Paper on challenges faced during the Hospital Building and supervision of new hospitals in Uganda, Africa

1. 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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2. 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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3. 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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4. 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
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5. 5
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

6. 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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7. 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 5,000
Health 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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8. 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, Gulu
and 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

9. 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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10. 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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11. 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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12. 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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13. 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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14. 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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15. The Solutions
 Same service design, 2 different sites
 Ten-storey main hospital building on a compact site
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16. 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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17. 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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18. 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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19. 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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20. 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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21. 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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22. 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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23. 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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24. THANK YOU
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FOR GOD AND MY COUNTRY