South-West to Kabale

            Field Visit # 2

              During our second week of field visits, our team travelled to the far south district of Kabale, a destination approximately 20km from the boarder of Rwanda and about 70km to the border of the Democratic Republic of the Congo. Our first stop was the AMREF Kabale office where we were introduced to Nicodemus a Project Coordinator and Project Manager for AMREF and Nzaba, the District Health Educator of Kabale.

                The first item on the agenda for our team was to meet with the District Health Authorities and to share the objectives of our visit, the LVBIHI concept. We discussed that, although Kabale is not considered within the basin of Lake Victoria, it has been identified as a district with a disproportionately high burden of morbidity and mortality when compared to other district within Uganda. Again, we were interested in hearing about the strengths and challenges faced by the health centers in this district and the top priorities generated by these Health Authorities.

                Kabale is unique from the other districts due to the elevation of the land and the resulting climate. The average temperatures range from 20-24 degrees Celsius in the day and drop down to 14-18 degrees Celsius at night and can fall as low as 10 degrees during the rainy season. These are huge variations in comparison to other regions where the range is typically 28-32, with low's of 24 degreees Celsius. The relative humidity in Kabale in the morning is close to 100%- it feels like walking through a rain cloud, very low visibility and extremely damp.  As far as the eye can see, the hills are high and rolling between 2,000m and 2,500m above sea level. Homes tend to be very isolated from one another and from the conveniences and cares available in the town centre.  

 Lake Bunyongi, Kabale

View from the hilltops overlooking the village Nyarurambi

                During the meeting with the Health Authorities we heard about several of their accomplishments over the past few years; increased distribution of Insecticide Treated Net (ITN) to pregnant mothers and children five years old and under; increased childhood immunization, de-worming and routine vitamin A supplementation programs; and widespread implementation of a project initiated by AMREF titled “PHASE”, Personal Hygiene and Sanitation Education. Challenges in the area were largely related again to staffing (both the training and retention of); primary care and prevention of disease at the household level; and issues with maternal and neonatal health, which again of course, is one of the issues our team is most interested in learning about. 

                There are three key indicators considered internationally for determining the health of a nation: 1) Life expectancy; 2) Infant mortality rate; and 3) Maternal mortality rate. In any effect, each of these indicators is intricately linked to the others. Just for the sake of an example of these intertwined relationships, consider first how a mothers education level impacts her socioeconomic status (SES), her age of conception, birth spacing, her ability to judge health issues, her knowledge of the importance of antenatal care and her decision to deliver in the presence of a medically trained birth attendant. Her SES will impact her nutritional status and thus the healthy development of her fetus and will impact her body’s ability to endure pregnancy and delivery. The health of her infant will rely on the mothers’ access to resources such as post-natal care, childhood immunizations and the ability to provide safe feedings.

                 If we consider Uganda in a snapshot, the maternal mortality rate is about 600/100,000. The infant mortality rate currently stands at 88 deaths per 1,000 live births (which does NOT take into account the 18% of infants born still). This means that 1/11 infants die before their first birthday. Of those infants who survive the post-neonatal period, 69 out of 1,000 will die before reaching their fifth birthday- this implies that 1/7 babies born in Uganda will not reach their fifth birthday. These statistics make it is easier to grasp the life expectancy rate here in Uganda- 50 years for men and 52 years for women. Now consider life expectancy in Canada- 79 years for men and 84 years for women. The under-five mortality rate of 6/100,000 and the maternal mortality rate of 7/100,000. In Canada, essential health services are free and accessible. We have safety nets that ensure equity. We have highways and ambulances. We have food banks, community health centers and voucher systems. Although these are challenging numbers to realize, I hope it helps with understanding of the goals of this project, to learn how to best improve maternal, infant and pediatric health to improve nation-wide health outcomes.

                After our first meeting, again began travelling to several Health Centers within the region to develop a first hand perspective of maternal, neonatal and pediatric care available in the district. We met with Dr. Gilbert, the superintendent of the referral hospital, Rugarama. We visited a labor suite where 50-60 births occur monthly and also the new operating theatre for caesarean sections (and other surgical procedures) which is currently being built with support from DRI. Next we entered the neonatal and neonatal intensive care units, then finally the general pediatrics nutrition centre. After extensive discussions with Dr. Gilbert, he and I came up with a plan for me to come work within neonatal and pediatric nutrition centers come January. Previous to this experience, I trained as a pediatric clinical dietitian at the Hospital for Sick Children in Toronto. I am eager to learn more about the feeding practices within this hospital and hopefully, will be able to share some of the knowledge I have afforded throughout my training.   

Village Health Team members meeting at Nyaksaru Health Centre II

Obstetrics ward, Rugarama Health Centre IV

The future home of the Rugarama obstetrics ward,
neonatal intensive care unit and surgical centre

                While consulting with the team at Rugarama Hospital, we asked their perspective of the national health statistics generated by the government of Uganda. Our curiosity was based on the fact that these new statistics suggest decreases in maternal and infant mortality. We wanted to know first, if the staff at the hospital believed the validity of these statistics and if so, how these vast improvements were achieved. We never made it to the second question. The hospital superintendent, the District Health Officer and several others agreed that these national statistics are largely misrepresentative. Reason being that these statistics are generated using registered data only, which fail to capture the majority of morbidities and mortalities faced in many districts.

                Aside from the Kampala district, where many have means with which to reach health services, those living in less developed, rural areas remain to have poor access. To better understand the flaw of these government generated stats, consider the issuance of birth and death certificates which are used to identify the occurrence of each for national data. Neither document is legally required here. National figures demonstrate that just over 60% of birth deliveries occur within the home, without the assistance of skilled personnel. The majority of these births therefore go unrecorded, as do resultant deaths. In terms of death certificates, most do not have the means to support end of life care so death within the home is common place. The cost of transporting a dead body is over five-times the cost of providing end of life care in registered facilities, so if the first is unattainable, the registration of death is certainly out of reach. National statistics are dependent upon the availability and accessibility of data, the comprehensiveness of coverage and overall validity. Can you see the gaps?

                 From now on I am going to be living in Kabale. There is a lot of work here for me. In the next post, I will describe the household health survey that we will be conducting which will commence within the next two weeks. Of the 60 sub-districts within Kabale, 30 have been selected as a sample of the region. In total, the survey we are proposing will require the assistants of 900 VHT leaders within the districts, each who are responsible for approximately 25 homes in which the average household number is 8-10 people. Through this survey we will reach approximately 180,000 people in total. We will cross check these government generated statistics. With this representative sample, we will cross-check government generated numbers which will help us to become more capable of identifying key priorities for strengthening health systems within Kabale and the Lake Victoria Basin.