The Role of Borama Hospital in Awdal Health Services: Prioritization of Services

[Jacaylbaro]

Introduction: Brief Overview of Hospital Roles

 

Hospitals are important, but costly component of the health system. Changes are taking place both globally and locally in the social, demographic, technological, epidemiological and economic spheres, and therefore affect the hospital policies and its role.

 

The infrastructure development, expansion of services; updating the technology in use and mechanisms for maintaining that technology—all of these coupled with financially escalating cost and resistance of professionals to accept the resources dimensions of clinical decisions in spite of cost containment strategies had affected the performance of both technical and allocative efficiency.

 

Hospitals absorb the major share of health expenditure in any country. Share of hospitals from the total government health expenditures globally ranged 50-60 and producing 20% of the sector output, still many hospitals are run at a very low occupancy rate, with concentrated staff and equipments, most in urban areas, and inefficient use of available resources. Until the 12th century, most hospitals were small and basic and seldom offered medical care. These early hospitals were refuge for sick poor people who were admitted for shelter and basic nursing care and were also a means of isolating those with infections. Hospitals had developed and evolved over the centuries in response to changes in social, political and medical knowledge.

 

The changing role of hospitals continued through out history. New technologies, procedures and pharmaceuticals enable patients to receive more complex interventions. An important evolving feature of hospitals is that many past hospitals restricted interventions are transferred to be practiced either at less complex settings (ambulatory and home care). The involvement of hospitals in health prevention and promotion had gained widespread implementation since 1980s globally but not in our homeland. The percentage of inpatients receiving preventive and promotive services in Borama hospital is not encouraging. Where prevention and promotion services are of low quality or not even provided, people are not aware of risks associated with so many deadly diseases and conditions.

 

With respect to management, globally the key determining managers were senior clinicians and tended to be reactive to daily issues and emergent problems rather than proactive in developing corporate objectives. Information on new hospital models in management is available through the internet, in public health text books and biomedical journals. Quality assurance is at the center of hospital management. Patient and staff safety must always be the guiding principles and leading functions of the hospital management. Patient safety is indeed a critical area of activity that hospital personnel including managers and auxiliaries need to grasp and implement to best of their capacity. If this concept is missing hospitals turn into a deadly disease distribution sites.

 

In many developing countries, hospitals are not integrated into primary health care system, leading to contrasts in resources and workloads. For e.g Borama hospital outpatient facilities are often crowded due to non-functioning referral system. It can be idle, underutilized or inoperable high technology litters the hallways, while health centers in remote districts lack basic laboratory or diagnostic equipments. Districts health teams or MCHs cannot visit remote areas due to lack of transport, while hospital ambulances are used primarily for administrative and personal tasks rather than servicing the patient.

 

Hospitals are confronted with complex problems as far as resources are concerned. Patient overcrowding in wards, long waiting queues in outpatient unit, questionable quality of care, low staff morale, dirty and decaying facilities—all of these are compounded by lack of clearly defined role and relationship to other parts of health system.

 

Health Problems In The Region (In Brief)

 

Infectious diseases including parasitic infestations continue to be the leading cause of morbidity and mortality in our community. The major infectious diseases are tuberculosis, malaria, HIV/AIDS, vaccine preventable diseases and epidemic prone infections such as cholera, shigellosis, typhoid etc. Hepatitis B and other blood borne disease are widespread most probably associated with the level injection safety and sterilization. In other words, waterborne (cholera), water-based (trachoma), water-related (quantity-driven), blood-borne, and insect borne diseases are common and do represent major public health problems.

 

Non-communicable diseases including cardiovascular, diabetes, cancer and mental disorders have acquired greater momentum in the area owing to the quality of lifestyle and environmental health. Although we can not authenticate with concrete data, we are witnessing that non-communicable diseases are taking their toll. An estimated 35% of all deaths of above 50 years of age are attributed to cardiovascular diseases. If an appropriate intervention is not put in place, that number will double by the next ten years. A major risk factor is the Khat with its confounding factor—tobacco in all its forms (cigarettes, pipes, water pipes, smokeless, tobacco and bidis)

 

Making Tough Choices: Purpose of The Paper

 

We usually see information/news on websites about donations from the diaspora to Borama Hospital. If you try to recall how many donations were made over the past 10 years for Borama Hospital, it is a quite a lot. Perhaps it forms around 80% of all donations sent from outside. We are grateful to those who have been profoundly engaged in mobilizing resources for the community hospital. Gargaar, Gurmad, and other foundations have demonstrated an extraordinary sensitivity to health services which we deem it as some of most valuable contributions to a social cause.

 

The last perhaps most interesting is the donation to Borama new Fistula Hospital. The community certainly appreciates such an innovative and groundbreaking project. A new specialized center contributing to women’s health is vital and will address the appalling conditions of those who suffer from pregnancy & delivery related complications. Fistula is the byproduct of obstructed labour and the latter is a condition which can be addressed through various interventions which are cost-effective and affordable.

 

The analysis made by the doctors in Borama on this would-be first fistula facility in Somalia or Somaliland whatever is quite convincing. The emotional part nevertheless associated with its need should be understood. It is true that young women suffer and are being ostracized because of obstetric fistula, it is true that fistula is a terrible condition which requires special attention and it is strongly true that fistula remain a significant or a major public health problem in the area.

 

While recognizing the importance of secondary or tertiary care, it is imperative to understand your available resources, both human and material and your priorities. We need to understand the most cost-effective and sustainable interventions for tackling the major or most common public health problems. If we succeed in delivering these basic interventions, we will save many lives, reduce the burden of diseases and significantly reduce Borama hospital recurrent cost.

 

Embarking with basic analysis on Awdal health care delivery system, there are two elements, I would like to share in this paper: It is not a debate but a mere individual’s perspective

 

1. How can we reduce or address the hospital recurrent cost? (a) Given our disease prevalence and epidemiological picture, do we believe addressing the hospital needs will help reduce morbidity and suffering?

 

2. Does the fistula hospital is priority in service provision? (a) Are other interventions available and at what cost?

 

Let’s first know that the situation described above is not unique in Awdal, it is everywhere in Somalia or in other developing countries.

 

Whatever the answer to those queries might be, we should always thank to our people who volunteered to collect donations for the health sector. They are indeed touched by the health needs, they understand the importance of health and health services and they feel the pain and suffering of those who need most. There is no doubt however that our volunteers, foundations need to understand where we are heading with these donations, and how it is contributing to laying down a sustainable foundation of the health system.

 

We know people’s perceived knowledge about the condition of Borama hospital. It is quite simple and clear. They believe patients are suffering in the hospital so they must help but it’s the opposite, the hospital is suffering because of many inpatients and indeed the over-riding fact is that people are already suffering before they arrive at the hospital. The point is how we can prevent having so many inpatients? Having so many sick? Having so many disabled? Having so many depressed? And having so many injured?

 

It all boils down to what we all know and i.e. Prevention is better than cure. Strengthening our preventive and promotive services is the answer to those questions. If we keep spending the bulk of our meager resources to maintain the hospital laundry or bed sheets and nothing for preventive and promotive services, then we are stuck with huge recurrent cost and influx of inpatients.

 

The following is quite important for reducing the hospital needs and cost and most importantly the disease burden.

 

We are now bringing people to health care i.e. people from all over the region and beyond are coming to Borama hospital to seek health care. We must do the opposite and that is we should bring the health care to people by increasing access, by increasing utilization, by raising awareness, and by involving themselves. Community-basic healthcare system is vital in addressing the most common health problems.

 

On Fistula—we have no data on how many cases the region see every quarter or every semester. Data is usually sketchy or does not exist at all. If you want to establish a road safety project, you should how many road accidents occur in your area. I’m sure doctors back home have estimates about the number of fistula cases they observe.

 

Obstetric Fistula is defined as an injury to the pelvic tissue caused by prolonged, unrelieved obstructed labour that can last up to five days. It is a devastating and preventable tragedy that primarily affects young, poor women who lack the means to access quality maternal care. Poverty is therefore the fundamental cause of Fistula. Inadequate nutrition, stunted growth, limited access to health care, and traditions of early marriage and pregnancy—all contribute to the likelihood of obstructed labour.

 

Given the above, we must ponder on how we can face this daunting challenge. Early on, we said the main culprit of fistula is obstructed labour. If we succeed to establish a facility to treat this agonizing and distressing condition, it is remarkable. Nevertheless, what are the collateral effects you may expect to see in an environment where the root cause of a problem is not addressed? Shaving every morning your beard does not stop, the stuff keep coming?

 

We address here the core issues, reflecting our innovative approaches without discouraging or undermining ongoing efforts. The following include some of the basic and affordable interventions that are used to prevent and reduce the pregnancy complications:

 

At facility level: use of partograph (a tool to assess the progress of labour) is pivotal. If this intervention is well documented in Awdal health policy, it must reach all districts and health facilities. Health workers, particularly skilled birth attendants must be trained on partograph.

 

There is what we call “three delays” when we are dealing with delivery. This is referring to interventions taking place at different level. At household or community level, people must know the danger signs of labour. (If family members or the Umuliso doesn’t recognize the danger signs during labour or delivery, they just wait and wait and wait until the poor, agonized expectant mother face the nasty complications or even die—this is called first delay and it takes place at home.

 

The second delay occurs during the transportation of the patient (pregnant mother) to health facility. This is the worst we have no ambulances, we have no roads and at times we are lacking fuel and we have no referral system. Solutions to such a challenging factor are not easy but they can be attained through appropriate community-based interventions.

 

The third delay; it occurs at facility or hospital level (the intervention is delayed because the anesthetist is not there, because it is a weekend, because the doctor is busy with other life threatening emergencies, because bed is not available, because the severity of the condition is misjudged by the attendant, because blood is not available, because there is no electricity, because the medical store is closed…etc. etc.

 

Any effort targeting these delays is a direct intervention mitigating the threat of obstructed labour and therefore its grave complication—the fistulae.

 

The Following is The Key Message:

 

1) Revitalizing the primary health care program throughout the region and reaching the community will help reduce disease burden. If appropriate health policies are not exercised, we can not get away from the narrow vision that is placing our efforts into endless circles. Self-referral is common practice due to low image and competence of primary health facilities.

 

2) Promoting sports and healthy lifestyles in the area can reduce 50-55% of both morbidity and indeed mortality of all cause.

 

3) If the fistula facility is considered indispensable, we can still think of integrating

into Borama maternity hospital, eking out the limited resources. If the cases are not alarming, we can use part of the maternity facility for various complications.

 

Once again thanks to our volunteers and foundations!! Health is central to development.

 

 

I apologize for using medical terminologies.

 

 

Dr. A. Momin Ahmed

Email: MominA@afg.emro.who.int