DE LOS SEGUROS

The outcome of EVD outbreaks is largely due to the capacity of the health system to respond in controlling and managing them. The mass mortality rate that resulted from the unprecedented West African outbreak was largely due to the inadequate health systems and lack of resources in the affected countries underlined by extreme poverty. In the case

of Sierra Leone, years of civil war resulted in an almost non-existence of a health system at the time the EVD emerged (Boozery, Farmer & Jha, 2014).

Data Presentation 4.2.2

Theme 2: Structural Determinants of Delayed Diagnosis Category 2: Weak Health Systems

(i) Non-preparedness (Data Presentation 4.2.2.1) (ii) Overburdened health system (Data Presentation 4.2.2.2) (iii) Poor surveillance and diagnostic capacity (Data Presentation 4.2.2.3) (iv) Lack of resources to implement infection control (Data Presentation 4.2.2.4) (v) Lack of support to health workers (Data Presentation 4.2.2.5) (vi) Endemic burden of disease (Data Presentation 4.2.2.6)

4.3.2.1 Unpreparedness

The findings convey the resources available to the heath workers to manage an unknown infectious disease in Bundibugyo and Kibaale as recalled by the participants at the time EVD emerged in 2007 and 2012 respectively.

Data Presentation 4.2.2.1

Theme 2: Structural Determinants of Delayed Diagnosis Category 2: Weak Health Systems

Open Code 1: Unpreparedness

• The challenge was understaffing because we started few here we had to work day and night no rest, those were the challenges (IDI, K4)

Out of stock so whenever we

• We had nothing exactly [] yeah just normal soap [] we didn’t have even gloves in the whole district, because they were out of stock so whenever we could get a patient we could ask a patient to buy some gloves so that we, we manage using those gloves and they were a bit expensive (IDI, B2) • We didn’t have, cause even uniform because we were just like we are, we didn’t even have uniform,

so even gloves were not there by that time, patients were just buying, patients could buy themselves gloves (IDI, B2)

• The challenge which came immediately after that [diagnosis of Ebola] was we had no funds available, they told me the budget line is too low [] after reducing our budget we don’t provide meals for our patients, so that one also became a big challenge to us [] we had these grumpy nuts, between us we started giving and then even those who were strong started rioting and nobody would provide them with food. Eh it was a real problem (IDI, K11)

Unused launderette, Kagadi Hospital, Kibaale District 2014 Source: Researcher (DO, P4)

4.3.2.2 Overburdened systems

In addition to the weaknesses within the health, facilities to respond to epidemics the systems themselves were overburdened on a daily basis by the existing burden of endemic diseases affecting a rapidly expanding population.

Data Presentation 4.2.2.2

Theme 2: Structural Determinants of Delayed Diagnosis Category 2: Weak Health Systems

Open Code 2: Overburdened health System

• Like the hospital was supposed to be having at least a hundred patients at the time it was constructed in the sixties [] but now it is getting over 300 [] they have wards but they are overwhelmed by patients, you find some patients are on the floor, the space is not enough

(IDI, B10)

• We run out of supplies most of the time, because they supply quarterly and the supplies are not enough for the quarter. It’s a 100 bed hospital but most of the time you are having more than 200 in-… 300 in-patients and then the outpatient is so high, it is so so high so the supplies are completely insufficient and even then, even the funds for other services, for the last 10 years they have been funding the same amount of money as capitation work as being given by central government (IDI, K1)

• The Congolese refugees, they drowned in the water and we had more than 200 bodies brought here [] they were escaping from their side there, coming to Bundibugyo [] yeah, so it was a disaster [] they were taken across Congo but those that came after 72 hours they refused to bury them so they were brought back [] so now the town Council could not get land and after here and there they decided to borrow a piece of hospital land, its just across somewhere, that’s where they buried them (IDI, B7)

• You even find that the water system is breaking down in health facilities in Bundibugyo Hospital, and as I said Bundibugyo Hospital was constructed in 1969, the infrastructure in Bundibugyo hospital in terms of staff quarters, in the water system and the toilet system is very poor, leaves a lot

to be desired. Yes so the sanitation in Bundibugyo Hospital is extremely poor whereby the buildings are very old and the sewage line blocks frequently and there is overcrowding in the staff quarters, can no longer cope with the number of the staff they are supposed to accommodate (IDI, B4).

Morgue Kigadi General Hospital, Kibaale District 2014 Source: Researcher (DO, P5)

4.3.2.3 Poor surveillance and diagnostic capacity

Data Presentation 4.2.2.3

Theme 2: Structural Determinants of Delayed Diagnosis Category 2: Weak health system

Open Code 3: Poor surveillance and diagnostic capacity

• We are supposed to use money from surveillance but we don’t get money from surveillance and it is WHO that is supposed to sponsor such things [] you fail to do surveillance work, all the health units in the district you are supposed to do active surveys and disease surveillance, but this money is never enough at times there is not even means of transport like transporting that sample going to Kampala (IDI, B2)

• Really minimal procedures they could do, some microscopy, some bit of parasitology, and these mainly antigen antibody tests, I don’t know how you want to put them [] We can’t do good microscopy, I mean microbiology and parasitology (IDI, K1)

• The team came with a preliminary diagnosis where they said this could have been worms, actually I remember the first preliminary diagnosis was concluded as worms but it was not concluded by that team because the Ministry responded immediately and came the following day, (IDI, B6)

Despite the levels of health service delivery outlined in the Health Sector Strategic Plan (Chapter one, Table 1.2) that suggest a bottom up approach commencing at the village level, it became evident from the data that even if investigations of the reports of multiple deaths in the village were taken seriously the resources needed to commence surveillance or investigative procedures were not available.

4.3.2.4 Lack of resources to implement infection control

At the time of EVD emergence in Bundibugyo and Kibaale, the basic resources to control the spread of infection were not available as evidenced from the findings. Whilst the community was blamed for delaying to seek conventional health services, the capacity within those services to conduct surveillance, perform or confirm laboratory diagnosis of EVD were also not available. In the Bundibugyo case study the diagnostic equipment specific to identifying the virus was not, available in Uganda at that time and that the particular strain of virus, Ebola Bundibugyo (BEBOV) had not previously been identified.

Data Presentation 4.2.2.4

Theme 2: Structural Determinants of Delayed Diagnosis Category 2: Weak Health Systems

Open Code 4: Lack of resources to implement infection control

• I was taking some samples, stool samples, then in the process, we didn’t have protectives, we didn’t have gloves, so in the process I contracted the infection (IDI, B2)

• there was no clear cut information so they ended up bringing patients here and where we got a problem was because we lack some skills on infection control. [] It was unfortunate that during that time we had a shortage of gloves in the hospital here...there wasn’t enough gloves and of course no protective gear (IDI, B8)

• We are always improvising, at least we make sure there are gloves and aprons for the surgical, for the main theatre and some other procedures on the ward where, but you cant say there are enough gloves for every, for every staff on the ward (IDI, K1)

• The main problem we have with the water is the supply system has broken down. It was last repaired in 1998 I think [] So most of the systems, even the toilets are broken down and the pipes are blocked, [] so the cleanliness, hygiene and infection control is generally difficult when you don’t have those water systems (IDI, K1)

• we have a number of cleaners, at least one cleaner is attached to one ward, so they normally clean in the morning, so you find from the morning up to the evening, you find the ward being dirty, they have to wait until the next what [day] (IDI, K4)

Non-functioning incinerators, Kigadi Hospital, Kibaale District 2014 Source: Researcher (DO, P6)

4.3.2.5 Lack of support to health workers

Lack of intervention and support resulted in the deaths of health care workers who also experienced powerlessness in their efforts to seek government intervention.

Data Presentation 4.2.2.5

Theme 2: Structural Determinants of Delayed Diagnosis Category 2: Weak Health Systems

Open Code 5: Lack of support to health workers

• When we started the isolation unit the district got concerned that there is an outbreak of some infectious disease but then they didn’t have much help, no support at that time, because even at the time we started we didn’t have protectives. I remember one time at a DHT meeting, district health team meeting, I argued for provision of protectives but it was taken lightly (IDI, B5)

• Ministry was only coming and it was stopping at that office over, say higher office, they would come and meet the CAO or the DHO and discuss how do we manage, that was all, but Ministry had not sent health workers support (IDI, B6)

• it took a long time because imagine from August up to Novemeber people were dying there and they had not realised that it actually was Ebola, it took a long time (IDI, B8)

• I: how long were you left in that situation before you got real intervention, how long was the hospital coping with...

4.3.2.6 Endemic burden of disease

Throughout the data several references were made to the endemic diseases in Bundibugyo and Kibaale districts. The most common diseases presented at the health facilities included malaria, diarrhoea, respiratory diseases and anaemia related to sickle cell disease. Several references were also made to previous cholera, measles and dysentery outbreaks within the camps hosting refugee populations and informal settlements near the shores of Lake Albert.

Data Presentation 4.2.2.6

Theme 2: Structural Determinants of Delayed Diagnosis Category 2: Weak Health Systems

Open Code 6: Endemic burden of disease

• When there is rain, in Bundibugyo, you expect malaria and diarrhoea, because of mosquitos around, stagnant waters and whatever. And with pneumonia when it is cold, children who are not covered well, they can develop cough and then pneumonia can come in (IDI, B11).

• We controlled it, it was a deadly type of dysentery because we lost more than 10 patients (IDI, B5) • we used to experience cholera epidemics almost every year, actually for a very long period from

like, from around 1980 up to 2000, also we used to have some cases of dysentry both amica and bacilla dysentry, also we had some epidemics of meningitis actually (IDI, B4)

• Yeah malaria is the most common, the reason is we have so many water channels in the district and people are thins but mostly the water channels are so many malaria and pneumonia, respiratory tract infection yeah and diarrhoeal diseases those are the commonest two and in addition to that we have so many sickle cell (IDI, B7)

• I remember, about the same time [EVD outbreak, 2012] we had cases of cholera at the lakeshore side so we had to go in and also manage that, at the same time there was some bloody diarrhoea, just dysentery which had occurred in a certain sub-county. (IDI, K7)

Respiratory conditions reflect between 12% and 20% of all morbidity cases in Bundibugyo and Kibaale respectively (UBOS, 2011). Several references were made to cholera

outbreaks in both case studies. Uganda reports a maternal mortality ratio of 438 per 100,000 live births and an under five mortality of 90 per 1000 live births.