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


	

On Sunday the president of Uganda,Yoweri Museveni, re-imposed a strict lockdown including school closures and the suspension of travels between districts to help facing a wave of COVID-19 cases in the East African country. A new lockdown hits Uganda. A cold shower for all of us, in Kalongo as in Italy.

Last month infections began to rise, and new cases increased due to more aggressive variants such as English, Indian and South African, particularly among the younger ones, fueling fears that the country could slip into a new wave out of control. The announcement of transport blockade has caused a movement of students and workers who, eager to go home, have left from districts where the rate of infection is already very high, bringing the infection to their villages.

The virus started running suddenly and faster than before across the country: the positivity rate rose from 2% to 17%. There are 61,977 positive cases to date, but it is feared that the numbers are many more than those officially reported.

Dr. Carmen Orlotti, surgeon in Kalongo at Dr. Ambrosoli Memorial Hospital, updates us real time: “Even in Kalongo we started to register the first positives. We have reopened the center for the isolation and treatment of Covid cases. The first hospitalized patients show a typical picture of respiratory failure with dependence on oxygen. Oxygen that can be supplied only from oxygen concentrators. The ministerial protocol provides the transfer of all these patients to Gulu, the closest regional isolation center, but it is already overcrowded. Those will be difficult days to come. Facing an epidemic without having all the means to do it in the best way exposes staff, patients and their families to very high risks. We go on, a look up to ask once again that Fr. Ambrosoli looks after his hospital and all those who work there or seek help ”.

Fortunately Kalongo's staff have been vaccinated, but now we fear the spread of the virus among patients and families. The fear is that hospital beds will run out soon, without forgetting that there are only 218 places in ICU compared to 44 million inhabitants. Oxygen is scarce everywhere, the regional isolation centers are already at the limit of their reception capacity. The government has made numerous efforts to secure the country but what Uganda is really lacking are vaccines. Out of nearly 2 billion doses in the world, only 30 million doses (equal to 1%) arrived in Africa.

According to Matshidiso Moeti, WHO's regional director for Africa, the threat of a third wave is real and growing on the continent considering that the vaccination campaign is essentially at a standstill: the forecast made for months by scientists around the world, according to which the lack of vaccines in third world countries would have facilitated new waves of infections and the birth of new variants, is unfortunately coming true.

Let's not leave them alone! We are very worried but aware: we must help the hospital to face the new wave in the best possible way by continuing to take care of those most in need.

This is the teaching and warning that Father Giuseppe left us with Kalongo hospital and the midwifery school that as a Foundation we carry on every day, continuing to promote the local medical and managerial training, with a specific focus on human and professional training of women, thanks also to the work of many volunteer doctors who work in the hospital.

Like the pediatrician Tito Squillaci, the first Italian doctor that returned to hospital after the outbreak of the pandemic and who worked alongside Father Giuseppe in 1984.

 "This morning, speaking to the students, I indicated the date engraved on the entrance of the midwifery school, 1956. I told them that that year, so far away, had marked our life. All of us, from the various corners of Uganda and Europe, were there because a man with an eye to the future was concerned with preparing a crowd of women capable of working for women and for their most precious good: their children. . Father Giuseppe had realized Daniel Comboni's ideal, "Saving Africa with Africa", and understood that women are the real power of African society. All this is clear when observing the professional but also psychological path that the students start: disoriented and scared on arrival, prepared professionals and self-confident in the end, capable of taking over the fate of a mother and intervene with competence. Most of them come from rural areas, where women are still subject to strong conditioning, their studies therefore become a path of emancipation, and they become examples of change and progress for other women. 

Father Giuseppe, who knew well what it meant to give birth without even a midwife, during the civil war, although aware of the risks to his life, decided not to leave Uganda: he did it to save the school for midwives, to avoid the interruption of the training of  such an important figure, but also of a new civil conscience. And today the school is there ".

Tito Squillaci

Kalongo, March 2021

Today, more than ever, the school and the hospital need regular and constant support to be able to continuously carry on their training activities, which are essential to offer qualified assistance and care every day. Thanks to the people who are supporting us and continue to trust us!

Dear friends,

the past year was dramatic, but it offered us some new opportunities such as intensifying the relationship with you in
a general moment of fear and loneliness. To be honest, due to the spread of the pandemic, we were afraid of not being able to
keep the commitments made with the hospital and the midwifery school.

Your prompt and concrete response in such an uncertain moment surprised us once again. It is thanks to you if we intervened promptly to support the
hospital facing the pandemic and to ensure that no medical activities were suspended. It is thanks to you if despite all the inevitable difficulties we managed to carry on the ongoing projects, concluding the new isolation wards of pediatrics, toilet facilities and the new kitchens specific for that ward: essential interventions to improve the well-being of children forced into periods of isolation. We almost reached the last year of restorations of the accomodations for hospital staff, whose continuous presence is even more important today.

Unfortunately, these concrete results go with the indirect but still dramatic effects of the pandemic.

An example above all: the number of deliveries in hospital has been halved compared to the previous year. A lot of women have renounced safe delivery for the fear and the difficulties to go to the hospital, choosing to give birth at home without the assistance of qualified midwives.
2,707 versus 4,778 deliveries: this halved number tells of deliveries occurred in extremely life-threatening conditions for mothers and their children. The hospital staff is working hard to strengthen instruments and strategies to promote health in the villages among those who do not have access to the basic health services.

And of course they are continuing to take care of the nearly 50,000 people who go to the hospital every year. Our strength in being by their side has always been the mutual trust in the relationship between the Foundation and you who support us. A red thread that connects us and you with Kalongo and allows us to carry out with coherence and seriousness the legacy of love that Father Giuseppe Ambrosoli left us, in order that the hospital remains a concrete and safe point of reference for all the thousands of people who have trusted in it for over 60 years.

Women in Africa are the driving force of the Country, its strength. They do everything possible to get education, earn a salary which allow blended families to live and make their children study, cultivate the fields and above all they do not give up thanks to their inner power. But being a woman is still a challenge within a challenge: even if more and more are those trying to redeem themselves from a condition of economic and social disadvantage, the obstacles and difficulties to  overcome are still many.

Fertility rates in Africa are the highest in the world. In Uganda every woman has an average of 6 children and 15% gives birth to her first child between the ages of 15 and 19. More than 1 in 5 women between the ages of 15 and 49 has experienced some kind of sexual abuse in her lifetime, and most of this violence happens within the household, especially in the rural areas where education is poor. Gender-based violence can have devastating consequences for their lives: very often they have to face unwanted pregnancies, abortions carried out in unsafe conditions, with the risk of contracting sexually transmitted infections. Women conditions in Uganda are still extremely critical.

Recurring pregnancies are the main reason for health and social problems, especially when they are unwanted and happen in contexts of great poverty. A delicate and urgent issue. If fertility rates remain unvaried, United Nations forecasts expect that in 2050 the world population will be 10.6 billion and, with an unchanged trend, in 2100 it will reach 15.8 billion.

But with the stories of Gladys, Molly, Sida, Hellen who graduated from our Midwifery School, we have the proof that things can change, that the woman becoming self-efficient can overcome all the social problems by contributing to the community and protecting many new lives.

Work here at Kalongo hospital is in the hands of women: female nurses, doctors and midwives help in taking care of many mothers and children fighting mother-child mortality, and in training the midwifery school students.

Since its inception in 1959, about 1,500 midwives have graduated from the St. Midwifery School and, thanks to a proper training, they have professionally contributed to the prevention and the treatment of women not only in Uganda, but also in many Countries of sub-Saharan Africa.

The number of enrolled women has increased over the years and the annual average of female students who finish the courses is about 30 for the professional midwives course and about 12 for the head nurse midwives degree.

In addition to guaranteeing medical continuity in the maternity ward of the hospital, the School also contributes to the development of the social role of woman, considered important to reach the female empowerment. The training works entirely on the female figure and on being women, trying to help them to become independent in their decisions, to acquire common sense and clarity of thought without being influenced by the male figure.

Investing in women's empowerment means creating an essential prerequisite for the realization of social justice, it means encouraging a direct path towards gender equality, the eradication of poverty and an inclusive economic growth, especially in remote and rural areas of the world, where social, economic and cultural limitations are added to natural and environmental adversities. This is the important and forward-looking legacy that Father Giuseppe left us and for which he gave his life and that today can be read in the smiles, willpower and pride of all the students of the Midwifery School who know they can make the difference.

Thank you for helping us to make their dreams come true!

“Encouraging pregnant women to continue attending prenatal exams, to feed properly, and to exclusively breastfeed for the first six months, is essential to prevent malnutrition in younger children. As well as convincing parents to take malnourished children to the hospital as soon as possible, without waiting until it is too late, is crucial in vast, isolated and poor areas, like this one”, says Alice Akello, passionate nurse, on the front line in the fight against malnutrition in the Nutrition Unit of Kalongo Hospital.

“To stop malnutrition it is necessary to reach and involve mothers, parents and local communities so that they learn how to recognize the first signs of malnutrition and become aware of the importance of eating nutritious food to prevent it. That is also why we visit the villages and teach people which foods to grow in their gardens and how to cook them to safeguard nutritional values. We promote good health and hygiene practices to prevent diseases such as worm infestations, diarrhoea and malaria that cause long-term malnutrition. Unfortunately, Kalongo District is very large and we did not manage to reach all the villages, there are still many families who cannot benefit from our nutritional and health advice, but we are not going to give up, we want to reach as many families as possible. There are still many children to protect and save ”.

We can't stop!

In Africa, the spread of the pandemic is having serious effects on malnutrition and it is the only place in the world where children are the most affected.

Household poverty and food uncertainty rates have increased. Essential nutritional services and supply chains are going on in a discontinuous way. Food prices have skyrocketed. As a result, the quality of the children's diet has decreased and malnutrition rates continue to rise.

A Lancet investigation shows that the predominance of severe malnutrition among children under five could increase by 14.3% in low- and middle-income countries, due to the socio-economic impact of COVID-19. This increase would mean over 10,000 additional children deaths per month, with over 50% of these deaths in sub-Saharan Africa. The estimated increase in severe malnutrition among children is just the tip of the iceberg, UN agencies warn.

Severe malnutrition is life-threatening in children, as it makes them too thin and weak, with a greater risk of dying, or of growing, developing and learning inadequately. But COVID-19 can also increase other forms of malnutrition in children and also in women, including stunting, micronutrient deficiencies, overweight and obesity as a result of poorer diets and of the interruption of nutritional supplies.

Even in Kalongo, where hospitalized patients live much below the poverty line, the pandemic has worsen the already precarious situation of many families. Many people have lost their jobs and face many difficulties in having healthy diet and medical care.

The main victims of this emergency are the many malnourished children, whose number is growing day by day. In 2020, Kalongo hospital treated nearly 600 children suffering from malnutrition or born underweight. Many of them were also affected by malaria, anemia, pneumonia.

In the absence of an effective and timely action, COVID-19 will lead to a dramatic increase in malnourished children.

To deal with this emergency we are putting in place all the resources and skills necessary to promote antenatal visits, postnatal care and breastfeeding; to guarantee proper assistance to hospitalized children; to strengthen the visits in the area that can increase education in eating habits and reach those who, due to the pandemic, can no longer come to the hospital.

These simple but effective measures can make a difference for thousands of children that today more than ever are at risk of malnutrition. This is one of the many challenges we face.

DEAR FRIENDS,

thank you so much! It is thanks to you if even in 2020, whit a pandemic, we succeeded to guarantee treatments and care of high quality to thousands of people and to go ahead with our projects in Kalongo. You are helping us to write a beautiful story, that started more than 60 years ago with Father Giuseppe and is carried on even now, despite everything, by people able to look beyond one's own history, laying good and deep roots in the future.
In September, Covid-19 also arrived in Kalongo.

At the end of October a total of 44 cases have been registered, most of them within the hospital staff.

It was inevitable, considering how much the staff is daily dealing with all the others health emergencies. After a period of care and isolation positives people were discharged and the staff returned to work. But there is an even worse threat than Covid itself and it is the invisible effects of this sneaky virus. In the last months the hospital is recording numbers that raise the alarm about the real health situation of the district and threaten the economic sustainability of the hospital.

Up to September 2019, the pregnant women in the ward of maternity were 1,262, this year in the same month they were only 345, as well as the number of children hospitalized in pediatrics, that in the same period fell from 1,432 to 434. A dramatic decrease that tells us how the health emergency is impeding the access to care of hundreds of people, aggravating an already precarious economic situation and triggering a dangerous vicious circle that from a lack of health inevitably leads to poverty and vice versa.

The obstetrics school, closed since March for the pandemic, has reopened at the end of September for 109 female students of the last two years.
We are very happy for them but we are wondering what will happen to the 38 girls of the first year who for the moment cannot return to
school. Many of them will be forced to abandon their studies because the even poorer families will no longer be able to afford the expenses for the
school or will prefer to keep them at home contribute to the sustenance of the family.

Although we are aware that we are facing a 2021 full of challenges, we will tenaciously continue to do our best to ensure the
continuity and quality of care services offered by the hospital and the studies of the students of the midwifery school.

Together we can work for those without access to health and to an acceptable life, those who today feel also threatened by the pandemic, just like us.
We don't need to find any other reason to ask you to continue to support us.

Having you by our side today is all that matters.
Merry Christmas dear friends, and above all Happy New Year to you all!