SHSC trip to Uganda

21 June 2012

Friday 22nd June - and they're off!!!

With the help of a grant from the Department of International Development, a team of 6 staff from across SHSC have today set off on a 2 week visit to Uganda.  The aim is establish a structure for future working with staff at Gulu Hospital, and identify the priorities for future development.  The link will initially focus on
patient safety in an Inpatient setting

We will keep this page updated with news of their progress, photo gallery and a diary whilst they are away - so keep checking back for updates.

You can also download the Uganda Handbook / Illustrated Blog by clicking here.

Day 1 (Friday 22nd June)

After a rather stressful and very long journey we finally arrived in Uganda.  We are staying on one of Kampala's 7 hills known as Makindye surrounded by greenery, lush tropical vegetation, birds, and bars that play music to the early hours!  Kampala is a comparatively small and accessible city, safe and great to walk around.

The first walk into the city took us one and a half hours so we were almost late for our first meeting.

Our first official meeting was with Julius Kayiira, the executive director of Mental Health Uganda, an equivalent of Mind in the UK.  Their work centres on supporting carers - particularly mothers of service users and addressing human rights.  They are working with the Ministry of Health to influence government policy and the development of the mental health act, across 19 different districts.  They are also working to address stigma through the use of art, theatre and drama.  We discussed the tensions between the medical approach to the treatment of mental illness and the use of traditional healers.

Julius gave us a contact with the Mental Health Uganda lead in Gulu, and a link to the rotary club as many people here are Rotarians.  We committed to pass on his details to the Ugandan diaspora group in Yorkshire. 

Day 2 (Sat 23rd June)

The mixed weather continues, with a heavy down our of rain most of day.

We visited Heartsounds, a mental health service user led organisation.  Heartsounds is primarily run by Joseph Atukunda who runs the organisation from his house.  It consists of an Internet cafe, library, photocopying service, save to share scheme, and a newly developed peer support service with support from East London and Nottingham mental health trusts.

This massive development of their service has allowed Heatsounds to have an office in Butabika Hospital where staff can in-reach onto wards and service users and staff can access Heartsounds staff easily in the hospital.

Heartsounds is a formally governed organisation that makes decisions through an established committee made up of 8 service user members and 3 lay persons. 
Click here to view theHeartsounds website.
We had the opportunity to meet many inspirational service users who all had very different perspectives on their own mental health and the mental health services provided, however the one common feature that shone through was the positive and crucial impact that Heartsounds has had on individual lives - given people the family they may not have and the opportunities they may not have had.

Recovery as a concept came naturally to the people that we have met rather than a learned approach.  The individuals that we met are incredibly inspirational and progressive in their views, attitudes and approach to dealing with mental health. 

We are learning so much from being here in Uganda, how an individual's motivation to provide support can have such an impact on the service that people receive from minimally resourced people that are driven by love and care.

The  two mental health non government organisations we have met and spent time with are hugely impressive.  They are genuinely advanced in their thinking and approach and espouse a level of understanding and sophistication regarding care from a service user perspective, that we in Sheffield are privileged to hear about and could and will learn a lot  from.

Day 4 (Monday 25th June)

The trip took 6 hours in 2 cars.  The road appeared to be never ending and very long with many pot holes thus various parts of the journey were on the other side of the road.  The highlights were stopping off to buy fresh fruit from street-side vendors and crossing the Nile at Karuma Falls. The falls were magnificent but we were unable to stop and admire them as there were armed guards by the roadside moving us on. Secret photographs were taken of the falls and the baboons that greeted us by the roadside.

We arrived in Gulu and had a very warm welcome from our Manchester University colleagues although it took until the next day to actually see what they looked like due to the power cuts ( which has been a constant feature of our stay…we are currently writing this blog via candle light and a wind up torch which isn’t winding very well!!)

GULU HOSPITAL
Met with the Assistant Hospital Director of Gulu Referral Hospital  to outline our hopes for the link and the intentions of our visit, this was well received.  We had a tour of the hospital with a colleague from Manchester who is working on a medical ward for 6 months, visiting the A+E, Acute Care, Medical ward and labs. Observations of this tour were that this is a hospital trying to provide the best care with negligible resources available, the differences to our services were stark, an example being that patients do not receive any food and bedding from the wards unless it is provided by their families.

Days 5 -7 (Tuesday 26th - Thursday 28th June)
We met with the three senior staff who are coming to England later this year; Principle Psychiatric Clinical Officer (PPCO) Paul (with a background in nursing), In Charge Nurse Sister Immaculate and Psychiatric Clinical Officer (PCO) Dennis (with a background in Occupational Therapy).
The PCO role was developed to address the shortage of psychiatrists in Uganda and is a development of the professional role which allows PCO’s to prescribe and direct medical treatment.  This is mainly perceived as a medical role.
Not only are the PCO’s responsible for the inpatient service, they also hold a daily outpatients clinic (based on the ward) seeing up to 60 people a day.  PCO’s also hold a monthly outreach assessment clinic in the community based health centres.
At Gulu Mental Health Unit there are currently 6 PCO’S, 3 nurses and 11 ‘mental attendants’ (a locally used term equivalent to our support workers).  The unit is a training ward and the central courtyard acts as a venue for student nurse lectures, usually the whole class of 50 .
There are two voluntary organisations working within the unit:
•         Children for tomorrow – working with children, particularly children affected by war
•         PCAF – specializing in working with people with Post Traumatic Stress Disorder
There are an average of 15 patients on a 40 bedded ward which is divided into a female and a male area.  There is currently no age limit for inpatients therefore children and adults are admitted into the same unit.  The first day we visited, the age of patients ranged from between 3 and 70 years old.
One main difference that was noticed immediately was that patients cannot be admitted unless they have an ‘attendant’ (family member or friend) with them.  The attendant is responsible for the general day-to-day care of the patient, including providing bed linen and food.
Another striking observation was that epilepsy is considered a mental illness and a large proportion of patients on the ward had a primary diagnosis of and received treatment for epilepsy.
We had the opportunity to sit in on the outpatient clinic and were shocked by the distance some people travelled by foot for a brief consultation and to collect a further month’s supply of medication.  One person seen had taken a 100km round trip to the outpatient service!
There is a system similar to what we might recognize as ‘patient held records’ in which the patient brings along their book with all information of previous consultations and prescribed treatment.

Prescribed medication is an issue in that supplies often run out, hence patients being told to purchase their own.  Medication is expensive and difficult to obtain causing breaks in treatment and potential relapse.  Doses are often much higher than prescribed in the UK and can include intra-venous administration.  The variety of medicine available is limited therefore patients are frequently prescribed what is available, namely Chlorpromazine, Amitriptyline and Diazepam.

There are no current activities available for patients on the ward and Gulu staff identified occupational therapy as an area they wish to develop.
We observed that patients were often sleeping in bed for long periods of time so when the opportunity arose, card and ball games were played with patients which were greatly welcomed.  This emphasized that the need for an occupational therapy service was desired by both staff and patients alike.

There are clear environmental factors that impact on both the appearance and safety of the unit that need immediate attention.  A growing pile of rubbish, including clinical waste is burned within the hospital grounds, in close proximity to the mental health unit, causing a daily hazard to patients, staff and visitors.

Following our observations and numerous meetings with Gulu staff, patients and senior management, we have formulated a Needs Analysis.  This will form the basis of our action plan in partnership with Gulu Mental Health Services.

Days 8 - 14 (Friday 29th June - Thursday 5th July)

We arranged a meeting with the chair of the Gulu branch of Mental Health Uganda (MHU), JJ Paul.  Unexpectedly he had arranged for a number of service users and volunteers to attend the meeting, as well as staff from Gulu hospital.  A number of the service users/volunteers had travelled for several hours, which was humbling for us as we had only walked for 10 minutes.  The passion and dedication of the Mental Health Uganda members was immediately apparent, more so in the face of their extremely limited resources.  The members were organised, committed and eloquent and there was a cohesive group representing service users from Gulu and the surrounding districts.
Service users told us of micro-finance schemes called Livelihood Improvement, in which small amounts of money are given to service users in order to invest in small businesses to empower them and give them employment and an income.  Most people were keen for further initiatives like this to be available as the majority of people have land without the finances to cultivate it.

MHU identified a few areas of priority that they wished to develop further including the Livelihood Improvement Projects, the counselling services that are provided to service users and families, and finally their data collection in order for them to understand more about the community they support.
MHU also discussed the idea of a ‘drugs bank’.  This centres around ongoing issues when the hospital runs out of medication, MHU ideally wanting to create provision for service users when faced with this problem.

Another major practical issue for volunteers that work in the community based health centre is transport when conducting home visits.  Many of the towns are a long distance apart and the volunteers are either walking or cycling to keep in contact with and to support people and their families in the community.

Some of the team met with the Rotary Club, having established links with the Sheffield branch before departure.  The Rotary Club is an international organisation, which raises funds for worthwhile causes.  They agreed to support in principle the ward at Gulu hospital and a further meeting was arranged with the club's president.  In this meeting the Rotary Club pledged full support for the plan we presented to them and supported the idea of a ‘multisectoral’ partnership i.e. different sectors of the community contributing in their own way towards achieving a goal - in this case supporting mental health in Gulu. 

While this meeting was taking place other team members headed back to the ward to spend the rest of Saturday afternoon on the Ward playing games and learning the local language (Acholi) with patients through drawings and sign language.  It was encouraging to see that the activity attracted interest from both staff and patients, and that one of the Psychiatric Clinical Officers (PCOs), an Occupational Therapist (OT) by background, was keen to spend time whilst in Sheffield exploring how to develop a service at Gulu hospital.  One of the children there had the controversial and somewhat political diagnosis of Nodding Disease. 
 
That evening we visited the ward at around 9pm and were surprised to find that there were no staff on the ward.  Soon one member of staff arrived, a mental attendant who had been in the meeting earlier that day (and was also on duty the night before).  He was to be the only person working that night; we were unsure how long the ward had been without staff.

Sunday was our one day off, and unfortunately Kate was bitten by a red ant and advised she might become "disorganised"!

Further visits with the Dean of Gulu University and the Deputy Hospital Director were attended and support was received from them for our plan. We also met with Dr James Okello, a child psychiatrist who works on the ward on a voluntary basis.  It was useful to get his perspective on the key issues affecting the ward.

On Tuesday we took the long road back from Gulu to Kampala.  We had an opportunity to visit Butabika Hospital as the contact has been maintained from previous visits to Uganda and the recent commonwealth visit to Sheffield by Richard, the Lead OT and Luke who is a senior PCO.

We spent the day at the hospital and noted that some improvements had taken place from our previous visit two years ago.  A major problem that the hospital faces is overcrowding.  One ward we visited was meant for 60 patients but on the day we were there, had 120 with only three staff on duty.  All staff who have contact with patients have received training in the management of violence and aggression facilitated by the East London link which demonstrated to us the potential value of health links.  Our three Commonwealth Fellowship visitors in July will receive our Respect training in the early part of their stay.
Of particular note is the work that Richard Mpango, who previously visited Sheffield, has put in to developing the OT service.  As we approached the department we heard the sound of drumming and entered to see traditional dancing by patients as well as weaving, basketwork and beadwork, which the department sells in a shop in Kampala.  It was good to see that he has also developed an OT service into the children’s ward so that they have some social and educational stimulation.

Key differences between Butabika and Gulu are that attendants aren’t required at Butabika and patients receive two albeit very small meals each day.

Heartsounds
We had a very enjoyable evening with people from Heartsounds, some of the peer support workers and some staff from Butabika.  We had a meal and joined Joseph as he was able to bring together Heartsounds and the local Karaoke club.  ‘Let’s sing away the stigma’ was Joseph's comment as a large group including the Sheffield team sang ‘Lean on me’ which is the Heartsounds/Butabika anthem.  It was an inspirational evening as staff, service users and the community at large came together.  Differences were irrelevant.

On our final day we met with the Mental Health Lead at the Ministry of Health, Dr Sheila Ndyanabanangi (Principal Medical Officer for Mental Health) to report on our visit and present our strategic plan, which was very well received.  She talked through our plan in fine detail and has requested regular reports.

We are writing this on the flight home and reflecting on a remarkable and invaluable experience both professionally, personally and as Trust employees.  It has been on honour to get involved in this kind of work but we are all really looking forward to a long bath!

 

Summary

• We have found that we are constantly learning more each day.  Our opinions and assumptions have changed on a daily basis in response to increased understanding and contact with staff and patients.  There have been highs and lows that have challenged us physically, emotionally, professionally and ethically.  We have learned as much as we have shared.
• The conditions of travel and working are testing for everyone and the team spirit has been consistently high in challenging personal and environmental circumstances i.e. heat, dust, exhaustion and daily power failures.
• The ability to rise to the physical and emotional challenges presented to the team members has been exceptional.
• The variety of occupational backgrounds has added real value to the diversity of the group.
• Relationship with UHSM has been vital.
• Rotary Club connections hold real promise for future funding streams.
• MH Uganda are inspirational and we have engaged in serious learning from them particularly with regard to service user work and service user employment.
• Our notions of the relationship between the Ward and Service User movements have been challenged.
• Learning re: effects of war and cultural effects on mental health have only just begun but will grow.

Gallery

Life can be a daily struggle

 

Kuruma Falls, a place of outstanding natural beauty on the road from Kampala to Gulu

A view of Kampala

 

The ward in Gulu Hospital

 

Members of the Gulu branch of Mental Health Uganda - some of whom had bicycled 4 hours to reach the meeting

 

Heartsounds social evening

 

Internet Café at Heartsounds

 

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