Does the Orthopaedic Outreach Programme “Work” for Uganda?
Richard Coughlin MD, MSc
Musculoskeletal conditions
Account for much long-term pain/disabilityHave received far less public health attention
Successful management of childhood and communicable diseases
Has shifted the burden of disease to musculoskeletal and non-communicable conditions
WHO Scientific Group 2003
Increase in life expectancy along with increase in Road Traffic Accidents
Challenges already depleted health systems
Mock et al 2004
By definition: rural, remote, disadvantaged populations have overall less healthcareAccessAvailability
Less “Health”Schlenker et al 2002
Orthopaedic Outreach Programme
With recognition of significant service delivery inequalityThe Dept of Orthopaedics at Mulago instituted the Orthopaedic Outreach Programme in 1991“provide specialized quality orthopaedic sevice to upcountry patients in their community”
Recent Cochrane Review: “Specialist Outreach Clinics in Primary Care and Rural Hospital Settings”
Gruen concludes:Need for further studies in
rural/disadvantaged “where outreach interventions may offer the most benefit to access, better health outcomes, and greater impact”
Gruen 2004
Need for Study
Very few Southern studiesMutyaba presented ASEA 2003
OOP to Fort PortalFound cost-effectivenessCost per referral patients (US $35)Cost per Outreach patient (US $8)
Methodology
Literature/Document ReviewQuantitative methodsQualitative
Key Informant Interviews(NGOs/IPH/MOH/Mulago)Semi-structured Interviews
Visited 4 Regional HospitalsMbaleAruaMasakaFort Portal (surgical camp 2004)
Limitations of Study
All interviews conducted/coded/analyzed by one ortho surgeonLack of overall burden of musculoskeletal disease in UgandaPoor follow-up on outreach resultsNo beneficiary interviews
Observations and Results
Between 1991-2002: 50 missions with MOH supportBetween 1999-2004: 67 missions with partnership with USDC
Obsevations and Results
Quantitative outputDecentralization of orthopaedic
services and decongestion of Mulago Hospital by:6,653 patients1,071 surgeries
Capacity Building Objective
New Orthopaedic surgeons at:MbararaMbaleMasaka
Qualitative Assessment
41 interviews conducted July 2004
Interviews
Mulago / Kampala
Mbale Arua Masaka Fort Portal Total
Orthopaedic Surgeons
3
2 0 1 0 6
Orthopaedic Officers
2 0 0 0 1 3
Orthopaedic Technicians
0 1 0 0 0 1
Nurses 2 0 0 0 1 3 District Dir. of Health Svcs
0 1 1 1 1 4
Medical Supervisor
0 1 1 1 1 4
Medical Officer
1 0 1 1 0 3
NGO Representative
4 1 2 1 0 8
Ministry of Health
4 0 0 0 0 4
PT / OT 0 0 2 1 2 5
Total 16 6 7 6 6 41
Barriers to Access
Barriers to access
Unavailability Stigma
Poverty No money
Distance to facility Poor roads/transportation
Lack of awareness Lack of sensitization
Language barriers Cultural priorities
Deficient services Traditional healers
Fear of Mulago/Kampala Poor support services
War Security
Harms of OOPHarms of Orthopaedic Outreach Programme
To the outreach site: To the Department/Surgeon:
Opportunity costs away from PHC Time away from service/education
Increased local workload Financial loss from private practice
Depletion of supplies Demanding work schedule
Increased local costs Ethics of post-operative care
Potential worse outcomes from poor
follow-up/non-adherence
Loss of outcome information for clinical
lessons learned
Professional jealousy
Benefits of OOP to SystemBENEFITS OF OOP TO SYSTEM
Major themes Minor themes
Support/Supervision of medical officers Solidarity/Commitment to regional/district hospital
Increase in communication Improved status of health system
Support of PHC with musculoskeletal conditions
Advocacy of burden/risks/preventive measures
Medical education and skills improvement Stimulus to upgrade infrastructure
Benefits to Patients/FamilyBENEFITS OF OOP TO PATIENT/FAMILY
Major themes Minor themes
Higher standard of care Decreased stigma of disability
Lessening of economic burden Decreased reliance on traditional healers
Improved patient satisfaction Empowerment for self-improvement
Increased awareness of service Cultural and needs awareness
Decreased time to service Improved communication
Operational ConstraintsCentral Regional Local
Mulago poorly functioning as a referral hospital due to: bureaucracy workload overcrowding corruption
Declining infrastructure/ manpower/capacity inadequate beds inconsistent electricity inconsistent water supply poor x-ray machines poor operating theatres
Need for greater sensitization
Irregular/inadequate funding from donors MOH
Inadequate funding (capped during the last three years)
Need for greater mobilization
Need for more visits Need for data/information systems for monitoring and evaluation
Need better follow-up/ adherence
Need for improved communication, especially post-op
No funding for post-operative care/rehabilitation
Need better network/CBR
Need for improved coordination
Indifference/inadequate skills for musculoskeletal conditions
Need for ownership
Need for improved coordination
Need for improved coordination Need for improved coordination
Need for shared commitment
Need for shared commitment Need for shared commitment
What “Works” for Uganda?
Overall- “more benefit than harm”But- “single disease approach”Need for systematic, integrated surgical services delivery
That is part of a comprehensive, prioritized health care delivery system
Conclusions and Recommendations
Musculoskeletal conditions pose an increasing BOD to UgandaSurgery is increasingly seen as cost effective and possibly part of the essential package of clinical careDespite decentralization, rural/disadvantaged/”poorest of the poor” lack access
Conclusions and Recommendations cont.
Specialty Orthopaedic Outreach provides short-medium term solution to equity and access issuesOOP “works for Uganda” but
Needs improved organizationNeeds integrated surgical services and PHCNeeds follow-up, data systems, regular monitoring and evaluation
Recommendations
Obtain baseline studies to quantify need and priority interventionsStrengthen and further develop community-based rehab networkGarner greater involvement from grassroots level
Bottom-up planning/implementation/evaluation
Recommendations cont.Work toward attainment of ortho surgeons at all regional referral hospitalsCreate partnerships of all actors
MOH/Public/Private NFP Hosp/OOPPH/CBR/Civil Society(NGOs, Service Org, Prof. Societies
Greater emphasis on teaching/training/capacity buildingSustainable funding