Does the Orthopaedic Outreach Programme “Work” for Uganda? Richard Coughlin MD, MSc

Musculoskeletal conditions Account for much long-term pain/disability Have 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 healthcare Access Availability Less “Health” Schlenker et al 2002

Orthopaedic Outreach Programme With recognition of significant service delivery inequality The 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 studies Mutyaba presented ASEA 2003 OOP to Fort Portal Found cost-effectiveness Cost per referral patients (US $35) Cost per Outreach patient (US $8)

Methodology Literature/Document Review Quantitative methods Qualitative Key Informant Interviews(NGOs/IPH/MOH/Mulago) Semi-structured Interviews

Visited 4 Regional Hospitals Mbale Arua Masaka Fort Portal (surgical camp 2004)

Limitations of Study All interviews conducted/coded/analyzed by one ortho surgeon Lack of overall burden of musculoskeletal disease in Uganda Poor follow-up on outreach results No beneficiary interviews

Observations and Results Between : 50 missions with MOH support Between : 67 missions with partnership with USDC

Obsevations and Results Quantitative output Decentralization of orthopaedic services and decongestion of Mulago Hospital by: 6,653 patients 1,071 surgeries

Capacity Building Objective New Orthopaedic surgeons at: Mbarara Mbale Masaka

Qualitative Assessment 41 interviews conducted July 2004

Interviews

Barriers to Access Barriers to access UnavailabilityStigma PovertyNo money Distance to facilityPoor roads/transportation Lack of awarenessLack of sensitization Language barriersCultural priorities Deficient servicesTraditional healers Fear of Mulago/KampalaPoor support services WarSecurity

Harms of OOP

Benefits of OOP to System BENEFITS OF OOP TO SYSTEM Major themesMinor themes Support/Supervision of medical officersSolidarity/Commitment to regional/district hospital Increase in communicationImproved status of health system Support of PHC with musculoskeletal conditions Advocacy of burden/risks/preventive measures Medical education and skills improvementStimulus to upgrade infrastructure

Benefits to Patients/Family BENEFITS OF OOP TO PATIENT/FAMILY Major themesMinor themes Higher standard of careDecreased stigma of disability Lessening of economic burdenDecreased reliance on traditional healers Improved patient satisfactionEmpowerment for self-improvement Increased awareness of serviceCultural and needs awareness Decreased time to serviceImproved communication

Operational Constraints CentralRegionalLocal 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 visitsNeed 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 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 Uganda Surgery is increasingly seen as cost effective and possibly part of the essential package of clinical care Despite 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 issues OOP “works for Uganda” but Needs improved organization Needs integrated surgical services and PHC Needs follow-up, data systems, regular monitoring and evaluation

Recommendations Obtain baseline studies to quantify need and priority interventions Strengthen and further develop community-based rehab network Garner greater involvement from grassroots level Bottom-up planning/implementation/evaluation

Recommendations cont. Work toward attainment of ortho surgeons at all regional referral hospitals Create partnerships of all actors MOH/Public/Private NFP Hosp/OOP PH/CBR/Civil Society(NGOs, Service Org, Prof. Societies Greater emphasis on teaching/training/capacity building Sustainable funding