The Fancy Fanatic: DR ABC

3.3 The Uganda National Minimum Health Care package

The HSSP II defines the Uganda National Minimum Health Care package (UNMHCP) and it has four clusters namely:

(i)                   Health Promotion, Disease Prevention and Community Health Initiatives;

(ii)                 Maternal and Child Health;

(iii)                Prevention and Control of Communicable Diseases

(iv)                Prevention and Control of Non-Communicable Diseases 

Emphasis during the implementation of the Health Sector Strategic Plan (HSSP II) was placed on a limited set of interventions which have been proven effective in reducing morbidity and mortality. This section summarises progress that has been made in reaching targets as were set in the HSSP II for each of the clusters of the UNMHCP.¹

In the past couple of months, I have been pondering, so much I have certainly grown a couple of grey hairs. I have been trying to define the state of EMS in Uganda. Does Uganda have an EM Service? Surely there must be a way the acutely ill receive care. Who? What? Where? When? How? Like I said-pondering. A quick survey of my medical colleagues is disheartening, so to speak – a resounding NO!!! No in all languages Ugandan-Jonam, Luganda, Ateso, Rukiiga, Lulamoji etc……  Sadly a No!

How can we even think of EMS when malaria, Diarrhoea, pneumonia and of course HIV/AIDS are lurking at the horizon? Historically, global health policies emphasised multiple, vertically oriented programs that concentrated on Maternal and Child health and the control of Communicable Childhood diseases ^2. This resulted in major public health agencies focusing their support on selective programs that address priority diseases and activities. Unfortunately, vertical programs do not encourage the development of strong and efficient health care delivery systems. The weakness of this approach is most apparent during crises, such as medical emergencies or incidents involving large numbers of casualties.³

The EMS shall come, but not now – we have to get our priorities right; sort out the important conditions first then that Fancy Fanatic-DR ABC with his “irrelevant” bag of tricks can be welcomed. You have to crawl before you walk, RIGHT?

Actually-WRONG WRONG WRONG!!!  (Again, WRONG in all Ugandan languages)

The three fundamental functions of a health system are to improve the health of the population, respond to people’s expectations and provide financial protection against the costs of ill-health. Emergency medical care can contribute positively to these functions. While Prevention is a core value of any health system, many health problems continue to occur despite preventive services. A significant burden of diseases in developing countries is caused by time-sensitive illnesses and injuries, such as severe infections, hypoxia caused by respiratory infections, dehydration caused by diarrhoea, intentional and unintentional injuries, postpartum bleeding, and acute myocardial infarction.

SO LET ME TELL YOU ABOUT DR ABC……

DR ABC (Danger Response Airway Breathing Circulation) has defined emergency care in its entirety world all over. The reality of it is as the famous adage says, “Emergencies occur everywhere, and each day they consume resources regardless of whether there are systems capable of achieving good outcomes”. Therefore, as my Ugandan colleague remarked “This statement challenges physicians around the world to develop systems to improve emergency care delivery for their people”.

What is conventional EMS anyway? The purpose of emergency medical care is to stabilise patients who have a life-threatening or limb-threatening injury or illness. In contrast to preventive medicine or primary care, emergency medical care focuses on the provision of immediate or urgent medical interventions. It includes two major components: medical decision-making, and the actions necessary to prevent needless death or disability because of time-critical health problems, irrespective of the patient’s age, gender, location or condition.²

It may seem therefore that Uganda does have a form of emergency care services though not necessarily a system. An emergency medical system is care with interdependent components that link pre-hospital care and health facility based-care, working together to provide adequate acute care for the population.

Imagine you were suddenly in need of urgent care in Kampala – Uganda? (and I hope for your sake you are not-at least not until we have DR ABC). Kampala City-the biggest swankiest place in Uganda with the highest concentration of Uganda’s 4,363 Registered Doctors and 1:24,725 Ratio. So let us imagine you are in Uganda’s “safest city”.  Say, a final year medical student is heading home on a Saturday night boda boda after dumping all that percussion stress on the dance floor, and crosses paths with some drunken fool ( I have no kind words for drinking and driving-unless of course you are “drinking in” the scenery). He is involved in a hit and run accident by that drunken fool, but is luckily is pulled aside by boda boda riders who rush to the scene. Not to search for his phone and wallet  but to actually help.  He is “rapidly” whisked away by the ever dependant police pickup truck, bouncing over potholes to a public hospital, by-passing 3 private hospitals with 24 hour emergency services. (Health care is getting more costly. This is where I tag the long awaited-still delayed National Health Insurance Scheme-#NHIS). Anyways, a quick triage at the Accidents and Emergency unit and he ends up at the “surgical side of the A&E”. (The 6 bed trauma Unit is filled, and oh, Yes we have two A&E sides- Medical and surgical, and you better not have some hidden trauma with no obvious blood, and bleed to death in the Medical side). He is identified by a colleague doing a rotation on the surgical side of the emergency ward who opens quickly fills in his details in the file. Unfortunately he suddenly deteriorates requiring resuscitation. The intern doctor, first day on the job, frantically calls the Senior House Officer (Resident), the patient is stabilised and prepared for an emergency craniotomy by the Neurosurgeons on call, who are luckily in the hospital at that time, reviewing a post-op patient. He has a succesful operation with good long term prognosis. 

This would be one of the luckiest chaps to have an accident in Uganda. Somehow all those not very fitting pieces have “fit”. He ends up at the wrong place but everything thereafter somehow works in his favour. This is NOT a typical picture.

Imagine a link missing in any one of those steps-and this student could have died. That is a clearer picture. And I shall not go into the sad picture, should this accident have occurred in Moroto, or Nebbi or Kapchorwa-hundreds of miles away from a Health facility with emergency services, a trauma center and  a Neurosurgical unit.

The sad reality is that this picture will only worsen unless we have a system in place to ensure timely care for the best possible outcomes. Whether or not Uganda has a functioning EMS, is something I will leave to you. What I am certain of, however, that Emergency Medical Care is evolving in Uganda. One day it will not be a matter of chance, maybe and "hopefully". 

One day Uganda's EMS will be a matter of DR ABC, a matter of certainty and reliability.

Next week we have an exciting Interview from “the Boda Boda frontlines

REFERENCES:

1.       GOVERNMENT OF UGANDA, Ministry of Health, HEALTH SECTOR STRATEGIC PLAN III

2010/11-2014/15

2.        Macfarlane S, Racelis M, Muli-Musiime F. Public health in developing countries.

Lancet 2000;356:841-6.

3.        Walt G. WHO under stress: implications for health policy. Health Policy

1993;24:125-44.

4.       Junaid A. Razzak1 & Arthur L. Kellermann. Emergency medical care in developing countries: is it worthwhile? http://www.who.int/bulletin/archives/80(11)900.pdf (accessed 31/10/2014)

By Joseph Kalanzi