46
40
51
30 20
19.6
18.3
14.7
20.3 10.2
10 0
5 2012
46
Doctors with Africa CUAMM
3 2013
Annual Report 2016
4 2014
Report Africa
3.5 2015
1 2016
Average
RATE OF CESAREAN SECTIONS OUT OF TOTAL BIRTHS The Cesarean section rate can vary a great deal between hospitals and depends on numerous factors. For example, women in different countries may differ in their body shapes and may need Cesareans more or less frequently as a result. If the hospital is the only place to go for complicated cases, there tends to be a higher concentration of complicated births and, therefore, more Cesareans, depending on the efficiency of the referral system. In different settings, surgeons and gynecologists may have different habits regarding Cesareans. However, within each hospital, we can see considerable stability over the years, with the exception
of Pujehun (Sierra Leone), where the rate grew considerably. The explanation for this is the major work done on the referral system which means a growing number of complicated cases are brought to the hospital and that may, therefore, need Cesarean sections. The PCMH, also in Sierra Leone, has a fairly high rate as well, but it is a referral hospital for the Western Area of ​​Freetown and serves over a million and a half people, thus increasing the likelihood of handling complicated cases. At Lunsar, the rate is high because of the low number of total births. The percentage of Cesareans is higher because, unfortunately, those who come most often to the hospital are the few complicated cases that manage to overcome the many barriers to access (even though lowered by exemption from paying hospital fees).
Maximum
Minimum
Average
50% 40%
38%
43%
30% 20%
40%
39%
34%
18%
19%
18%
20%
6%
5%
3%
3%
16%
10% 0
2012
2013
RATE OF MATERNAL DEATHS DUE TO MAJOR OBSTETRIC COMPLICATION OUT OF THE TOTAL NUMBER OF MAJOR OBSTETRIC COMPLICATIONS WHO suggests a rate below 1% as the target for good care of obstetrical complications. In the hospitals listed, the data do not necessarily represent a poor quality of care; the numbers are in all probability overestimated because of the inadequacy of the information system that fails to accurately track all major obstetric complications treated. Frequent changes to recordkeeping criteria have to do with the change between different doctors, who do not give continuity or uniformity in applying diagnosis criteria. The exact definition of diagnostic criteria requires more study to achieve consistent, comparable data. Generally, despite the worsening of some 2016 data, most of the hospitals in the last five years had an improvement trend.
Focus on the Hospitals
2014
4%
2015
2016
HOSPITALS
2015
2016
Aber
0.4%
1.2%
Beira
2%
2%
Chiulo
1.6%
2.4%
Cueibet
2.9%
1.4%
Lui
4.0%
2.0%
Lunsar
1.7%
4.7%
Matany
0.9%
0.4%
Mikumi
1.5%
1.9%
Palma
3.0%
3.8%
Pujehun
0.9%
1.3%
Tosamaganga
0.2%
0.3%
Turmi
n.a.
n.a.
Wolisso
0.8%
0.1%
Yirol
0.4%
1.6%
47
HOSPITAL DATA * 2016
COUNTRY
HOSPITAL
BEDS
OUTPATIENT VISITS
ADMISSIONS ANTENATAL VISITS
BIRTHS
CESAREAN SECTIONS
VACCINATIONS
ANGOLA
Chiulo
234
18,531
5,094
4,629
1,365
132
18,529
EThIOPIA
Turmi
20
13,127
174
2,763
564
4
5,345
Wolisso
200
78,716
14,742
8,244
3,687
562
5,552
Beira
644
205,153
26,855
8,483
6,848
2,543
14,802
Palma
64
61,971
2,872
7,192
1,031
103
1,361
Lunsar SJOG
100
14,474
3,932
2,004
524
204
5,767
Freetown PCMH
129
12,481
8,549
14,334
5,718
1,692
0
Pujehun CMI
50
2,625
3,784
1,692
939
364
5,710
Cueibet
55
31,721
4,096
3,394
894
40
6,391
Lui
98
28,210
4,594
2,000
426
79
6,866
Yirol
103
62,013
12,458
9,669
1,375
50
18,182
Mikumi
97
16,692
7,496
3,998
2,098
375
8,880
Tosamaganga
165
25,850
6,931
1,661
2,708
1,013
8,298
Aber
181
39,190
14,110
7,097
2,181
448
32,988
Matany
250
24,005
8,665
3,707
1,118
252
50,462
MOZAMBIque
SIERRA LEONE
South SUDAN
TANZANIA
UGANDA
TOTAL
48
2,390 634,759
Doctors with Africa CUAMM
Annual Report 2016
124,352 80,867 31,476 7,861
Report Africa
189,133
*Hospitals not in the table are those for which it was impossible to provide meaningful data because our activity started at the end of the year.
STILLBIRTHS/ LIVE BIRTHS
RATE OF CESAREANS
DEATHS FROM DIRECT OBSTETRIC CAUSES
INCOME FROM USER FEES
TOTAL INCOME BY RECURRENT EXPENSES
RECURRENT EXPENSES
TOTAL STAFF
QUALIFIED STAFF
8
8%
2.4%
79,850
970,603
1,089,331
187
112
23
0.7%
31
25
2.4
15%
353
228
1
37%
1,570
994
7
10%
3.8%
115
65
11.7
36.8%
4.7%
118
84
51
30%
2.4%
351
276
4
39%
1.3%
34
28
2.4
4.5%
1.4%
653,000
92
27
2.3
19%
2%
433,000
108
36
6
4%
1.6%
-
907,000
110
27
19.6
19%
1.9%
308,761
526,564
534,279
107
59
6.6
36%
0.3%
250,890
1,060,441
1,003,903
165
109
5
22%
1.2%
252,353
727,481
1,198,726
168
114
3
23%
0.4%
100,486
759,106
647,422
208
81
3,717
2,265
Focus on the Hospitals
0.1%
619,842
1,786,379
-
1,621,760
49
HUMAN RESOURCE MANAGEMENT HUMAN RESOURCES IN AFRICA
SUPPORTING THE HEALTH CARE SYSTEM IN SOUTH SUDAN
Countries undergoing rapid change in increasingly complex political, religious, cultural contexts — this is the Africa where the staff of Doctors with Africa CUAMM works at many levels. CUAMM recruits and selects human resources to fill the positions needed for our own projects:
South Sudan is still very fragile and cannot manage and support its health services. Doctors with Africa CUAMM was, therefore, chosen as the organization to support the country’s health care system in eight counties and four hospitals, contributing directly to their management and the salaries of the personnel of peripheral health facilities and hospitals. We will continue with this “extraordinary management” until the government has the ability and resources to manage the staff of its health facilities itself.
- international Europeans - international Africans, from countries neighboring those where we operate; - nationals, from the country of operation. In 2016, in the seven countries where we are active, we managed 1,628 human resources, and 1,023 of these were under “extraordinary management” in South Sudan (see details). Out of the 605 human resources involved in projects, 421 are qualified professionals (not just health care, but also administrative, logistics and Community experts), and 184 support staff, such as drivers and guards.
ACTIVE STAFF IN 2016
605 human resources involved in projects:
421
qualified professionals, including
1,628
158
national Africans
human resources
45
international Africans
218
1,023 human
international Europeans
resources under “extraordinary management” in South Sudan
50
Doctors with Africa CUAMM
184
support staff
Annual Report 2016
Report Africa
STAFF PROFILE
JUNIOR PROJECT OFFICER (JPO)
It is significant that 145 doctors out of 165 (88%) are international Europeans, and 55 out of 91 non-medical staff (60%) is African nationals. These numbers show that Doctors with Africa CUAMM gives priority to investing in national staff in terms of capacity building while sending international staff to fill positions for which the African country still lacks available national professionals.
The Junior Project Officer (JPO) initiative is in its fifteenth year. The initiative gives medical residents an opportunity for theoretical and practical training in Africa, supported by a medical specialist who serves as a mentor. In its fifteen years, 120 residents have come from universities throughout Italy; 15 went in 2016 alone. Many completed their specialization theses in the field by contributing to CUAMM’s operational research. Though the most structured, the JPO initiative is not the only example of in-the-field training for young people who would like to work in international cooperation in the future. In 2016, we sent another fifteen young people who joined our professionals in the field for a shorter training period. To find out more about opportunities for young people, see the “Education and Awareness Raising” section on p. 59 and visit our web site www.mediciconlafrica.org.
RECRUITMENT, SELECTION AND TRAINING The staff involved must demonstrate solid professional training and motivation, essential for honing skills of analysis, research, knowledge, planning, and organization. In 2016, we gave 385 interviews in Italy with European international staff to fill 140 positions. After being selected, the aid workers receive information and specific documents to prepare them for the job and the setting. They are then sent to CUAMM’s offices (European internationals in Italy, and international and national Africans, on site) to complete their training. Throughout the year, 65 pre-departure training days were organized in Italy and 151 international European professionals went to Africa, joining the human resources already active in the field.
THE ORTHOPEDIC GROUP The orthopedic group, founded in 2002, joins professional specialists (orthopedists, physiotherapists, and nurses) who support ongoing projects with fundraising, technical support, and consulting. In 2016, the group completed three supervisory missions to the Wolisso Hospital in Ethiopia, where 582 major orthopedic surgeries and 178 minor surgeries were done. The group also helped procure orthopedic materials. Luigi Conforti is the group’s president.
PROFESSIONAL PROFILES AND ORIGINS OF SKILLED PERSONNEL 150
145
125
38%
100
52%
75 55
50
45 35
Human Resource Management
9
10 0
8
0
Country representatives
5
Logistic specialists
4
Administrators
Doctors
0
23 11
Other
23 9 11
10%
27
Non-doctor health workers
25
1 International European staff
International African staff National staff
51
COMMUNICATION
In 2016, we continued our work to raise CUAMM’s visibility in Italy and Africa through print and digital publications, involving spokespeople, producing videos, materials, and receiving ample press coverage. Out of the more than 2,300 works of journalism in print and digital formats, of special note were the reports “”Our Africa in Italy” about the “ghettos” of migrants in Puglia, which was published in La Repubblica, by Paolo Rumiz; “Us, After Ebola: Life Comes Back” by Pietro del Re, also in La Repubblica. In terms of publications, we continue to inform and engage with our bimonthly èAfrica and with Health and Development, published in Italian and English, focusing on issues of cooperation and international health policy. For the special audience with Pope Francis, we published “A Beret, Africa and the Joy of Giving,” written by the journalist Gian Antonio Stella in memory of Don Luigi Mazzucato.
Online communication is gaining an increasingly important role because it lets us give regular updates about what we are doing in Africa and Italy and involves the many people who follow us, including through social networks where engagements are growing every month. Our website www.doctorswithafrica.org is available in three languages (English, Italian, and Portuguese). Weekly and monthly newsletters are sent to 21,000 subscribers, the blog Postcards from Africa (blog.iodonna.it/volontari-africa /) is put out in collaboration with the weekly magazine “Io Donna” from the Corriere della Sera, bringing together the accounts of CUAMM workers in Africa. Our historical archive has continued to safeguard the material we have and collected in our over 66 years. Especially noteworthy in 2016, a study was completed about the professor Anacleto Dal Lago, the first CUAMM doctor who went to Africa and a pioneer of cooperation in Italy.
EVENTS SPECIAL PROJECTS IN ITALY
Two extraordinary events marked 2016: On May 7, CUAMM had a special audience with Pope Francis; on November 5, we held our Annual Meeting in Padua, where we presented the results of the “Mothers and Children First” program, with the attendance of the Italian President of the Republic, Sergio Mattarella, and Secretary of State of the Vatican, Cardinal Pietro Parolin. These moments were opportunities to involve many of the friends and supporters who follow the CUAMM and further our reputation among new supporters. The overall number of supporters has not changed much since 2015, but these new relationships will be strengthened in coming years. In addition to these two major events, our work throughout Italy continued, up from 280 events in 2015 to 293 events in 2016.
52
Doctors with Africa CUAMM
Annual Report 2016
CUAMM has focused its attention in Italy too in order to support vulnerable groups. The Doctors with Africa CUAMM Bari group launched a "Mobile Clinics for Farm Workers" project to give medical support to the "Ghana Ghetto" in the province of Foggia. About 1,000 people were treated in the first year.
Report Italy
In September, Io Donna and Morellato launched the #IoNascoConTe campaign to support "Mothers and Children First" program, raising €13,865. An additional sum of an equal amount was donated in support of the victims of the earthquake that struck Central Italy. This enabled us to build a clinic in the town of Arquata del Tronto (AP).
SUPPORT GROUPS
Trento Asiago
Lecco Varese Biella
Conegliano Bassano del Grappa
Bergamo
Vicenza Verona Padova Cremona
Milano
Reggio Emilia
Trieste
Campagna Lupia
Ferrara Modena
Firenze
Ancona
Siena
Doctors with Africa CUAMM’s support groups are made up of friends who choose to combine their energy and enthusiasm to make the voice of Africa heard throughout Italy. Among their many activities, there is a particular commitment to supporting the organization’s awareness raising initiatives and taking part in fundraising to support specific projects. CUAMM can now count on 2,354 active volunteers who are a key resource to support our work. In 2016, a new group was formed, Doctors with Africa CUAMM Bergamo, joining the others throughout Italy for a total of 26 support groups. In October the first weekend of group participant training brought together 52 people from 22 groups.
Chieti
Roma Bari Potenza
Torre Santa Susanna
Cagliari
Palermo
53
EDUCATION AND AWARENESS RAISING
We work for the right to health through education and awareness raising. We believe that engaging young people, doctors and health professionals in development and cooperation issues can help create a fairer world and the more responsible exercise of the medical profession. CUAMM organizes a residential training course every year for this purpose in its Padua offices to introduce young people to health cooperation. The 110-hour course is for residents and doctors from throughout Italy who want to learn more about health issues in developing countries — public health, infectious diseases, gynecology, and pediatrics — and possibly prepare to go to those countries. We also work with a network of Italian universities and with the FNOMCeO (National Federation of Physicians, Surgeons and Dentists) to offer workshops, courses and conferences on issues of global health and health cooperation. In 2016, courses offered by the Orders of Doctors and Hospitals were attended by approximately 250 health professionals, and 13 courses were organized about international health cooperation in Italian universities. We also offer students
Varese Milano
Brescia
Pavia Torino
SISM: STUDENTS SINCE 2006 248
Udine
Monza Novara
and residents training in the field in Africa. Working with SISM – Italian Secretariat of Medical Students, we offer four students a month a chance to spend a period of training in Ethiopia or in Tanzania to give them an early experience in international health cooperation. For residents, since 2002, CUAMM has a Junior Project Officer (JPO) program. In accordance with CRUI – Conference of Deans of Italian Universities, we offer a period of field training lasting 6-12 months that is recognized by the home university as part of the educational program. By the end of 2016, 248 students from all over Italy had gone to the field, as well as 120 residents from 22 universities. During the year, the Senior Medical Officer (SMO) project took its first steps. The program is for “senior” health professionals who want to learn firsthand about CUAMM is Africa and Italy’s actions and approach, finding routes to be of service and help. In April, an introduction day took place involving 60 health professionals. Some also took the training course before fieldwork, in September in advance of the first mission that will start in 2017.
Verona
Trieste
Padova
Parma
students have gone to the field so far:
Ferrara
Modena
Bologna
Genova Pisa
66
Firenze Ancona
Siena
to Tosamaganga, Tanzania
Perugia Chieti
182
Roma Campobasso Napoli
Sassari
to Wolisso, Ethiopia
Foggia Bari
JPO: INTERNS SINCE 2006 120
interns have gone to the field so far:
37
in pediatrics
12
in gynecology
20
in internal medicine
Salerno
26
in public health
18
Catanzaro
Palermo
in surgery
Messina
7
Catania
in infectious diseases Medical students SISM (Italian Secretariat for Medical Students) offices from where they leave for Africa with CUAMM
54
Doctors with Africa CUAMM
Interns Universities from where they leave for Africa with CUAMM
Annual Report 2016
Report Italy
ORGANIZATION
Doctors with Africa CUAMM is legally part of the “Opera San Francesco Saverio” foundation. Though it is a single foundation, it consists of three branches of activity:
- FOUNDATION - DOCTORS WITH AFRICA CUAMM NGO-NPO - UNIVERSITY COLLEGE The Foundation is governed by a Board of Directors. The Director of Doctors with Africa CUAMM NGO-NPO is responsible for the organization and management of all activities. He or she is appointed by the Board of Directors with a three-year, renewable term. Country Representatives are the legal representatives in the country where they operate and have local programming and management functions. The coordinating committee for the solidarity groups consists of five members, elected by the internal chairperson of the groups, with the task of coordinating the activities of groups and connecting them with those of the head office. The assembly consists of active members and aims to contribute to defining strategic guidelines, operational plans and initiatives, and formulating instructions and proposals.
STAFF IN 2016 50
employees
16
32%
68%
men
34
women
AGE GROUPS 12%
Sotto 30 i 30years anni Under
26%
30 - 35years anni 30–35 36–40 36 - 40years anni
18%
41–45 41 - 45years anni
18% 26%
Over years Oltre46 i 46 anni
0
3
6
9
12
15
YEARS OF SERVICE 42%
Less than years Meno di 55anni
20%
5 to 10 anni years e 10
24%
11 to 15 anni years 11 e 15
14%
Moredithan 15 years Più 15 anni
0
Education and awareness raising
5
10
15
20
25
55
Organizational plan Angola Country Representative
Board of Directors
Ethiopia Country Representative Mozambique Country Representative Director
University College
Coordination in Africa
Sierra Leone Country Representative South Sudan Country Representative Tanzania Country Representative Uganda Country Representative
Secretary to the Director
Management, Finance and Control
Planning
Administration Department
Project Department
General Secretary
International Relations
Communication and Fundraising
Monitoring and Evaluation
Human Resources Department
Community Relations and Fundraising Department
Communication Department
Angola Desk
Secretary
North-East Area
Publications and Materials
Information Technology
Ethiopia and Uganda Desk
Training
North-West Area
Media Relations
Staff Management
Mozambique Desk
Selection and Management
Center-South Area
Web, Visibility and New Media
Project Management
Sierra Leone Desk
Accounting
South Sudan Desk
Education and Public Awareness Department
Events
Tanzania Desk
Assembly of Active Members
56
Doctors with Africa CUAMM
Annual Report 2016
Report Italy
Group Committee
BUDGET 2016 Report by independent auditors on financial statements
Tel: +39 049 7800999 Fax: +39 049 8077936 www.bdo.it
Piazza Zanellato, 5 35131 Padova
INDEPENDENT AUDITORS’REPORT
To the Chairman of the Board of Fondazione “Opera San Francesco Saverio” – C.U.A.M.M.
Report of the financial statements We have audited the accompanying financial statements of Foundation “Opera San Francesco Saverio” – C.U.A.M.M., which comprise the balance sheet as of December 31, 2016, the statement of income and related explanatory notes. Such Financial Statements, although not specifically required by law, has been prepared in accordance with the Italian Civil Code, except for non disclosing the cash flow statement. Directors’responsibility for the financial statements The directors are responsible for the preparation of financial statements that give a true and fair view in compliance with Italian accounting Standards. Auditors’ responsibility Our responsibility is to express an opinion on these financial statements based on our audit. We conducted our audit in accordance with International Standards on Auditing (ISA Italia) drawn up pursuant to art. 11 of Legislative Decree N0. 39/2010. Those standards require that we comply with ethical requirements and plan and perform the audit to obtain reasonable assurance about whether the financial statements are free from material misstatements. An audit involves performing audit procedures to obtain audit evidence about the amounts and disclosures in the financial statements. The audit procedures selected depend on the auditor’s professional judgment, including the assessment of risks of material misstatement of the financial statements, whether due to fraud or error. In making those risk assessments, the auditor considers internal control relevant to the entity’s preparation of financial statements that give a true and fair view, in order to plan and perform audit procedures that are appropriate in the circumstances, but not for the purpose of expressing an opinion on the effectiveness of the entity’s internal control. An audit also includes evaluating the appropriateness of accounting policies used and the reasonableness of accounting estimates made by the directors, as well as evaluating the overall presentation of the financial statements. We believe that the audit evidence we have obtained is sufficient and appropriate to provide a basis for our audit opinion. Opinion In our opinion, the financial statements give a true and fair view of the financial position of Fondazione “Opera San Francesco Saverio” – C.U.A.M.M. as at December 31, 2016, of the result of its operations for the year then ended in accordance with Bari, Bergamo, Bologna, Brescia, Cagliari, Firenze, Genova, Milano, Napoli, Novara, Padova, Palermo, Pescara, Potenza, Roma, Torino, Treviso, Trieste, Verona, Vicenza BDO Italia S.p.A. – Sede Legale: Viale Abruzzi, 94 – 20131 Milano – Capitale Sociale Euro 1.000.000 i.v. Codice Fiscale, Partita IVA e Registro Imprese di Milano n. 07722780967 - R.E.A. Milano 1977842 Iscritta al Registro dei revisori Legali al n. 167911 con D.M. del 15/03/2013 G.U. n. 26 del 02/04/2013 BDO Italia S.p.A., società per azioni italiana, è membro di BDO International Limited, società di diritto inglese (company limited by guarantee), e fa parte della rete internazionale BDO, network di società indipendenti.
the Italian regulations and accounting principles governing financial statements excepted for cash flow statement. Other matters This auditors’ report has not been issued for Italian statutory purposes, due to the fact that the Foundation has no legal requirement. Padova, May 10st, 2017 BDO Italia S.p.A.
Signed by Partner
This report has been translated into english from the italian original solely for the convenience of international readers
Budget 2016
57
In 2016, Doctors with Africa CUAMM NGO-NPO’s costs totaled €23,275,897. Out of this, 88.6% (€20,623,852) were invested in prevention, treatment, and training projects in the countries where we operate. Operating costs account for 4.2% and include: staff costs, general organizational management, purchase of raw materials, amortization, various operating costs, financing
fees, taxes, and duties. Communication, awareness raising, and fundraising costs accounted for 7.2%, including event organization in Italy, publications, media relations, development education, donor engagement, new campaigns, and staff for the communications, local relations and fundraising.
HOW WE RAISED FUNDS IN 2016 TOTAL ¤23,567,344 100%
PRIVATE FUNDING
INSTITUTIONAL FUNDING
PRIVATE FUNDING
INSTITUTIONAL FUNDING
8 mln
8 mln
7 mln
7 mln
¤12,061,568 51.1%
¤11,505.776 48.9%
6 mln
22%
€4,188,235 17,8%
4 mln 3 mln
4 mln
€2,853,302 12.1%
2 mln
€1,142,926 4,9% €549,988
1 mln
€439,118
2,3%
€733,580 €339,997 3.1%
€237,905
1,9%
1.4%
1%
0
Doctors with Africa CUAMM
Annual Report 2016
Report Italy
European Union
Local agencies
Italian cooperation
C.E.I.
International agencies
Individual donors
Groups
Foundations
Corporate
0
5X1000 58
5 mln
3 mln
2 mln 1 mln
33.5%
6 mln
€5,185,509
5 mln
€7,896,783
HOW WE USED THE FUNDS Total ¤23,275,897
FUNDS USED IN THE COUNTRIES OF OPERATION
100%
¤20,623,852 88.6%
COMMUNICATION, AWARENESS RAISING, AND FUNDRAISING
OPERATING COSTS
¤969,254 4.2%
¤1,682,791 7.2%
The Doctors with Africa CUAMM’s budget (closing with an operating surplus of €291,447) is part of the budget of the Fondazione Opera San Francesco Saverio, which includes the activities of the foundation itself and the University College. The total operating surplus of the Fondazione Opera San Francesco Saverio 2016 was €11,848, allocated to the extraordinary reserve fund available to the organization.
OPERATIONAL COSTS IMPACT ON BUDGET
25 mln
9%
€23,275,897 22 mln
8.5%
8.7%
€21,711,666
8%
7.7% 19 mln
7%
€16,724,132 16 mln
6%
6% €12,947,905
13 mln
€11,296,831
5%
€12,111,059 4.9%
4.2%
10 mln
4% 2011
2012
2013
The chart shows trends for total costs and impact of operating costs for the period 2011–2016.
Budget 2016
2014
2015
Total cost (expressed in euros)
2016
Incidence of operating ratio (expressed as a percentage)
59
THANK YOU FOR BEING “WITH AFRICA” ON THIS INCREDIBLE JOURNEY Institutions Agenzia Italiana per la Cooperazione allo Sviluppo Azienda Ulss 8 Berica Comune di Dueville Conferenza Episcopale Italiana Cooperazione Britannica DFID-UK Global Fund Health Pooled Fund International Organization for Migration (IOM) Manos Unidas OCHA Population Services International Provincia Autonoma di Trento Regione del Veneto Regione Toscana UNFPA Unicef Unione Europea World Food Program World Health Organization Foundations African Innovation Foundation Bristol Meyer Squibb Foundation CIFF-Children Investment Fund Foundation Comic Relief Compagnia San Paolo Elton John Aids Foundation Eni Foundation Fondation Assistance Internationale – FAI Fondazione Cariparo Fondazione Cariplo Fondazione Cariverona Fondazione comunitaria del lecchese Fondazione Flavio Filipponi Fondazione Giuseppe Maestri Onlus Fondazione Happy Child Fondazione Intesa Sanpaolo Onlus Fondazione Madonna dell’uliveto Fondazione Maria Bonino Fondazione Nando ed Elsa Peretti Fondazione per la collaborazione tra i popoli Fondazione Primaspes Fondazione Prosolidar Fondazione Rachelina Ambrosini Fondazione Rizzato Cerino-Canova Fondazione Un raggio di luce Onlus Fondazione Zanetti Onlus KOFIH - Korea Foundation
60
Doctors with Africa CUAMM
for International Healthcare Rotary International Symphasis Foundation World Diabetes Foundation Groups and associations Amici del cuore Alto vicentino Associazione Amici dei bambini contagiati da Hiv/Aids Onlus Associazione Amici del Graticolato Associazione Arianna Associazione casa accoglienza Padre Angelo Associazione Ho avuto sete Associazione Internazionale Farmacologia Clinica e Terapia Associazione Madre Teresa di Calcutta Associazione Medici con l'Africa - Como Onlus Associazione Operazione Mato Grosso Avis provinciale Ogliastra Caritas diocesana di Firenze Centro missionario di Vicenza Circolo Acli Rivolta d’Adda Comitato organizzatore Rally dei campioni Comitato per la lotta contro la fame nel mondo Federazione Italiana Medici Pediatri dell’Emilia Romagna Ferrovieri con l’Africa FIPAV Gruppo Missionario Mejaniga Gruppo Missionario San Martino di Lupari Gruppo di appoggio ospedale di Matany Onlus Insieme per l’Africa Onlus International Initiative for Impact Evaluation (3ie) Operazione occhi dolci Ordine dei medici chirurghi e odontoiatri della provincia di Mantova Pink Ribbon Red Ribbon Rotary Club di Udine Rotary di Parma Sindacato Pensionati Italiani CGIL Uno per cento Onlus Women’s Hope International World Vision
Annual Report 2016
Report Italy
Companies Adige Spa Aquasystem Srl Arneg Spa Azienda vitivinicola Scavino Bettiol Srl Elica società cooperativa sociale F.lli Mazzon Spa G.M.T. Spa Gilead Sciences Grafica veneta Spa Intesa Sanpaolo Io Donna Rcs Mediagroup Spa Laboratorio chimico farmaceutico A. Sella Srl Leoncini Srl Midac Spa Morellato Spa S.E.V.A. Srl Sea Vision Srl SINV Spa Trevisan macchine utensili Spa Zilio Industries Srl We would also like to thank: Associazione musicale Summertime La tinozza Sas Latterie vicentine Masi agricola Spa Pandoro Principe Srl Pastificio Rana Spa Publistampa arti grafiche We would also like to thank: the 2,354 volunteers who helped us to do our work in Italy and to all those who have contributed to our work in Africa in so many ways.
OUR COMMITMENT TO ACCOUNTABILITY, YEAR AFTER YEAR.
MEDICI CON L’AFRICA CUAMM ANNUAL REPORT 07
PAG — 2 / ANNUAL REPORT 2009 / MEDICI CON L’AFRICA CUAMM
MEDICI CON L’AFRICA CUAMM / ANNUAL REPORT 2009 / PAG — 3
REPORT ANGOLA ETHIOPIA KENYA MOZAMBIQUE SUDAN TANZANIA UGANDA
annual rEport 2010 - doctorS witH africa cuamm
Doctors with Africa
italiano — EnGliSH
annual rEport 2010 - mEdici con l'africa cuamm
BEHIND THE NUMBERS: FACES AND STORIES OF REAL PEOPLE HARDSHIP, JOY, AND DETERMINATION.
Doctors with Africa Cuamm via San Francesco, 126 35121 Padova Italy
7 COUNTRIES 19 HOSPITALS 511 HEALTH FACILITIES 1,628 HUMAN RESOURCES 126,197 ATTENDED BIRTHS 16,269 TRANSFERS FOR OBSTETRIC EMERGENCIES AND BIRTHS 13,054 CHILDREN TREATED FOR SEVERE ACUTE MALNUTRITION 12,140 PATIENTS IN ANTIRETROVIRAL TREATMENT 7,704 HEALTH WORKERS TRAINED
tel. 0039 049 8751279 cuamm@cuamm.org www.doctorswithafrica.org