Executive Summary

This proposal presents the findings, recommendations and implementation plan arising from a three-week visit, in August 2009, by a team from EMAS CANADA to RAMBIA, an indigenous NGO which undertakes various community activities including a Health Centre (category II) in Kyamakube, which serves a catchment area in Katebwa Sub-county of about 30,000 people.

The team comprised of Drs. Paul and Debbie Zeni, Lynda Broughton (a public health nurse), Anna Dunets (a water and sanitation engineer) and Michael Wills (Executive Director, EMAS CANADA). We worked closely with the staff of RAMBIA and its Health Centre, saw over 600 patients and interviewed a wide range of officials and community representatives.

Uganda faces a high disease burden, including perinatal and maternal mortality (20.4%), malaria (15.4%), respiratory infections (10.5%), HIV/AIDS (9.1%) and diarrhoea (8.4%). Malaria, acute respiratory tract infections, diarrhoea and malnutrition contribute to over 70% of overall child mortality which stands at 75 per 1,000, while under-five mortality is 137 per 1000. The maternal mortality ratio is high, although there has been a decline from 527 maternal deaths per 100,000 live births in the 1994-2000 survey to 435 in the 2004-2005 survey. High fertility, the high incidence of infectious diseases, poverty and poor health services for pregnant mothers all contribute to these high levels of maternal mortality. In 2004, 953 doctors served a population of about 28 million.

RAMBIA's Health Centre, which has a staff of five, is headed by a clinical officer, supported by a nurse, two nursing assistants, a midwife and a laboratory technician. It has an out-patient's department and a maternity ward, under construction. It has the objective of attaining a Category III status, which would attract some government funding for staff. It currently provides vaccinations under a government-supported program and receives a small allowance from the Uganda Protestant Medical Bureau for purchasing essential medications. RAMBIA manages to operate the Health Centre by supplementing modest user fees with funds raised from other activities such as bee-keeping and brick making and using them for the purchase of medications and payment of salaries.

RAMBIA is a licensed NGO which functions with a volunteer Board of Directors and an Executive Director. However, it would benefit from strengthening its capacity in a number of areas, particularly financial.  It is constantly short of funds, resulting in insufficient medications, inability of the Executive Director to travel to Fort Portal, to work on the internet or operate cell phones, and inadequate facilities particularly for pregnant mothers. EMAS CANADA has provided some funds which have been used for progressing with construction, installing windows in the new out-patient department and purchasing medications, but the remaining needs are substantial.

 

Work Package	Cost (est.)	Possible Implementation Partners
1. RAMBIA Institutional Strengthening
•  Local volunteer to prepare financial statements and improve financial management	$500	RAMBIA to find
•  International advisor to provide training and support re: internal controls, financial management, donor reporting	$5,000	Accountants Without Borders? With support from EMAS
•  International advisor to improve governance, project management, community mobilization	$5,000	With support from EMAS
2. Completion of In-Patient/Maternity Ward
•  Construction	$10,000	RAMBIA (overseeing contractor)
•  Latrines	$ 4,000	RAMBIA (overseeing contractor)
•  Equipping (including oxygen, suction machine, incubator)	$25,000	RAMBIA
3. Provision of Housing for Six Staff
•  Construction	$30,000	RAMBIA(overseeing contractor)
•  Kitchen and toilets	$10,000	RAMBIA(overseeing contractor)
4. Reconfiguring the Existing Building
•  Finalize plan	N/A	RAMBIA
•  Cost, contract, renovate	$15,000	RAMBIA (overseeing contractor)
5. Provision of Running Water in all Buildings
•  Connections, piping, sinks, taps, soak-aways etc.	$2,000	RAMBIA(overseeing contractor)
6. Provision of Rainwater Tank for Washing Purposes
•  Tank, connections, tap	$2,000	RAMBIA(overseeing contractor)
7. Electricity
•  Feasibility study into best option	$500	RAMBIA (overseeing contractor)
•  Purchase and installation of best option	$5,000	RAMBIA (overseeing contractor)
8. Construction of Fences and Pathways
•  Plan for improved accessibility	N/A	RAMBIA volunteers
•  Construct fences and pathways	$500	RAMBIA volunteers
9. Disposal of Medical Waste
•  Identify, cost and evaluate options for proper disposal	N/A	RAMBIA
•  Purchase and implement	TBD
10. Promote Use of Anti-malarial Bed Nets
•  Investigate/survey price at which nets are affordable (including community meetings)	$500	RAMBIA (with support from community worker)
•  Assess pros and cons of local purchase vs. local manufacture (through Rotary)	N/A	RAMBIA with support from EMAS
•  Prepare plan for local purchase/manufacture, community awareness, distribution etc.	N/A	RAMBIA with support from EMAS
•  Provide loan for materials, training, wages, distribution	$5,000	EMAS
11. Training
•  Included in cost of next EMAS trip	See 18 below	EMAS
12. Health Records
•  Improve patient health records	$100	RAMBIA with support from EMAS
13. Pharmacy
•  Establish pharmacy record system to minimize stock-outs	$100	RAMBIA with support from EMAS
14. Sanitation
•  Review survey results	N/A	RAMBIA
•  Work with VHTs and community leaders to understand community attitudes etc.	$100	RAMBIA with EMAS support
•  Plan and execute pilot project	TBD	RAMBIA with local NGO
•  Assess and plan roll-out	TBD	RAMBIA with local NGO
15. Water
•  Monitor Kyamakube water project	N/A	RAMBIA
•  Identify and assess other water sources in Katebwa Sub-County	See 18. Below	RAMBIA and EMAS
•  Propose and cost a plan for addressing other water needs in the Sub-County	See 18. Below	RAMBIA and EMAS
16. Community Health Education & Outreach
•  Work with VHTs, MoH and community leaders on water, sanitation and community education issues
•  Provide training to VHTs during team visit
•  Assess and plan for resource requirements
17. Support for RAMBIA Administration
•  Motorbike	$1,500
•  Office equipment (computer etc.)	$3,000
•  Gas, internet, cell phone etc. (p.a.)	$2,000
•  Honorariums for RAMBIA staff (p.a.)	$5,000
18. 2010 Team Visit
5 team members' costs ($3,000 each)	$15,000	EMAS team members
Purchase of HPIC and other medications	$5,000	EMAS team members

In this report, we provide costed recommendations for strengthening RAMBIA and upgrading its Health Centre to an HCIII, constructing and equipping badly needed facilities and addressing the determinants of poor health such as malaria, poor water, inadequate sanitation and limited health education. Over time, we plan to deepen our involvement, adding team members and supporting RAMBIA on an ongoing basis with carefully defined and managed programs. The total cost of the recommendations in the report is under $200,000. Some funding is being provided by EMAS CANADA team members, who will be returning in 2010, and the balance of funding is now being sought from other sources.

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