Challenges faced during the Development of new high demand Public Hospitals - with

limited Budgets, Land and Time Constraints in the City of Kampala, Uganda

by

D. Abola, P. Kaliba, R. Sengonzi, S. S. B. Wanda and C.I. Meirovich

SAFHE/CEASA 2015 – Johannesburg, South Africa

11-13th August 2015

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Presentation Outline

Introduction and Background Project Rationale Health services delivery in Uganda and

Kampala City Project Challenges Project Management Solutions Conclusion and Recommendations

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Introduction and Background … 1

Uganda: East Africa and bordered by Kenya, Southern Sudan, DRC, Rwanda and

Tanzania. Coverage : 241,038 km2

Population: 34.1 million

Kampala, the Capital City of Uganda

Coverage: 189 km2

Day Population: approx. 4 million Resident Population: approx. 1.79

million

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Introduction and Background…2

Project Name: Improvement of Health Service Delivery in Mulago Hospital and in the City of Kampala Project (MKCCAP).

Project Funded by: African Development Fund (ADF) and the Nigerian Trust Fund (NTF)

Project coverage: Mulago NRH and Kampala Metropolitan Area

Project Period: July 2012 – 31 December 2016

Project costs : Total Cost: $85 m

Executing Agency: Ministry of Health 4

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Project Rationale

Improve delivery of quality health services in Mulago Hospital & the City of Kampala

Increase access to quality and affordable healthcare services for the population of Kampala Metropolitan area

Decongest Mulago Hospital by improving services at the Division levels and redirecting high demand for basic health care

Health Service Delivery in Uganda and Kampala City…1

An estimated 24.5% of the population lives below the poverty line: 34.2% from rural areas; and 13.7% from urban areas

Health service provided through a tiered structure: Village Health Teams (VHTs) at village level to National Referral Hospital Level as per Table overleaf.

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Health Service Delivery in Uganda and Kampala City…2

Health Unit Infrastructure (Medical) Beds Location Population

Village Health Teams (VHTs)

None 0 Village 1,000

Health Centre II OPD 3 Parish 5,000Health Centre III OPD, Maternity / General Ward 8 to 24 Sub-County 20,000

Health Centre IV OPD, General Ward, Theatre, Maternity Ward

25 to 59 County 100,000

General Hospital (GH)

OPD, various Wards, Lab, X-ray, Theatre, Kitchen/Laundry.

60 to 249 District 500,000 to 1,000,000

Regional Referral Hospital (RRH)

All the above plus Specialist Units in various fields

250 to 500 Region (3 to 5 districts)

1,000,000 + to 2,000,000

National Referral Hospital (NRH)

Advanced Tertiary Care 450 to 1,500

National Over 30,000,000

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Health Service Delivery in Uganda and Kampala City…3

Government Hospitals in Uganda

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Category Hospital Name

National Referral and Teaching

Hospitals (4No.)

Mulago (including the Heart and Cancer Institutes), Butabika, Guluand Mbarara

Regional Referral Hospitals (12 No.) Arua, Hoima, Jinja, Kabale, Fort Portal, Masaka, Mbale, Lira, Soroti,Naguru, Mubende and Moroto.

General Hospitals (41No.) Abim, Adjumani, Anaka, Apac, Atutur, Bududa, Bugiri, Bukwo,Bundibugyo, Busolwe, Buwenge, Bwera, Entebbe, Gombe, Iganga,Itojo, Kaabong, Kalisizo, Kagadi, Kambuga, Kamuli, Kapchorwa,Kisoro, Kawolo, Kayunga, Kiboga, Kiryandongo, Kitagata, Kitgum,Kyenjojo, Lyantonde, Masafu, Masindi, Mityana, Moyo, Nakaseke,Nebbi, Pallisa, Rakai, Tororo, Yumbe

Health Service Delivery in Uganda and Kampala City…4

Breakdown of Kampala health facilities by ownership and level

A significant percentage (over 90%) of the health facilities in Kampala are Private For Profit (PFP) facilities and are at Health Centre (HC) II level.

Public facilities account for only 1.90%

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Project Challenges …1

Competing needs for effective delivery of essential healthcare services Lack of other public providers implies: Mulago Hospital is usually

diverted from its core mandate of providing national referral services to cater for the lower level health service provision.

Lack of adequate infrastructure and logistics for provision of equitable health services especially for the urban poor About 15% of all pregnancies develop life threatening

complications and require emergency obstetric care (EmOC); and, Only 11.7% of women deliver in fully functional comprehensive

EmOC facilities the slow progress in addressing maternal health problems in

Uganda is partly due to lack of appropriate buildings and equipment (Health Sector Strategic Plan (HSSP III)

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Project Challenges … 2

Challenge: ensure a network of functional, efficient and sustainable health infrastructure for effective health services delivery closer to the population especially for the urban poor who cannot afford to pay for services in the predominantly for-profit healthcare industry in the City.

Budgetary Constraints: At project appraisal, construction and equipping the three

hospitals was estimated to cost USD 75Million The 2 new hospitals are expected to provide various services at

the Regional Referral Hospital level Challenge: Budgetary constraints arising from having to

establish the 2 new hospitals and fully renovating the national referral hospital, as well as fully equipping all three, within the budgeted 75Million UD Dollars.

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Project Challenges … 3

Outdated project estimates: Project appraisal carried out in 2009 Actual project implementation did not take place until

October 2012 Challenge: Estimates prepared at inception of the

project rendered outdated because of the long passage of time between project appraisal and project implementation stage

Project implementation team has to constantly keep adjusting the original scope at the same time having to strike a balance with the expected project outcomes

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Project Challenges … 4

Late recruitment of the Biomedical Engineer: Plan at appraisal stage of this project: few key

technical staff would be initially recruited to supervise day-to-day project activities

long-term technical staff recruited at the time included: the project health architect, the project engineer,

the project quantity surveyor, the procurement officer, the financial specialist and his assistant

The biomedical engineer came on board much later on: hospitals’ designs had already been reviewed and construction of the structural frame and walling in advanced stages

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Project Challenges … 5

The Biomedical engineer found several design flaws that could affect the optimal functionality of the hospitals and equipment and advised on remedial design changes: which involved demolition of walls and electro-

mechanical works re-alignment These changes further stretched an already

constrained budget and caused delays due to rework

Suggested increasing the equipment budget from under USD 2 m to USD 4 m

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The Solutions

Same service design, 2 different sites Ten-storey main hospital building on a compact site

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The Solutions…….2

Compromising with space standards In order to meet the high demand for lower level

services, project to provide various clinical services (i.e. A&E; pathology; OPD with services including dental, Eye/ENT, orthopaedics, antenatal, paediatrics; imaging diagnostics & laboratories; 5 operating theatres and inpatient services) on existing land of less than 2 acres

Each hospital – also designed for 173 beds housed in a ten (10) storey building

Total area for different clinical, clinical support, non-clinical support and administrative services: estimated at 7,800 m2.

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The Solutions ……3

Compromising with space standards Total space per bed = up to 76 sq m Used to be considered adequate in the 1980s Now considered low for achieving and compliance

with a number of international standards Ratios above 100 would be more appropriate but

would lead to:- a reduction in the number of beds per room/bay and

consequently 150 beds However, due to space constraints, having to deliver

the project objective of decongesting the National Referral Hospital less beds not an option.

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The Solutions….4

Stakeholder Involvement

At the onset of the project’s implementation, architectural and structural designs had already been prepared

Due to passage of time: key stakeholders had changed; new information available; and, Original budgets no longer sufficient Designs had to be reviewed and modified by

another consultant

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The Solutions….5

It was deemed critically important to involve key project stakeholders in the design review These stakeholders were be part of the

problem-solving Stakeholder buy-in was considered

critical to the success of the constrained project

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The Solutions….6

Stakeholders have since been involved in the project’s implementation: at design review stage; at evaluation stage for both supervision

consultants and building contractors; as well as, the construction stage - active role

in decision making and attending the monthly site meeting

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The Solutions……7

Re-programming project funds In order to overcome budgetary deficits

brought about by: Under funding of medical equipment allocations Price fluctuations arising from passage of time between appraisal

stage and actual implementation (2009 v. 2013), as well as, fluctuating dollar rates

The project has had to re-programme funds that were previously allocated to activities that are no longer considered a priority in order to the complete construction and equipping.

e.g. The two hospitals originally allocated less than USD 2 million for medical equipment and furniture have sourced the shortfall be sought from other planned but non-priority project activities.

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Conclusions

The construction of the 2 new hospitals is in advanced stages, at about 65% progress and with a scheduled completion date of 31st

December 2015. Equipment tenders advertised and hopefully the hospitals to be occupied by end of January 2016

It is hoped that service delivery will be as planned to achieve project objective

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Recommendations

Phasing of works in case of inadequate budgets to avoid stretching expectations

Assembling full technical teams early on in the project to avoid project delays and rework arising from late technical advice

Provision of contingency funds as part of the project appraisal – safety net to cover unforeseen eventualities

Early engagement of key stakeholders to enable effective management of expectations and increasing satisfaction with end product.

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THANK YOU

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FOR GOD AND MY COUNTRY