The youngest and more vulnerable children have been the most affected by the Covid- 19 pandemic in the past two years.

The hospital bed occupancy was constantly over 100%- which means that health operators almost daily had to care for more people than each ward could accommodate. Unfortunately, the mortality data also confirm this dramatic scenario: mortality amongst children admitted to Pediatrics Ward was the highest registered in the past 14 years. In this dramatic scenario, the pediatric staff has always being operational, ready to welcome and assist all young patients, reserving constant attention and care for the most fragile.

For this reason, today we are even happier to inform you that, overcoming the great difficulties caused by the pandemic, we have managed to complete the renovation works of the Kalongo Pediatrics ward, continuing to guarantee continuity and quality of pediatric care.

A heartfelt thanks to Fondazione Mission Bambini Switzerland, Fondazione 13 Marzo, M&G for the important support and practical help of those who strongly believed in our project and supported it.

The new department already hosts many young patients with their families, in a renovated and child-friendly environment, to guarantee the best possible treatment and a safe and quality workplace for the staff dedicated to children.

THANK YOU SO MUCH to all those who helped us to make it happen!

DEAR FRIENDS,

Father Giuseppe Ambrosoli is being beatified on 20th November 2022 in Uganda, after a two-year delay and a long wait due to Covid 19- pandemic.

We are joyful and grateful for his beatification. We are looking forward to sharing with all of you all the events being organized to celebrate such a long waited moment: it’s a unique opportunity to encounter and remember once again the remarkable personality of Father Giuseppe, who is still a source of surprise and inspiration these days. His encouragement helps us to persevere in supporting the miracle of Kalongo Hospital.

Exactly 65 years after the foundation of the Hospital named after him and in the year of his beatification, I wonder about the future of this extraordinary endeavour, his effort to guarantee equal rights and access to medical care and schooling to everybody. A very vital institution in an area which is now even more neglected, poor and unknown to the world.

The present situation is quite uncertain, it’s a long way to go, and sometimes it feels endless.

These days, looking at the terrible events we are witnessing, let’s not be overwhelmed by a feeling of helplessness, which distress us all. Following the path of resilience revealed by Father Giuseppe, we intend to continue our work in truthfulness and hope, doing our best to promote a more honest and fairer world.

We intend to persist in conceiving new growth and development paths, together with the Hospital and the midwifery school, to provide tangible solutions to the needs of the more vulnerable people in the community. This will also offer a better future to these two organizations, which are vital to the survival of thousands of people each year.

The Hospital informed us of their many, significant needs: old buildings’ portions need to be renovated, plumbing, electrical and power systems, together with the waste disposal system – all must be refurbished, to meet the increase in complexity of hospital management and the more efficient standards required. Other needs are: roofs to be remade, an Intensive Care Unit to be added to the surgery, a new incinerator to be built and new clean energy sources to be installed.

These are priority needs, which have to be added to our ongoing support to the daily hospital needs, which in turn sharply increased during the Covid-19 pandemic; medical and technical missions must also be supported and, finally, local personnel shall be encouraged to stay on and contribute to such a challenging mission.

Please do help us to persevere in carrying on the legacy of Father Giuseppe Ambrosoli in Uganda, to let it be known to everybody. To let its needs be known. To allow his wonderful work to keep saving human lives and bear fruit. Not only in Uganda.

A good deed is a river in flood, it runs over the banks, it overflows, it’s overwhelming. It overcomes, everything.

Giovanna Ambrosoli

"From the very first moment I set foot on the lands of Agago District, where Kalongo Hospital is located, I was amazed by the extension as far as the eye can see of hectares of uncultivated, arid land, shaded only at times by scraggy trees. Lands that seem to discourage even the most motivated to take home a few potatoes for dinner at the end of the day. Potatoes, beans and boiled rice are the daily diet for those who can afford it, for the others there are malakwang and akejo , spinach-like vegetables served with peanut butter.

Nutrition persists as a very ancient problem in these areas, worsening at the end of the dry season when the reserves of the most recent harvest gradually run out. Thus the number of children - but also of adults - hospitalized for severe acute malnutrition increases, as well as the number of deaths.

In Uganda, every single medical exam has to be paid for in advance to avoid insolvency and if the patient can't afford the cost, they simply don’t do the exam. The advantage of the Ambrosoli Hospital over other Ugandan health facilities is that the costs of health services are reduced, thanks to the principle of charity, which is the basis of the mission.

Thanks to this, the patient is required to pay only a small fee for admission to the ward and for discharge, while access to drugs is guaranteed for the entire duration of hospitalization, regardless of the patient's financial resources. This may seem taken for granted in Europe, but in Uganda it is a milestone.

One of the main problems of Ugandan health care is the scarcity of health facilities, that can be even 10 kilometers away from the villages. The delay in the access to treatment is sometimes fatal. It can take several hours on foot to reach the hospital; a shorter time for those people who can afford a motorcycle ride – with "boda boda". The paradox of poverty is the staggering number of patients hospitalized with trauma to legs and feet (who regularly develop infection) caused by the tumultuous journey in boda boda on unpaved roads.

But despite the scarcity of means and resources, the tireless work of the medical and nursing staff of Kalongo Hospital guarantees daily assistance to hundreds of patients who are treated as well as possible. The plague of HIV, malaria and tuberculosis will certainly not be solved in this century. But the dedication and trust that the local population has in the mission make the fight against such conditions a priority commitment for each of us. 'To love and serve with joy' is the motto of the Midwifery School. Let’s try to make it our own, too ".

Elena Salvador, resident doctor in Infectious Diseases, Kalongo, April 2022

DEAR FRIENDS,

in the last year and a half we have all faced a challenge that we never would have imagined, from which we are finally emerging with great strenght and resilience. In Italy 83% of the population is vaccinated against Covid19. A precious goal for the good of all, especially for those who cannot receive the vaccine. Unfortunately, this is not the case everywhere.

In Uganda this challenge is still in its infancy. Out of a population of 44 million inhabitants, only 0.9% have received both doses of the vaccine, while the side effects of the pandemic are driving to the limit the poorest population, living in rural areas.

Today more than ever, every action implemented by our hospital in Kalongo wants to contribute concretely to the elimination of the gap between poverty and the right to health. This gap has dramatically widened during the pandemic and today threatens the health of women and children in particular.

The data speaks for itself and is of enormous concern. Since the beginning of the pandemic, immunization rates for children have decreased by 29%, antenatal visits by 26%, while the number of premature babies has increased (+ 122%). Maternity hospitalizations fell by 56%, while the number of assisted deliveries fell by 44% and the percentage of caesarean deliveries performed in emergency increased (+ 4%).

Faithful to its maternal-child vocation, the hospital is investing resources and energy to protect the health of women and their children. Because women are the backbone of Ugandan society. Taking care of them, training new midwives, educating women on the main health issues is today even more urgent and necessary if we want to save the greatest number of women and children not only from Covid19 but even more from the main preventable diseases, that because of misinformation and poverty are often fatal.

In this context, mothers are not only passive subjects. When informed and involved they become part of the solution to saving lives and promoting healthy behaviors.

Collecting the legacy of Father Giuseppe also means this: supporting the commitment of the hospital and the obstetrician school for and alongside Ugandan women. For a sustainable and lasting progress.

The right to health can no longer be the privilege of a few, we have now understood it well too, we took it for granted. If anyone falls behind, we all fall behind. Today, to really leave Covid behind us, we need to take care of those who cannot do it alone.

The work we carry out every day aims not only to support the hospital, but also to make it grow; first of all by training health personnel and actively involving and sensitizing local communities.

All this alone, however, would be impossible.

A big thank you to our small and large supporters, partner companies, institutions and friendly organizations who have chosen to support us even in this difficult year and a half. Your generosity allows us to carry out our plans for a more equitable, safer and healthier tomorrow for all.

From the heart, our best wishes

Giovanna Ambrosoli

Dr. Ambrosoli Memorial Hospital and St. Mary's Lacor Hospital are two effective examples of the impact of RBF on the quality of pediatric services.

In recent decades, new funding methodologies have been developed with the objective of increasing support for health programs, overcoming the lack of traditional funding mechanisms. Among these is the Result Based Financing (RBF), a financing mechanism that aims to improve the quality of donations by binding the disbursement of funds to the achievement and audit of predetermined results.

The conference, which was held last October 29 in the Auditorium of University of Naples Federico II, organized in collaboration with the Corti Foundation and the Ambrosoli Foundation, was an opportunity to present the results of the study promoted in collaboration with the University on the effectiveness of the RBF project funded by the Italian Agency for Development Cooperation (AICS) and Cariplo Foundation.

A moment to reflect, thanks to the intervention of authoritative guests, and bring attention to one of the most important methods of supporting global health. At the same table the representatives of the two Foundations, experts in development and global cooperation of international standing such as Nicoletta Dentico of the Society of International Development and Eduardo Missoni of Bocconi University. AICS speakers Mariangela Pantaleo and Andrea Stroppiana took part; James Mwaka, representative of the Ugandan Ministry of Health, underlined how Uganda believes in this financing system and in collaboration with public and private entities of international importance.

The RBF has been found to be the driving force of change for pediatric services, considering that 50,000 children are welcomed and treated every year at Lacor, thanks to one of the largest pediatric wards in Northern Uganda, while Dr. Ambrosoli Memorial represents a life-saving stronghold in a district where 37% of the population is under the age of 10.

St. Mary's Lacor Hospital (Gulu) and Corti Foundation have designed a privately funded RBF system primarily based on quarterly external audits of quality standards. Initially developed to finance outpatient activities, the RBF system was extended to the pediatric wards of Lacor Hospital and introduced for the first time at Dr. Ambrosoli Memorial Hospital in Kalongo in the pediatric ward. After 3 years, this methodology has shown great potential for improving the quality of hospital services.

 “The RBF system consists of a support given to a structure according to the quantity and quality of the results it achieves. More than half of the support projects in developing Countries do not reach the predetermined objectives and do not transform the local reality. Evaluating the quality of the services offered is a real revolution "- says Professor Luigi Greco, Professor of Pediatrics at the Faculty of Medicine of University of Naples Federico II and Associate Dean of the Faculty of Medicine of the University of Gulu which contributed to found, head of Federico II's GULUNAP project and cooperation projects with Uganda - “We compared the quality of care for children of two big hospitals in Northern Uganda, St. Mary's Lacor Hospital and Dr. Ambrosoli Memorial Hospital, performing a quarterly supervision. In light of these results, we have verified that the project has produced for the first time a significant improvement of 30-40% in the quality of care in these big hospitals ".

The analysis of the data starting from the medical records and RBF check-lists sent by the two Ugandan hospitals was carried out by the team headed by Professor Sergio Beraldo of the Department of Economics and Statistics of the University of Naples Federico II: "The examination of patient records showed that the quality of medical care improved, mortality in children, reinfection rates and hospital stay time decreased ",

The RBF method consists in assigning a fixed amount, equal to about 15 Euros, for each pediatric hospitalization. This figure includes the investigations and therapies needed by the child, regardless of the length of hospitalization and the type of illness. To this is added a quality bonus which is attributed based on the score achieved by verifying the quality of the services quarterly. The score ranges from one to five and allows you to increase the amount paid to the hospital from 5 to 25 percent, thus attributing a financial bonus to the hospital. (note to Laura: I deleted this part because Corti and us, we use the bonus differently and it would take too long to go into detail on the different ways of managing the bonus)

Both at Lacor and at Dr Ambrosoli Memorial Hospital quality and quantity indicators have been developed: it is a very detailed list with parameters monitored every three months by members of an internal quality committee and by a representative of the Ugandan Ministry of Health.

An approach that has managed to aggregate private and institutional donors thanks to the security it offers and the regular and frequent monitoring that allows the donor to follow the project step by step, with its successes and challenges. The Italian Agency for Development Cooperation, which, since April 2018, has financed the initiative with a total amount of 750 thousand euros, believes it to the end.

"At Lacor Hospital there have been structural improvements and increased attention to infection prevention, the availability of drugs, the preparation of all personnel for emergencies and the development of protocols for clinical and nursing procedures - said the Dr. Venice Omona, specialist in pediatrics and head of the pediatric ward of Lacor - “The sense of responsibility of the staff with respect to the resources of the ward has improved; they are all more attentive to every step that concerns the care of little patients. We have developed new protocols and the challenge is to be able to follow them in the best possible way. The dialogue between the staff and with the parents of the young patients was also at the center of the work and I noticed improvements in the ability to explain diagnoses, necessary investigations and therapy "

Even in Kalongo, where the RBF methodology with quality checks was introduced for the first time with the project funded by AICS, the program has produced a truly remarkable impact, as shown by the data developed by Professor Greco in the examination of medical records.

 “The clinical management of pediatric patients has improved significantly since 2016, most notably in Kalongo. Observe for example the increase in variations from 2016 to 2020 to evaluate the marked changes that have occurred: the compilation of a detailed clinical history and the accuracy of the child's examination have improved by more than 6 times (= 600%). Likewise, good sepsis treatment has increased 9 times, ” underlines Professor Greco.

Dr. Godfrey Smart Okot, director of Dr. Ambrosoli Memorial Hopistal, confirms the evidence found through the examination of medical records: "Before the start of the project, three years ago, the clinical and ethical practice regarding the care of the sick child in the hospital was more rooted in the routine. Subsequently, the approach evolved. More emphasis is now placed on studying the sick child, communicating eloquently with the child's caregiver, and ensuring that the treatment environment is sufficiently holistic (clean, safe and calm). The preparation of the project actively involved the staff, through training on 'best practices' and the related advantages. The staff therefore realized how much this method not only guarantees that the sick child heals, but also affects positively their professional skills. The final result is that the overall quality of care has improved significantly compared to the period before the project ”.

This result is even more significant if we consider the stress to which the Kalongo hospital and the pediatric ward were subjected for the always lurking epidemics: between 2019-2020 due to malaria, total hospitalizations increased of 83% compared to the same period the previous year,  the bed occupancy rate of 198%. This means that for months the hospitalized children exceeded the availability of beds in the ward and the staff was forced to accommodate more patients in one bed or use improvised spaces for hospitalization. Then followed the long period marked by the pandemic, where all the ward staff remained always operational and ready to welcome the numerous patients, despite the fear of contagion.

“The RBF method is a tool that helps to maintain a surveillance and control system on the quality of services”, emphasizes Professor Greco. “It is a model that helps to avoid waste”. Many, therefore, have been the successes and many more challenges. “The greatest is that the changes induced by this three-year project become everyday life”, concludes Luigi Greco

We thank the University Service Center for the Coordination of Special Projects and Organizational Innovation (COINOR) and the support of Federico II Department of Economics and Statistics.

Even if the total hospital’s admissions have decreased by 19%, the most significant and worrying drop concerns maternity ward access, which decreased by 56%, with a 44% decrease in deliveries. These numbers come to us directly from Kalongo and give us a worrying picture of the impact that the pandemic has on the daily life of the community.

The decrease in antenatal visits is a consequence of the strict rules to prevent the spread of Covid-19, of the increased poverty that doesn't allow women to pay for the trip to the Hospital, and of the fear of infection. Such situation has caused a reduction of preventive therapies provided, with inevitable consequences on the health of the fetus and future mothers.

Such a high reduction in deliveries means an increase in unassisted deliveries, with consequent risks of maternal mortality, neonatal mortality, development of serious complications during delivery which can lead to permanent disabilities for both the mother and the unborn child.

However, in the midst of this difficult and disheartening moment, there are also many stories that thanks to the tenacity and resilience of the doctors and hospital staff, combined with the courage and strength of these mothers, reach a happy ending and make us look to the future with glimmers of positivity.

Like the story of Esther, a 19 years old young woman at her first pregnancy who came to the Kalongo hospital from the Komotor Health Center in Agago because she was in labor and with Covid symptoms. Arriving at Dr Ambrosoli Memorial Hospital, she was immediately tested for Covid and turned out positive. She was admitted to the isolation ward. A "special delivery

room" was created for her in the same ward, where she was constantly assisted by a midwife and the medical team who started treatment for Covid. Unfortunately, Esther's labor failed to progress for 2 days, probably due to high fever of the mother. The fetus started developing fetal distress.

The medical staff did not lose heart and promptly decided for an emergency caesarean section to save the lives of both the mother and the baby.

Everything went well, Esther and her baby recovered very well and they were discharged a few days ago from the hospital.

This is Kalongo, this is the strength of Dr. Ambrosoli Memorial Hospital who fights every day for the joy of life.

The delta variant is spreading among Africans at a shocking level of diffusion - 225 times faster than the first wave of the original virus in Africa. Uganda has a high number of cases in the under 40 age group, with an increasing mortality. Most patients require hospitalization in intensive or sub-intensive care units. The oxygen demand, with patients consuming between 4 and 6 tanks per day against the 1-2 tanks of patients admitted to sub-intensive care for other pathologies, has increased exponentially.

At Kalongo hospital COVID19 - reference center for mild and moderate cases, the positivity rate is now 22%, but the cases are certainly many more given the scarce number of tests available.

"Our testing algorithm is primarily aimed only at people who have COVID-like symptoms to optimize the scarce testing resources we have" - ​​says Dr. Smart, director of the hospital - "This means that the positives who do not show symptoms cannot be reached and also those who have come into contact with infected people cannot be tested. We recommend that all traceable contacts self-isolate for at least 10 days. Traceability is very complex and difficult to put into practice in our communities of isolated villages".

Since June 20 patients have been hospitalized and treated and 80% of them were oxygen-dependent, but thanks to the tenacity of the doctors and hospital staff only 3 patients have died. To face this pandemic, which is added to an already precarious health situation, the hospital was able to guarantee treatment thanks to the support of Ambrosoli Foundation, not charging patients any costs, unlike many other hospitals in the country. To help the hospital coping with the pandemic, the Foundation has allocated approximately € 82,000 since 2020 for the supply of masks, gloves, disinfectants, breathing equipment. Our thanks go to you who support us and who are close to us! The situation could not be more dramatic, not only in the present, but also in perspective. The vaccination campaign in Africa is not following the expected pace, only 1% of the population has been fully vaccinated.

“We have a difficult path ahead. There is a lack of drugs, medical devices and basic equipment - Dr. Smart states - "with the speed of spread of the virus, the reserves of the hospitals have run out, even here in Kalongo. Our isolation ward is old, unsuitable and unsafe for patients care. But above all, the supply of oxygen remains very demanding. It is risky and we cannot rely on concentrators which often break due to constant use. An impact that affects the entire hospital: children continue to be born, premature cases increase, malaria, malnutrition and tuberculosis do not give a break.

Do not leave them alone!

Public funding of health programs has recently been characterized by increasing conditionality in the provision of resources. This trend typically includes result-based financing programs (RBF), which promise rewards to individuals or institutions, conditioning them to the achievement of the agreed objectives.

The St. Mary's Hospital in Lacor (Gulu, Uganda) and the Corti Foundation, after a first experience with the RBF approach funded by the British government, have extended the adoption of incentive mechanisms of this kind with the aim of improving the quality of healthcare provided.

Thanks to the three-year contribution of the Italian Agency for Development Cooperation (AICS), results-based financing mechanisms have been tested in the pediatric wards of Lacor Hospital and Dr Ambrosoli Memorial Kalongo Hospital, showing considerable potential in improving the quality of the services provided, hence in contributing to the reduction of the high infant mortality rates.

Starting from this experience, and from the analysis of the evidence gathered in the hospitals of Lacor and Kalongo, the University of Naples Federico II, in partnership with the Corti and the Ambrosoli Foundation, promotes a conference on result-based financing programmes with the aim of discussing their effectiveness in favouring sustainability and quality in the health sector.

Evelyn is 28 years old, pregnant for the third time. When she goes into labor, she decides to deliver at the nearby Health Center. The previous two deliveries were uncomplicated and this third one was also proceeding regularly.

But this time things aren’t going well. After the birth of the child, the placenta is not expelled, Evelyn is losing a lot of blood, the young midwife struggles removing it manually. She finally succeeds but it is immediately clear that the patient needs blood. An ambulance picks Evelyn and her baby up and take them to Kalongo hospital. She arrives at the Out Patient Department unconscious, she has no blood pressure. The staff rushes to perform resuscitation maneuvers while the baby is sent to Neonatal Intensive Care Unit. Finally the patient regains consciousness, is stable, and is transferred to the ward. In the following days comes the diagnosis of malaria, which worsens her anaemia. However, Evelyn seems to go through all her misfortunes with an enviable strength.

Unfortunately after a few days in which she seemed to have recovered, Evelyn has high fever again, her stomach is swollen, she is coughing and has difficulty breathing. We think of a puerperal fever, probably induced by obstetric maneuvers. We start the antibiotics, but Evelyn is finding it harder and harder to breath. We have no doubt, we do the rapid test for Covid-19. To everyone’s dismay the test is positive.

They call me, it’s already Sunday evening, we cannot refer the patient to Gulu, where the isolation center is. We then arrange the transfer to our isolation area.

We prepare the oxygen, make some infusions. To our relief, her saturation seems to hold up well. We are optimistic.

But if her breathing maintains normal parameters, the abdominal situation doesn’t improve. Perhaps a surgery will be necessary. We explain that to the patient and her relatives, they are desperate. We contact Gulu again who inform us that they have no possibility of performing surgery, nor the suitable material to protect the ventilator.

I feel lonely, we all feel lonely. I think about our intensive care therapies, the beeps of the monitors resound in my head, I see again the team of doctors consulting.

I look around in the room where Evelyn is now asleep, the drip, the oxygen concentrator on standby, the pulse oximeter. I think about this young life that is facing such a great battle, against obstetric complications and against Covid. I say to myself “Come on Evelyn, we have to do this!”

 

Dr. Carmen Orlotti

Surgeon at Kalongo Hospital