We have all seen the speed at which the pandemic has spread across the globe and the impact on many countries. We pray for those of you reading this in lock-down situations, isolated and may be frustrated by the effects of the disease and the resulting restrictions. Even more, we remember those of our colleagues in healthcare who are working so hard to care for a seemingly never-ending line of patients.
Uganda had no cases on 19th March but now they are being reported in people who had been to Dubai. Uganda has taken firm measures and has closed schools, banned big meetings, etc to try and avoid the virus getting a foothold. Entebbe airport and all borders are now closed with the exception of cargo planes and limited freight vehicles.
Although thankfully we have not seen any cases in the hospital, Kisiizi has already experienced significant challenges:
Impact of international trade disruption
- Some medicines e.g. oxytocin are not available from our usual supplier, Joint Medical Stores
- Alternative sources may not always be reliable medicines and are often more expensive
- Medical sundries and equipment also affected
- Export of items including agricultural produce has ceased with the border closures and there is a consequent rise in prices and therefore our community will have more problems paying for hospital care.
Impact of exchange rate falls
- The pound has dropped in value relative to the Uganda shilling and so the support from Kisiizi Partners and friends in the UK will be worthless when money is transferred.
- By comparison, the Euro has maintained or even gained relatively.
- Clearly, many of our supporters are themselves going through very difficult times and their ability to support Kisiizi may be impaired.
Impact of the closure of the School of Nursing & Midwifery & Primary School
- The School closed with just 2 days notice following President Museveni’s address to the nation on Wednesday 18th March. It is for 32 days in the first instance but may then be extended.
- This will mean the student nurses who support us in the hospital doing patient observations, making beds, giving medication, etc. will no longer be here. This will cause increased pressure and demands on our Staff.
- We had already paid for large supplies of food for our Student Nurses that will not be needed.
- The income stream of fees from the students will stop.
- In Uganda, health workers with children are less likely to miss work when their children are sent home from school than parents in the West as there are house-girls or other helpers who can look after the children.
- However, some staff have had to disappear with no notice to collect children from schools further away leaving some staffing gaps though these are only brief
- Tutors from the School are now helping in the Hospital which is appreciated
Impact of cancellation of trips by elective students and groups
- We are just entering what is usually the busiest period of the year for our Guest House but now, understandably, all our booked visitors from different countries have canceled.
- This means we have to lay off most of our Guest House staff
- It also means that the contribution our visiting elective students automatically make to the Good Samaritan Fund (instead of paying any fee for tuition etc) will not be received
- We have said goodbye to some of our ex-patriate visitors who have decided to return early to the UK to be with their families so we will miss their presence
Impact on our Community Health Insurance Scheme
- Kisiizi has the oldest and largest community health insurance scheme in Uganda with over 45,000 beneficiaries in 6 districts in 220 community groups up to 60km from Kisiizi.
- It must be the cheapest in the world as the premium for a year of acute health care cover is between 11,000 and 17,000 UGX.
- The Scheme has a very simple principle, that risk is spread across the group so that the small proportion who become unwell are supported by the majority of the members who remain well.
- This principle usually works very well, however, COVID-19 risks a very different scenario where high numbers of members become unwell. They would be entitled to acute medical care and admission so this would cause massive unexpected expenditure to the Scheme which would probably collapse as a result.
- This would be tragic as research in the past 3 years has demonstrated that as well as offering financial protection against catastrophic expenditure for health needs, the scheme dramatically reduces childhood stunting by 4.3% a year compared to control families who are not members of the scheme.
- In addition, admission rates from our clinics of Scheme members are less than half the rate of non-members. This is Universal Health Coverage in action.
- To lose these tremendous benefits would be awful.
What might be the impact of COVID-19 disease in our region?
- Nobody really knows… the international data so far is in different populations. We are not sure what will happen if the disease spreads in a community with background malnutrition, immunosuppression, and conditions such as TB.
- Large numbers of Kampala based workers and their families are returning to their home areas as their places of work and all schools have closed. Public transport may also soon be stopped by the government.
- It could be a massive problem. If so, it is likely to be widespread which will mean that other units and referral hospitals will be overwhelmed and not able to support Kisiizi. In addition, many other units may be relatively unprepared and so severe patients may be brought to Kisiizi because of its good reputation which will then put high pressure on our services.
- Experience also tells us that quite a few will not be able to afford the more intensive treatment they will need. Others will “escape” without paying if there are large numbers of patients everywhere.
- There is a risk that some of our own Staff may become infected and then unable to work causing more pressure on services.
What level of care will Kisiizi aim to provide COVID-19 suspected cases?
- Kisiizi only has one ventilator which is linked to anesthesia. We do not currently have an Intensive Care Unit but we do run High Dependency areas in our different departments.
- We can assess patients including their vital signs and oxygen saturation, adult echocardiogram/ECG, Chest x-ray, Laboratory investigations, etc.
- We can offer oxygen, Continuous Positive Airways Pressure, blood transfusion as well as IV fluids, inotropes to support patients with shock, and antibiotics and a range of other treatments.
- However, we have a finite number of oxygen concentrators and cylinders and there are some challenges at present with arrangements for refilling empty cylinders.
So what contingency plans have been made and what actions is Kisiizi Hospital taking?
PATIENT FLOWS / ALGORITHMS
- Introducing triage of all people arriving in Kisiizi – directing patient flows, hand washing provision at the gate, initial triage for the presence of any respiratory symptoms or fever; if the positive moving patient to a more detailed second triage area
- We have moved patients from the end room of the Rehabilitation Unit dormitory block to create a clinical room for second-level triage of patients arriving with respiratory symptoms who will be segregated from those without such symptoms. This has required the installation of fencing to separate rehabilitation unit patients from this area; a tent to provide additional waiting area; an Ethernet cable connection to allow linkage to Stre@mline from that room etc.
- Preparing lower medical (isolation) ward to be available for COVID-19 suspects and working on providing more cubicles in Children’s Ward to support isolation
- We have made provision for further isolation facilities in the old Ahumuza ward which may be used for patients with Tuberculosis currently in the Lower Medical Ward
EQUIPMENT, MEDICATION, AND SUPPLIES
- We sent an extra urgent trip to Kampala for bulk supplies of alcohol from the sugar cane factories to use in the manufacture of WHO recipe alcohol-based hand-rub for infection control.
- Assessing how to provide extra respiratory masks – including options for autoclaving and reuse if supplies run short. We need to be good stewards of the limited resources available.
- Assessing how to provide extra oxygen – aiming to acquire more oxygen cylinders with the necessary valves and flow meters; ensuring all oxygen concentrators are operational including repairing any with problems
- We are looking at the potential use of Chloroquine as there is some evidence it is helpful in-vitro and may suppress respiratory complications in patients with COVID-19
- Resources are being uploaded to Stre@mline so available 24 hours a day to our Staff
- These include WHO Personal Protective Equipment (PPE) and Case Management Guidelines
- Practical demonstrations and practice sessions have been run in the past and are being repeated and we plan to make a video of the correct use of PPE.
- Contingency plans to mobilise other staff to support clinical services are being established, e.g. we may utilise our Primary School teachers who are free as the school has been closed to give logistical support to the Clinical workforce.
- Support workers such as Security Staff need the training to minimize visitors to suspected cases to reduce transmission risks and to help control movement of people
- Infection control training for support staff e.g. laundry, cleaners as well as front line clinical staff
HEALTH EDUCATION for the public
- We hope to support Radio messages to our community regarding this disease to stop false information being spread and to help people minimise their risks.
We are liaising with the District Health Officer and his team in Rukungiri and with the Uganda Ministry of Health to have clear procedures e.g. for conducting tests for COVID-19 and for contact tracing follow up.
We are seeking clarification about the implementation of the national regulations. For example, there are not supposed to be meetings or gatherings of more than 10 people. However, we are due to run Mental Health community clinics with much higher numbers. If these are canceled there are risk patients who are currently well controlled may relapse.
To deliver all the above the real need is for financial support. We serve a very poor community so we cannot just increase patient fees.
Any support will help to
- Cover the cost of extra trips and work done for the above contingency
- Help us purchase extra equipment such as oxygen cylinders, spare parts for concentrators, etc.
- Cover some of the major losses of income which otherwise will challenge our ability to sustain services
- Allow us to continue our policy of “Care for the Vulnerable” never turning away anyone who needs care even if they do not have the resources to fully pay for the services they need
- Support the costs of Staff to run the services
We are SO grateful for all who already support Kisiizi with a regular monthly gift. So whilst we are VERY grateful for any one-off gifts, the regular standing order donations help us in planning as we can predict what income will come.
For those who pay UK taxes then donations via Kisiizi Partners can be Gift Aided to attract a further 25% so a big extra contribution. Alternatively, some choose to Gift Aid via their church who then make a donation to Kisiizi.
For others, the choice is between the Kisiizi Hospital National Westminster UK Account or one of our Ugandan accounts. Details are available on www.kisiizihospital.org.ug on the Supporting Kisiizi page.
As we all face uncharted waters and a lot of uncertainty, we remember the power and comfort of these ancient words: “I lift up my eyes to the hills… where does my help come from? My help comes from the LORD, the Maker of heaven and earth.” Psalm 121
Thank you for standing with us through these challenges so that we can continue to share Life in all its Fullness with our patients, attendants, staff, and community.
Kisiizi Management Committee