Health care delivery on the edge

Health care in rural Uganda is a million miles away from anything you might imagine if you have been brought up in UK since 1948. Yes, the NHS has plenty of faults and will never have enough resources, but it has an impressive way of swinging into action when anything life-threatening occurs.

Not so in Uganda. There are hospitals, yes, but they rarely have many, if any, doctors in them, and the nursing staff can be hard to find. When you do find them they may not be very quick to respond to patients’ needs, and the care is all done by ‘attendants’ – long-suffering relatives who volunteer to feed, wash, toilet and accompany the patient through 24 hours, sleeping on a mat beside the bed. Such is the tradition of extended family responsibility here.
There is nothing equivalent to a GP, unless you count the private medical practitioners who keep shop in the town and charge high prices for dubious investigations and treatments. And then there are the witchdoctors of course......

But on the ground in the rural areas are the health centres. These small buildings, often in remote locations in the bush, are the mainstay of healthcare for most. Of the five health centres run by the Church of Uganda in this Diocese, none has running water or mains electricity. A small solar panel might run a satellite phone and emergency lighting. Their equipment is old and battered, and they don’t have nearly enough of anything. They are staffed by a couple of nurses, midwives and nursing assistants, with perhaps a laboratory technician, a guard/groundsman and a cleaner. The staff live in at the centre in grass thatched houses like those of the community around. They provide out-patient consultations for everything from malaria to worms, from attempted suicide to HIV testing. They cater for a range of maternal and child health services including deliveries, family planning and immunizations. Some include in-patient facilities, and even those that don’t will put a mattress on the floor to keep a dehydrated cholera case under observation until he or she is well enough to move. None has a doctor or clinical officer.

Visiting Kei health centre for a meeting with staff and community members, I was reminded of the constraints under which they work. Kei is the most remote of the five health centres I help to supervise, but it is also one of the biggest and busiest. It serves an area of rural poverty very close to the Sudan border in the far north of the Diocese, and is reached by a terrible road that is regularly impassable in the rainy season. The health centre, like the region it serves, has seen its share of disturbance in recent years. But at present it is well run by Mary, a nurse In-charge who has a sweet but strong character, and is a very committed Christian.

After the meeting, while we were drinking tea and eating cassava and biscuits, Mary approached me to ask if we could take a seriously ill patient to the nearest government hospital on our way home. There are no ambulances here. She wanted to refer him because he had been an in-patient at Kei for two weeks, was deteriorating, and she felt he needed more specialist care. He has AIDS, and had a serious infection in one leg that was causing much swelling and pain. There were already five of us squashed in a ‘double cabin’ pick-up, which left only the open back of the truck available. But that was what was wanted. The staff and relatives spread blankets on the floor of the pick-up, then lifted the thin, frail man onto the back. One of his sons sat upright against the cab, cradling his father’s head on his lap so that the patient was as comfortable as possible on the rough road. We set off for the 20km journey with five of the family in attendance, together with bedding, cooking pots and personal belongings.

It wasn’t an ambulance journey I would have chosen for myself, but it was the only one available and the family were grateful. We left them at the hospital in Yumbe – the patient might get some medical attention there, eventually, but I doubt he will receive as much care and concern as he did whilst at Kei.