Uganda: a situational analysis of Health in North Uganda - Equilibri.net

A SITUATIONAL ANALYSIS OF HEALTH IN NORTH UGANDA AND THE EXPERIENCE OF A VITAL HOSPITAL IN THE SAVANNAH

10 Giugno 2014 Vincenza Lofino

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THE UGANDAN CONTEXT Winston Churchill once stated that "Uganda is the pearl of Africa" in reference to the country's striking natural beauty, climate, and variety of rich landscapes. Unfortunately, the country currently ranks 161th out of 187 countries analysed according to the Uganda Bureau of Statistics, UNDP Human Development Index 2011. This is due to a lack of basic infrastructure such as running water, electricity, waste management, health care, and education. Since 80 percent of the nation’s workforce is employed in the agricultural sector, changes in the climate and the HIV/AIDS epidemic are having devastating effects. As a result, many Ugandans are forced even deeper into poverty.

Today, after the end of the ethnic conflicts that for decades (since the early 1980s) tore apart the entire nation and its possibilities of development, peace has been restored and the confidence of the people has grown. Uganda remains, however, one of the 20 poorest nations in the world, where the medical emergency, in particular the health of mothers and children, must become a national and international priority. In this country, with an average income per capita of approximately US$490 annually in 2011, 24.5% of the population lives under the minimum poverty threshold.

Uganda also has the youngest population in the world: more than half of its 36.35 million inhabitants (World Bank 2012) is made up of children and youths under the age of 18 (20 mln) and the growth rate of the population, equal to 3,3%, is one of the highest in the world (UNICEF 2012).

As women and children are the most vulnerable social categories, the lack of adequate and accessible medical services and facilities (in Uganda the ratio of doctors per inhabitants is 1:13.000) explains the high maternal and infant mortality rate and life expectancy of 56/58, versus an average of 68 worldwide. Easily curable illnesses have a high cost in the country in terms of loss of human life. In Uganda 99 children per 1000 live births (UNICEF 2010) do not reach the age of five with an infant mortality rate three times higher than the average of sub-Saharan Africa. Each year approximately 20.000 infants are affected by the HIV virus, transmitted to them by their mothers during pregnancy. 14% of children under the age of 5 are malnourished and only 1 in 2 is immunised.

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The maternal mortality rate is 310 deceased mothers for every 100.000 babies born alive whilst in Italy it is only 3/100.000. The reduction of maternal mortality is among the medium/long-term objectives of the Ugandan Ministry of Health (Millennium Development Goal).

In Uganda, malaria is the main cause of infant illness and death, followed by respiratory infections and diarrhoea, and 88% of the population is at risk of contracting the disease.

HIV and TBC (Tuberculosis) are the other health emergencies of the country. The most recent data available on the spreading of HIV indicates that the infection has been drastically reduced from 18% in 1992 to approximately 5,4% in 2007.

According to the World Health Organisation, in 2007 Uganda registered 5155 cases of HIV in the adult population, compared to a world average of 206. According to the same source, in 2007 the TBC incidence rate in Uganda was double that of the rest of the world (426 cases versus 206).

NORTH UGANDA AT A GLANCE

The historical context and the civil war The situation in North Uganda is characterized by a level of poverty and underdevelopment markedly higher than in the rest of the country. The twenty-year long conflict (1987-2007) that tormented North Uganda largely influenced the healthcare conditions of the affected Districts (in particular Gulu, Kitgum, Lira and Pader), due to the evacuation into protected camps of approximately 90% of the population.

Since the 1980's North Uganda has been the theatre of a bloody civil war between the rebel movement of the LRA (Lord's Resistance Army) and the National army, which provoked devastating attacks on the civilian population, in particular women and children. It is estimated that, during the conflict, the LRA killed more than 100.000 people. The conflict in North Uganda also became sadly famous for the use of child soldiers: at least 30.000 children were kidnapped Copyright Š Equilibri 2014

and forced to join the rebel ranks, pillage their own villages and often torture and kill their own family.

The brutal civil war, which devastated North Uganda for over 20 years, caused the displacement of more than 1.600.000 people, forced to live in around 200 refugee camps where the basic living conditions were well below the tolerable humanitarian standard. In the Acholi region of North Uganda 90% of the population had to abandon their homes.

The United Nations Undersecretary-General for Humanitarian Affairs, Jan Egeland, on visiting the region in 2003, spoke of North Uganda as the most “forgotten” conflict of the world. The length of the war, the massive displacement of the population and the continuous attacks by the rebels caused the collapse of agricultural production, which sustains the whole country’s economy, and the breakdown of the health and social system. The population was entirely dependent on aid provided by international agencies. In May 2007 an agreement was signed regarding the necessary political and economic solutions to bring the war to an end. Since then, the situation has slowly begun to improve.

Now that the emergency of the war is over and the international spotlights have been turned off, there is the risk that Uganda will remain a forgotten country: 1,2% of the national population still displaced.

General situation of the northern area After many years of civil war, since 2008 security conditions have steadily improved. The population has gradually re-occupied their ancestral land.

The availability of power, although not on a regular basis, has been improving during the last few years, mostly in major urban centres. For instance, the Agago District, where the Dr. Ambrosoli Memorial Hospital is found (as we will see in 3rd chapter), is still lacking an adequate road network that occasionally causes disruption in the routine field activities of health care workers.

Accessibility of patients to health care facilities in case of emergency is also affected by poor road conditions. Telephone and internet networks are available, but their poor conditions significantly reduce the communication capacity among single structures.

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Social and economic organization Acholi is the main ethnic group in the North Ugandan area. Other tribal minorities include the Langi people (towards the southern border with Alebtong and Otuke Districts), the Dodos (from Kaabong District), Jiepeople (from Kotido District) and the Labworian people (from Abim District).

The level of literacy in the District population is still quite low and quite a large proportion of the population, especially among women, does not speak or write English. Rates of illiteracy among adults (most never attended school) are different from District to District in Uganda: the rural and northern areas of the country are less fortunate indeed. Approximately a third of children between the age of 6 and 9 receive no education.

The health status in the community In the Pader District only 23% of the population has access to medical facilities, compared with a national average of 49%. The infant mortality rate is 180/1000 versus a national average of 88, and the infant mortality rate before the age of 5 is 275/1000 live births, versus 99 in the country as a whole. The maternal mortality rate amounts to 700/100.000 live births versus a national average of 310 cases.

Available data on the health conditions of the population of Agago District are derived from the Annual Analytical Report of the Dr. Ambrosoli Memorial Hospital fiscal year (FY) 2012-2013 and they may still fail to capture the entire burden of diseases. Nonetheless, they do represent a valuable source of information.

In the table below, some of the demographic data presented can help in defining some of the basic health needs of the Agago District, especially when it comes to maternal and child care.

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Population groups (FY 2012-2013)

Agago District

Total Population

299,600

Total expected deliveries

14,531

Total assisted deliveries in health facilities Total assisted deliveries as % of expected deliveries

6,327 43.9 %

Children < 1 year

12,883

Children < 5 years

60,512

Women in child-bearing age

60,512

Children under 15 years

137,816

Orphans (estimated)

29,960

Suspected tuberculosis in the area

899

Mortality and Morbidity Mortality and morbidity data in North Uganda are summarised in the next tables which present the relative percentages of the ten top causes of morbidity and mortality respectively.

Malaria still ranks on top and actually increased its relative frequency by 2.8%. Mortality data are still poor and insufficient and may hardly represent the real situation. In FY 2012-2013 about 50% of deaths recorded were attributable to only three diseases (malaria, pneumonia and cardiovascular diseases). Mortality for malaria seems to be back on an increasing trend, after several years of decline, while malnutrition is no longer one of the top ten causes of morbidity, and is reducing its importance also as a cause of death.

Non-communicable diseases are most likely grossly under-reported and, therefore, the dimension of their role and impact may be largely underestimated.

The table below represents the relative percentages of the top 10 causes of morbidity recorded in the Agago District in the last three years.

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Diagnosis (%) 1. Malaria 2. Pneumonia 3. Intestinal worms 4. Diarrhoea 5. Skin diseases 6. Gastrointestinal disorders 7. Eye condition 8. ENT disorders (ears, nose, throat) 9. Trauma-injuries, wounds, burns 10. UTI (urinary tract infection)

2010-2011 34.0 20.9 6.4 4.8 3.4 n.a. n.a. n.a.

2.9 n.a.

2011-2012 26.9 25.5 7.4 4.8 3.4 2.6 2.8 2.3 2.0 1.5

2012-2013 29.7 28.6 7.1 4.8 3.5 3.3 2.9 2.3 1.8 1.6

The table below represents the relative percentages of the top 10 causes of mortality recorded in the Agago District in the last three years.

Diagnosis (%) 1. Malaria 2. Pneumonia 3. Cardiovascular Disease 4. Persistent Diarrhoea 5. PID (pelvic inflammatory disease) 6. Tuberculosis 7. Anaemia 8. Drug abuse 9. Severe Malnutrition 10. Road Traffic Accident

2010-2011 14.2 8.1 1.8 1.1 n.a.

2.9 5.4 n.a.

4.3 1.4

2011-2012 6.6 9.5 5.8 2.5 0 2.9 1.7 0.8 5.0 2.1

2012-2013 21.6 15.6 13.1 8.0 8.0 6.5 6.0 4.5 2.5 2.0

THE DR. AMBROSOLI MEMORIAL HOSPITAL CONTRIBUTION

General information Dr. Ambrosoli Memorial Hospital is a private non-profit institution. It is located in Kalongo Town Council in the Agago District and it acts as District Referral Hospital for 299,600 people. It is a 302-bed general hospital operating in a rural and quite poor environment, and it provides healthcare for outpatients and inpatients with a special focus on child/maternal care and a comprehensive HIV/AIDS programme.

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Historical facts The Hospital is named in the memory of Fr Dr Giuseppe Ambrosoli, a physician and Comboni missionary from Como (IT) who founded the Hospital in 1956, and served there until his death in Lira, in 1987.

It hosts The St. Mary’s Midwifery Training School founded by Fr Dr Ambrosoli in 1959. In the same year started the training activity in the field of midwifery with two government approved qualifying courses: the training of Enrolled Midwives and Registered Midwives. These courses are recognised for their the high standard of professionalism. Indeed, in 2011 the School was considered a “Leading facility in medical specialist training” thanks to its 1200 qualified midwives from its birth to today.

In 1987 the Hospital and the School were closed under government orders due to the war, then reopened in 1989. In 1998 the Family of Fr Dr Ambrosoli established the Dr. Ambrosoli Memorial Hospital Foundation with the purpose of supporting the Hospital and the School and maintaining the professional and humanitarian legacy of Dr Ambrosoli.

Activities and Mission The Hospital promotes access to health care for the weakest and most vulnerable social groups, like women, children, the financially destitute, and the chronically ill. It carries out an integrated array of work that includes: - basic and specialist medical work in situ - prevention work, medical treatment and education in the area in order to facilitate access to medical care even for the most fragile - management of the Health Sub District, the government dispensaries distributed in the area, with the aim of providing widespread medical assistance in the region - specialist training for midwives, ward sisters and health workers at the St. Mary's Midwifery School - technical-logistic services supplied by the Technical Department Copyright © Equilibri 2014

Some data and figures Thanks to its medical activities, the Hospital was able to achieve the following goals (data from Annual Analytical Report of the Dr. Ambrosoli Memorial Hospital): Activities Admissions Deliveries Major and minor operations OPD (outpatient department) visits Ante-natal Clinic visits HIV patients under care Immunisation doses administered

2012 11,374 2,805 2,468 23,714 7,936 1,996 20,807

2013 13,221 2,727 3,022 31,225 5,312 2,219 19,294

CONCLUSION: THE IMPORTANCE OF MORE HEALTH CARE UNITS IN UGANDA The Dr. Ambrosoli Memorial Hospital provided daily health care services and refuge for thousands of patients and internally displaced people over the 20-year civil war that affected Northern Uganda, showing an extraordinary resilience in extremely hard times. With the passing of time, the Dr. Ambrosoli Hospital played an essential health care role in the whole northern area of Uganda, gaining a high reputation above all in the fields of maternity and surgical services.

Today the Kalongo Hospital in the Agago District (established in 2010 by detaching it from Pader District) represents the referral Hospital for the neighbouring District of Pader to the West, Kitgum to the North and Abim to the East Uganda, in a very large area still covered by Savannah vegetation.

Uganda needs more structures like this. Indeed, it is important to promote the construction of more health care units everywhere in Uganda to improve living conditions for the whole population.

Despite Uganda's recent improvement in its healthcare performance, it is still ranked as one of the worst in the world by the WHO. Awareness of this fact could bring life-saving services to Copyright Š Equilibri 2014

thousands of people. The African Medical and Research Foundation (AMREF) which, with “FarmAfrica”, is working to improve the lives of Katine villagers, in the East Uganda, says health has proved one of the most complex and challenging components of its work. According to them, one of the biggest discoveries of the project so far is that helping to build functioning community structures, and training the community healthcare workers by providing professional training courses, can lead to a tangible improvement in healthcare and access to health services at a local level.

The recent global financial crisis could threaten to derail Uganda's national health budgets – half of which are now funded by the international community – and undermine all the progress which has been made in healthcare over the past decade. There is no doubt that the effects of any cut in aid budgets to Uganda's healthcare system will be felt in all Ugandan Districts. Anyway, local people should demand the right to decent health services and should require better access to healthcare services.

For more information: This report, especially in the 3rd and 4th chapters, is a part of the Annual Analytical Report of the Dr. Ambrosoli Memorial Hospital of Kalongo (North Uganda), covering the period of the Financial Year 2012-2013, prepared by the management of the Hospital on December 16th, 2013, whose aim is to contribute to a better understanding of the performance of the Dr. Ambrosoli Hospital in its various activities. The data presented are directly derived from the Hospital’s activity and financial database.

Referring to: DR. AMBROSOLI MEMORIAL HOSPITAL - P.O. Box 47, Kalongo, Agago District (UGANDA)

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SOURCES - AMREF (www.amref.org/it) - Comboni Missionaries (www.combonimissionaries.org) - Government of Uganda (www.gov.ug) - Federation of American Scientists, FAS (www.fas.org) - Foundation for Sustainable development (www.fsdinternational.org) - Fondazione Dr. Ambrosoli Memorial Hospital Onlus (www.fondazioneambrosoli.it) and Annual Analytical Report of the Dr. Ambrosoli Memorial Hospital - St. Mary’s Midwifery School (www.kalongomidwifery.org) - The Guardian (www.theguardian.com) - Uganda Bureau of Statistics (UNDP Human Development Index 2011) - UNICEF 2010-2012, Uganda Demographic and Health Survey 2007 - WHO 2006-2007 (World Health Organization) - World Bank 2009-2012

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