Collapsed emergency services lead Ugandans to early death

By Emmanuel Ainebyoona & Walter Mwesigye

It is lunch hour on a hot Wednesday afternoon. A staff at Ministry of Health’s call centre receives a distress call on emergency telephone number 0800100066.“Hello, I am in need of an ambulance to transfer a patient from Nansana [a city suburb] to Mulago referral hospital,” the caller said.

“Sorry, the ambulances are being managed by Kampala Capital City Authority (KCCA) in a pilot programme,” the female attendant responded, adding: “Please, here is their toll-free line 0800990000 and call and request for an ambulance.”
A call to this alternative toll-free went unanswered when our reporters dialed it last Friday, but an automated response referred to a client’s service number: 0204660000.

“KCCA, for a better city,” ends the ring tone that replays the mission and vision of the city authority.
Telephone calls to the client’s service number too went unanswered.  Last week’s unsuccessful attempts by our journalists to secure an ambulance mirror widespread struggles by ordinary Ugandans in need of emergency medical care, four years after the government launched a Uganda National Ambulance Service (UNAS).

Revised to the Emergency Medical Service System (EMSS), the anticipated first aid provision, pre-hospital care and faster transportation have not worked as envisaged.“The ambulance system has not been phased out,” said Health ministry Permanent Secretary Dr Diana Atwine, “but we want to ensure that we develop a more comprehensive emergency system, not having ambulances that will pick patients and just run away.”

Stationed ambulances

The revised approach is to devolve provision of direct ambulance services to regional referral hospitals and private actors while the parent ministry concentrates on policy formulation and coordination.
This resulted in Health ministry surrendering seven ambulances of its 10 ambulances to KCCA to manage.
Dr Daniel Okello, the acting KCCA director for Public Health and Environment, said they have stationed ambulances at black spots within and around Kampala to evacuate particularly accident and emergency victims.

“We are doing what we call facility at hotspots such as Clock Tower, the Fire Brigade headquarters and along selected accident black spots,” he said. Besides, directing or locating pick-up places for emergency patients is hampered by haphazard developments that block access or where plots are not numbered and roads exist without names.

The functionality of the ambulances have been questioned by professionals and users. Worse, 77 of Uganda’s 121 districts do not have an ambulance service at the public health facilities.
Many ambulances, where they exist, either have no fuel or are grounded due to tyre and repair problems.
While some are, in the words of one use, just “speeding vehicles” because they lack equipment and specialised health workers on board.

In many districts, double cabin pick-up trucks have been converted into ambulances, with the distinctive addition of a siren switched on to clear traffic and enable faster delivery of a patient to a health facility.

Prof Joel Okullo, who chairs the government ad hoc committee drafting the national guidelines, said Uganda’s emergency services are “poorly managed and uncoordinated” while the ambulance system is “insufficient and low capacity”, even to manage the injured. Pre-hospital care is given on an ad hoc basis, by fragmented providers such as police and community volunteers with no or inadequate training or skills.

His concerns echo findings in a 2009 research published in the World Journal of Surgery titled the “current patterns of pre-hospital trauma care in Kampala, Uganda and the feasibility of a lay-first-responder training programme”.

“Less than five per cent [of emergency patients] arrive by ambulance because few exist and these are mostly privately owned and prohibitively expensive. Furthermore, one in three patients arrive at Mulago (National Referral Hopsital) beyond the first hour after the injury, the ‘‘golden hour,’’ during which expedient treatment would greatly increase survival,” the researchers wrote.
One family that had a first-hand experience of a lethargic and costly emergency referral system was that of Abel Nsabimana.

His son, Michael Niyitegeka, says their 68-year-old suffered a heart attack on March 24, last year, while at his work place in Fort Portal Town, about 300 kilometres west of Kampala.
Nsabamana’s blood pressure had dropped drastically and he required urgent specialised care, but his children were notified three hours after he collapsed.They could not secure a government helicopter for air evacuation until Toro & Mityana Tea Company, Nsibamana’s employer, chattered a plane from the Kajjansi-based Kampala Executive Aviation to evacuate him.

There was another hurdle. The airline said it could not fly its plane beyond 6pm to an area without runway light for landing and, as such, the evacuation was done the next day. The flight cost $3000 (Shs11m), almost four-fold the per capita of a Ugandan.

The crucial hours for emergency intervention had lapsed and Nsibamana passed on at International Hospital Kampala on April 8 where he spent 10 days, five of them in intensive care.“From an emergency perspective, my father’s death left a lot of questions on what could have been done if the country had better facilities,” said Niyitegeka. Fewer Ugandan families have the money or power connections to pay for air ambulance and, as such, many patients in critical condition die prematurely and unattended to.

Last month, Ethics minister Simon Lokodo collapsed in the backwater Kalangala island district, and the army flew in a chopper evacuate him. Dr Lameck Ssemogerere, an intensivist and the head of critical care services at Uganda  Heart Institute where Fr Lokodo was transferred, said the minister’s case could have ended differently had emergency care further delayed.

The army and police helicopters have been at the ready to evacuate at tax payers’ expense top government official or their relatives relatively well-off than the average Ugandan. “It would be great to have air ambulance (services), but currently we do not have,” PS Atwine said, without discussing if any such an option is even on the table in the first instance.

World Health recommendations

The World Health Organisation recommends that emergency patients, particularly accident victims, should be evacuated within 5 to 17 minutes.The UN health agency notes the dearth of pre-hospital care in Uganda, which would enormously save lives, and says only 7 per cent of critically ill patients in the country are delivered to health facilities by ambulances.

Others arrive on the back of police pick-up trucks, in private vehicles, on boda bodas or carried on shoulders with improvised stretchers if not pushed  to emergency units on wheelbarrows. “The proportion of patients who die before reaching hospital in low and middle-income countries is over twice that in high-income countries,” WHO notes.

Health experts take

Health experts at the agency say transferring the critically ill, either from homes or accident scene to a facility, or between facilities, has two distinct components: transport and care during transport.
Four years ago, the government announced plans to buy 100 ambulances at $157m (Shs579b) phased over five financial years starting from 2014.

The fleet would, according to the plan, constitute the National Ambulance services, comprising dedicated medical workers, drivers and well-trained crews.
Each of the ambulances was to be equipped with modern diagnostic and treatment as well as communication equipment.

The government would provide a toll-free communication line to citizens, different from police’s 999, to access the referral system.Nothing happened. And a central element of the ruling National Resistance Movement (NRM) party remains in a limbo.

The party committed to voters that it would establish an Ambulance service so that “instead of every health centre having an ambulance, which is normally abused by the in-charge of the health units, the National  Ambulance System will have ambulances in strategic areas coordinated by a command centre”.Health units in need of ambulance services would dial up the command centre which in turn would dispatch the ambulance nearest to that health unit. The party got re-elected for, among other reasons, this promise.

No scheme

Almost two years into the five-year tenure, there is no air or vehicle ambulance scheme and officials are back to drawing board to incorporate what such an elaborate system should look like, pushing health consumers to a spot of bother.
Mr Moses Talibita, the legal officer at Uganda National Health Consumers Organisation, said the government must invest more in “ambulatory and blood services provision”.

“The right to health constitution inclusion proposal we mooted in 2015 chose to entrench emergency health care as a right in Uganda and that regardless of health facility, private or public, payments should not be priority except to save life in line with Article 22 of the Constitution, which protects life,” he noted in a phone text message reply to our inquiries. PS Atwine said the national ambulance service which was launched before her appointment was done in a rush and error.

“We later realised that as a strategic body, the Ministry of Health is supposed to do policy and not manage ambulances. Ambulances are supposed to be managed by hospitals,” she said yesterday.
Officials have now shifted attention to establishing a comprehensive emergency medical services which has well-equipped ambulances manned by special cadre of health professionals who deliver patients to functional hospital emergency wards. UHI’s Ssemogerere says there are only two vehicles in the country that are fit to be called ambulances; one at the institute where he works and the other at IHK.

Unconfirmed reports indicate that Uganda’s central bank has lately acquired a super-specialised ambulance.
“Critically-ill patients are found everywhere; in the community in the hospital and sometimes unknown locations,” he Dr Ssemogerere, adding that the government should supply hospital-on-wheels to every corner of the country so that doctor can work on patients while in transit. Already a battery of volunteers who can quickly respond to offer first aid at, say, accident scenes before an ambulance arrives to transfer victims is underway.“We have already trained health workers at Mulago Hospital and those at regional referral hospital. We are going further down,” PS Atwine said.

Asked if she was satisfied with the performance of KCCA on the devolved ambulance services, after our reporters failed to access one, the PS said she cannot pass a judgment because her ministry has not done such an evaluation two years later.
“It would be premature for me to comment. We have also not assessed the clients’ satisfaction,” she said, and did not explain the reasons for the inordinate delay in conducting the appraisal.

Government on specifications
The government says it plans to acquire ambulances by grades; if it is a basic ambulance, it should have emergency kits to administer first aid, have oxygen on board, blood monitoring equipment while a super-modernised one must be an equivalent of an Intensive Care Unit on wheels.
If implemented, the scheme is envisaged to reverse the needless and premature death of Ugandans from sudden onset of life-threatening conditions.

For instance, 3,000 people die on Ugandan roads in accidents, according to the 2014 Uganda Police Crime and Traffic Report, with deaths out of 13,500 survivors attributed to delayed emergency response.

About the ambulances
Inside a specialised ambulance. The Uganda Heart Institute’s ambulance has specialised stretcher, emergency kit, injection machine, air-conditioning equipment, hand washbasin, special doctor’s seat, medicines, lung machine and all medicines and sundries needed in emergency situations.
It is a level-three ambulance, with entire scope of medical services required to treat and stabilise a critically-ill patient.

Ambulance Fleet
According to the ministry of Works, the government has a fleet of 222 ambulances. About 190 are under Health ministry, 27 with Uganda Police Force while the rest are distributed among other ministries.
State House has two ambulances, ministry of Defense 1 and Prisons owns four. The motor vehicle inventory further indicates that over 70 districts have no ambulances.

Air medical evacuation
Mr Corliss Zylstra, the general manger of Kampala Executive Aviation which does air evacuations, says Uganda’s airfields lack lit runways which limits medical evacuations by air at night.
Under the current legal frameworks, private air operators cannot operate beyond 6pm, hampering evacuation of patients at the night.

In most of Europe, police and military conduct medical evacuations if it is not covered under a national health insurance programme, which Uganda currently lacks.

First Published by Daily Monitor

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