Running a charitable health clinic in Uganda

The experiences and the ongoing challenges and enjoyment of managing a philanthropic health facility. Watching it grow through active community support and helping through coordination with national programmes, local NGO and groups and international like-minded people.

Monday, June 02, 2008

USG Meeting in Preparation for HIV Implementers

On 2nd June the US Government delegates from countries implementing PEPFAR and related USG initiatives meet in Kampala. They are following the theme of Scaling Up Through Partnerships that will continue on the 3rd June with the HIV Implementers Conference.

A Critical Barrier to Implementation has been the apparent reluctance for ‘larger’ organisations to engage with ‘smaller’ implementers. Just as general practice medical services are a network of small clinics, medium sized health centres and large hospitals, the provision of HIV services require mentoring and referral mechanisms. The barrier that Hope Clinic needed to, and with great struggle did, overcome was how to make the first contact and be heard by the best practice organisations. For the funders of these implementers, greater flexibility to share training, share materials or provide mentoring support would be a welcome lesson to learn when designing the next intervention.

It is understandable that national or district-specific programmes or donors have priorities. These can be an excessive focus on indicators or seeking the ‘quiet life’ by working again and again with the same partners to a point of saturation. Once everybody has a mosquito net in one location, the next location still has no nets.

An example is HIV counselling and testing – obtaining the HIV test kits for Hope Clinic offered three options: buy them if a supplier can be found; ask the doctor in charge of VCT in the Ministry of Health; become a partner or site of an established HIV testing organisation – in 2000 that was TASO, AIC, Mildmay or JCRC. Hope Clinic wanted to ensure that it was following best practices. The clients attending ANC checks deserved access to a HIV test and PMTCT services. If mothers could have tests, anybody who asked should be able to be counselled and tested. If those that ask of their own volition are learning their status, shouldn’t all clients be helped to appreciate the HIV situation accurately, decide whether they want to test and then have financial access to a test. We were required to deal direct with the Ministry as the only means we could find to obtain tests as we knew our community would see a fee as a barrier to being tested.

Hope Clinic Lukuli now has a comprehensive HIV service which is integrated with our general practice services. This helps Prevention. Clients who visit Hope Clinic for fever evaluation, coughs or maternity check-ups are reached with prevention messages, encouraged to know their status and informed to reduce stigma and promote disclosure and community care and support. The service ranges from outreaches, mobilisation messages and roadshows, through counselling and testing, household counselling for infected persons and the palliative care and support including Cotrimoxazole, to OI testing and treatment and access to ARVs. Positive clients and their households benefit from peer education groups, drama and prayer groups and follow up counselling and CD-4 monitoring.

This is only possible through coordination among HIV implementation partners – Government, donors and the private sector. There are more than 10 projects or collaborators working with Hope Clinic Lukuli in direct support of the HIV services. This is because each have their own area of best practice and none can – or should – try to specialise in all aspects of the HIV response. Hope Clinic is following the national strategy and prevention is a key part of our work. We strongly believe that knowing one’s status is essential and the assurance of financially accessible treatment is a huge incentive to be counselled and accept to be tested. Through our GP character we reduce the stigma of attending Hope Clinic. Our entire HIV service is free to the client because we have formed partnerships. We sustain ourselves with a low cost but efficient GP service.

Hope Clinic had to work hard to coordinate and create links with larger programmes.

Greater openness to meet new partners and work with established but smaller implementers would be a huge boost to prevention services – not only in Uganda.


Schedule of 6 PEPFAR, 2 Global Fund and 5 private grants at Hope Clinic Lukuli

Activity

Intervention

Partner

Awareness/ Prevention

‘Stay Alive’ health and lifeskills education program in schools and for out-of-school children

US grant (Until There’s a Cure) and Ugandan implementer (Reach the Children)

Awareness/ Know Your Status

Road show and drama to lower income/ densely populated communities with onsite counselling

Kampala City Council, Makindye Division and Joint Clinical Research Centre (JCRC/TREAT)

Awareness/ mobilisation to test

Distribution of leaflets in English, Luganda and Swahili on 6 topics of HIV including VCT, prevention, stigma and care for those with HIV

Developed by USAID Business PART, printed by Aggreko International (whose staff also received HIV awareness training from Hope Clinic, following the PART curriculum)

Outreach, counselling and testing

Mobilisation to community, reducing stigma and providing pre and post test counselling at the Hope Clinic

Aggreko paid for 1 year. HCL is a Prime recipient from the US Embassy Small Grants team allowing HCL to keep counselling free.

Test Kits

The three types of test kit used for HIV at Hope Clinic Lukuli

Supplied by US Government, routed through National Medical Stores and DELIVER/SCMS project. Alternate supplies through JCRC or Joint Medical Stores (JMS)

Laboratory Services

Improved microscope and centrifuge equipment and safety for lab staff

DFCU Bank financed new equipment and renovation of the laboratory with technical advice from CDC Entebbe.

Basic Care Package (C,S&T)

The boxed kit comprising two LLIN, a water container with purification chemicals and condoms

Funded by PEPFAR through CDC and the PSI contractor. Initially provided to HCL through PREFA project, Muyenga.

Septrin and self-care materials (C,S&T)

Anti-biotic provided at Hope Clinic to all clients confirmed as HIV positive. Positive Living literature, peer groups and outreach home visits

HCL obtained a US grant from Until There’s A Cure (www.utac.org) for first 200 clients. Then self-funded and now provided by JCRC-TREAT partnership. Peer groups funded by PSI.

Testing for opportunistic infections

Positive clients need prompt diagnosis of infections including STI and malaria

Aggreko paid for laboratory staff and reagents for 12 months to allow free to PLHA and free to youth lab testing.

Care, Support and Treatment for OI/ STI

Drugs for treatment of opportunistic infections, including malaria and STI, for PLHA. Mosquito nets to pregnant women and children under 5 years.

Coartem (ACT) from the Global Fund is free to HCL via Kampala City Council. Hope Clinic Lukuli bears the cost of drugs for other OIs. The Safe Injection Project gives syringes.

CD-4 count and ARVs

Monitoring of CD-4 from date of test and access to ARVs when required

JCRC TREAT partnership involves fortnightly visit of team to HCL and free CD-4 counts

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Sunday, June 01, 2008

Uganda AIDS Commission - Thank you for the invitation

Scaling Up Through Partnerships: Overcoming Obstacles to Implementation

“The HIV Implementers conference has set June’s meeting in Kampala to help partners:

- exchange lessons learned and best practices in the scale-up of HIV/AIDS programs

- focus on building the capacity of local prevention, treatment, and care programs

- enhancing quality

- promote coordination among partners.

Dialogue about future directions of HIV/AIDS programs, with a strong emphasis on:

- implementation best practices, and

- the identification of critical barriers”.

Hope Clinic Lukuli is an example of partnerships between: a CBO that became an NGO; local village and city councils; the national Ministry of Health; Ugandan and international companies; and Uganda and international health NGO and development agencies. We say thank you to Patrick Mutabwire and Elizabeth Mushabe who were willing to hear about Hope Clinic's work and agreed that we were a valuable example for the conference to learn about.

Scaling up of health services must be a balance between huge and under-served demand among the community and the technical, human and financial capacity of the health service point that the community relies upon. Hope Clinic developed a network of implementation partners to gradually expand the clinic’s in-house services and to serve the community through collaborations until it was technically and financially capable itself. The financial capacity includes fees from out-patients, sponsorship of health services by Ugandan companies and using community resources to equip and improve the clinic.

Building capacity has also been a coordinated effort to ensure that best practices are adopted and partnerships provide training and mentoring to health providers and peer educators as well as the service for the client. Hope Clinic Lukuli is a general practice health facility encompassing:

- childhood illnesses, especially fevers and other causes of dehydration;

- maternity care including RH, FP, ANC and deliveries and neo-natal care;

- out-patients consultations, laboratory examinations and treatment;

- comprehensive and integrated HIV services from mobilisation and testing to ARV.

The community served by Hope Clinic requires broad medical services and the capacity of Hope Clinic had to be steadily built to address their needs – no government staffed site exists within 3km of Hope Clinic and yet close to 100,000 people reside in that area. The good relationship that the clinic has built with the community and popular opinion leaders means that we are trusted for quality and genuine interest in people’s wellbeing. Using an established CBO/ NGO is the simplest way to scale up HIV service delivery.

The scaling up through partnerships has been the means to build our specific capacity for HIV services. The incremental growth of HIV services has relied on identifying the partner with the best practices, engaging them to recognise that the Hope Clinic and its community needs their services and negotiating the mechanism for an implementation partnership.

Hope Clinic is the most integrated example of PEPFAR, Global Fund, Private Sector and community at a single site. Yet we are a highly transferable example of how to remove the barriers and support Prevention efforts. Call or Email to learn what we did.

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