Mulago’s referral system failure

Government health facilities still use old style paper forms decades after the country adopted the referral system cascading access to care from Health Center 1 or Village Health Teams and Community Health Workers (CHEWs) as first point of care, to Health Center IVs, district hospitals, regional referrals up to the level of the national referral.

The problem was noted and in 2006, when complaints of loss of records increased, Mulago appointed a committee to assess the possibility of having a computerized record keeping system. Nothing came of it.

Plans to have this system were again hinted on in 2017 when, during a tour of the women’s hospital and renovation works at the main hospital; the Mulago Hospital Director Baterana Byarugaba announced that they were installing a cyber optic cable to implement a customized Integrated Hospital Management system to enable them share and compare patient information easily with regional referral hospitals and the Kiruddu and Kawempe annexes of Mulago hospital. This is where most of the patients referred for super specialized care are expected to be from.

Dr. Diana Atwiine, the PS says the technology and everything will be in place early next year when the refurbished Old Mulago is expected to open and a more efficient US$12 million ambulance system will be introduced to ease the referral system.

She said the National Development Plan 2020 guides the leaders to implement the referral system.

Dr. Lawrence Kazibwe, the Deputy Director at Kawempe Hospital also says what they are learning from this is that implementing a referral system is more than having structures and buildings. He gives an example that as big as his facility is, he only has three ambulances to transfer patients when they need special care.

The situation at Mulago, it appears, is putting the much touted referral system to a test and the wing facilities are feeling the pressure.

The added pressure is felt at every department at the Kawempe hospital. At the radiology department, equipment previously used in the private wing has been transferred to the new hospital. We could not verify this but only one ultra sound scan was in use when we visited and it is in the general wing.

One of the top doctors here is J.B Tezita, who is also a long time consultant obstetrician. Previously he was based at the private antenatal wing of the Obstetrics and Gynecology extension of Mulago National Referral Hospital.

Monday is a busy day for him as it is antenatal day at the private wing of Kawempe. Women and couples flock his clinic for antenatal solutions, conception interventions, and post-natal advice.

He is usually at the clinic by 8am but his patients keep increasing and queues of patients soon flow into the corridor.

Oct.29 was a typical chaotic day. Patients scrambled for sitting space on benches in front of his consultation room.  But by 9am, the doctor had not arrived. The crowd kept swelling as no one was leaving. Some chose to stand –  not bothered by the seemingly unclean terrazzo floor with stains of dry blood drops and a stench that occasionally swept through – probably from a pile of hospital waste behind the building.

About 30 minutes after midday, Dr. Tezita arrived. He seemed overwhelmed by the numbers.

“I had asked someone to stand in for me,” he explained, “I had a case at the women’s hospital.” Then he was interrupted by a phone call and he seemed to be giving instructions to the caller on how to handle another patient.

Then he did something unusual; he advised the women to transfer to the new women’s hospital if they want. The suggestion was odd and showed how specialists like Tezita now have to divide up their time between seeing mothers admitted at both the general and private wing, attend to those coming in for antenatal at the Private wing and specialised cases at the new hospital.  It is clear they cannot wait for the referral system that Dr. Atwiine promises to kick in.