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December 2013

AFP RC G en. H osp/ 13.0 2

A F P R C G E N E R A L

H O S P I T A L

2 0 1 2 R E P O R T

AFPRC General Hospital Farafenni T own North Bank Region The Gambia

“ S t r i v i n g f o r E x c e l l e n c e i n T e r t i a r y H e a l t h C a r e S e r v i c e D e l i v e r y ”

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Table of Contents FORWARD .............................................................................................................................................................. 3 ACKNOWLEDGEMENT ........................................................................................................................................ 4 SUMMARY .......................................................................................................................................................... 5

1. INTRODUCTION........................................................................................................................................ 7

1.1 ORGANISATION, MANAGEMENT & ADMINISTRATION ........................................................................................ 7 1.2 CLINICAL SERVICES ...................................................................................................................................... 8 2.3 HUMAN RESOURCES ................................................................................................................................. 10

2. SERVICE DELIVERY STATISTICS ............................................................................................................... 11

2.1 OUT-PATIENTS DEPARTMENT ..................................................................................................................... 11 2.2 REFERRALS .............................................................................................................................................. 12

2.2.1 In-Referrals .................................................................................................................................. 12 2.2.2 Out-Referrals ............................................................................................................................... 15

2.3 IN-PATIENTS ............................................................................................................................................ 16 2.4 SURGICAL OPERATIONS .............................................................................................................................. 18 2.5 MATERNITY CARE ..................................................................................................................................... 21

2.5.1 Deliveries ..................................................................................................................................... 21 2.5.2 Maternal Deaths ......................................................................................................................... 23

2.6 DENTAL & EYE HEALTH SERVICES ................................................................................................................ 24 2.6.1 Dental Services ............................................................................................................................ 24 2.6.2 Eye Health Services ..................................................................................................................... 25

2.7 X-RAY SERVICES ....................................................................................................................................... 26 2.8 LABORATORY SERVICES .............................................................................................................................. 27

2.8.1 Malaria Screening ....................................................................................................................... 27 2.8.2 HIV Screening .............................................................................................................................. 29 2.8.3 Screening for Sexually Transmissible Infection ........................................................................... 30 2.8.4 Blood Transfusion ....................................................................................................................... 31

3. FINANCIAL MATTERS ............................................................................................................................. 35

3.1 USER-FEES .............................................................................................................................................. 35 3.2 SUBVENTIONS .......................................................................................................................................... 36

4. DONATIONS .......................................................................................................................................... 39

5. INTERVENTIONS .................................................................................................................................... 41

6. CHALLENGES & CONCLUSION ................................................................................................................ 45

6.1 CHALLENGES ............................................................................................................................................ 45 6.2 CONCLUSION ........................................................................................................................................... 46

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Forward

On behalf of the Hospital Management Board let me first register our profound gratitude

to the President of the republic – Shiekh Professor Alhagi Dr. Yahya A J J Jammeh,

whose government conceived and built this hospital. Furthermore, the operation of this

hospital is finance by the government of The Gambia, under the leadership of His

Excellency President Jammeh. The people of The Gambia and in particularly North Bank

Region are most grateful to the President and his government.

I invite all and sundry to read this comprehensive 2012 report about the AFPRC General

Hospital. The report among other things touched on all spheres of the hospital and

provide the reader with a gist of what obtains at the hospital including clinical services,

achievements and key interventions instituted for improved patient management and

outcomes during the year under review.

Lamin S.I. Jammeh

GOVERNOR NBR

CHAIRMAN, HOSPITAL MANAGEMENT BOARD

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ACKNOWLEDGEMENTS

First, I would to thank the Board, Management and staff of AFPRC General Hospital for the

support demonstrated without which this report would not have been possible. I would

also like to express our sincere gratitude to the people of the North Bank Region and to

our patients for having the trust in us for their tertiary health care needs. We register

our indeptedness to our trusted partners for they have and continue to provide to the

hospital.

The data provided herein could not be without the domonstrated commitment of the

hospital staff who are at all times endeavour to record transactions with patients. They

are cognisant of the adage “What is not recorded is not counted” which have motivated them all to be doing what they have already done. Through their different heads of

unit/department, I register my appreciation. The spirit behind the preparation of this

comprehensive report is team work where every member is valued and cherished.

To the government of The Gambia under the distinguish leadership of H. E. the President

Sheikh Professor Alhagi Dr. Yahya A J J Jammeh, I express our profound

appreciation and gratefulness for the assured funding towards the effective and efficient

operation of the hospital.

Dr. Mamady Cham (PhD)

CHIEF EXECUTIVE OFFICER

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SUMMARY

This report attempts to outline the activities and service delivery statistics of the AFPRC General Hospital for the year 2012. The hospital with at least six clinical departments including Internal Medicine, Pediatrics, Obstetrics and Gynecology comprise of a multi-disciplinary team of vibrant health workers providing clinical services 24/7. During the year 2012, a total of 28,730 OPD cases were attended to most of which (62%) were people ≥ 15 years of age. Referrals from peripheral health centers to the hospital for management were 1,187. In the same period the hospital sent out a total of 273 patients to the main referral hospital in Banjul for further management. Between January 1st and 31st December 2012, a total of 3,312 patients were admitted of which 80% were successfully managed and discharged home alive. Children, pregnant women and recently delivered women accounted for the most cases admitted. In 2012 a total of 313 surgical operations were performed compared to 205 (2011) indicating an increase of 52.7% in the performed surgery in 2012. Eye surgery accounted for the highest in 2012 (183) followed by cesarean section (175). The number of cesarean sections increased by 58% between 2011 (111) and 2012 (175). Equally, both the number of institutional deliveries and multiple births increased substantially between 2011 and 2012. Number of deliveries increased by 24% from 1,574 to 1,954 and multiple births by 58.8% from 34 to 54 sets of twins. Institutional maternal mortality ratio significantly reduced between 2011 and 2012 with a reduction of 38% in one calendar year. Dental clinic attendance also increased from 2,008 (2011) to 2,584 (2012) i.e. an increase of 29%. However, the number of X-Ray screenings reduced by 53% from 2,454 (2011) to 1,144 (2012). Of the total laboratory investigations performed, 43,511, malaria related test accounted for the majority (42%). Malaria positivity test results were higher among those above 5 years than those below for both screening approach used. Overall positive test results was 13.4% among those above 5 years compared 8.1% among those below 5 years using the BF test. Equally, using the RDT approach the positive test results was 11.9% among these above 5 years as against 2.5% among children under 5 years.

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HIV positive and VDRL reactive test results were generally low among the screened pregnant women estimated at 1.5% and 0.5% respectively. However, VDRL reactive results were higher among routinely screened men estimated at 3.9%. In 2012, a grand total of 884 pints of blood were transfused of which Maternity patients consumed 65%, Medical ward 13.2% and Pediatric Ward 13.1%. 64.4% of the transfusion blood acquired in 2012 was from relative donors. The high transfusion rate in the maternity unit can be attributed to the high prevalence of anemia among pregnant women. Of the 5,035 routinely screened pregnant women 66.9% (3,369) were found to be anemic with 18.3% (920) in severely anemic state. During the year 2012, revenue generated from user-fees was D250,939.00 a recorded increase of 13.8% from 2011 (D220,461.00). In 2012 the hospital received a total D17,889,412.81 on all subventions (D9,389,412.81 as PE and D8,500,000.00 as OC). By the 1st January 2012 the hospital bank balance was in the negative by D701,766.35. With prudent financial management by 31st December 2012 the hospital’s bank was D168,986.99 after settling all her liabilities. During the year 2012, the hospital received donations from her partners all in the quest to support health services delivery and by extension national development efforts. In the same vein during the year 2012 the hospital management having the aspiration to continuously improve the quality of tertiary health care service delivery in this hospital has taken initiatives and instituted strategic measures to that direction.

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1. INTRODUCTION The Armed Forces Provisional Ruling Council (AFPRC) General Hospital, located in the Farafenni Town of the North Bank Region, is the “first health facility among many” constructed after the 22nd July, 1994 revolution. The hospital operational since 1999, was officially inaugurated by His Excellency, the President of the republic of The Gambia – Sheikh Professor Alhagi. Dr. Yahya A J J Jammeh – on the 21st January 2003. This hospital aims at contributing to the attainment of the Ministry of Health and Social Welfare’s Vision “To provide quality and affordable health services for all by 2020” and Mission “To promote and protect the health of the population through equitable provision of quality health care”. The key roles and functions of this AFPRC Hospital are:

a) To provide high quality tertiary medical care services including curative and rehabilitative care that would enhance socio-economic growth and development;

b) To serve as a referral centre to peripheral health facilities located within the North Bank Region (NBR) and beyond;

c) To serve as a training centre for health care professionals including nurses, doctors and other health care professionals;

d) To attain client satisfaction in the delivery of tertiary care services.

This report attempts to outlines the services and activities of the hospital for the period 1st January – 31st December 2012. The specific objectives of this report are:

a) To outline the management and administrative structures of the hospital; b) To describe the clinical services offered; c) To provide service delivery statistics and where possible comparative analysis

with the year 2011; d) To chart out initiatives/interventions implemented during the period under

review; e) To enlist attainments registered and challenges encountered during the year

2012;

1.1 Organisation, Management & Administration

The hospital headed by the Chief Executive Officer (CEO) who is responsible for the overall day-to-day management of the hospital. The CEO works closely with the established structures for the effective and efficient operation of the hospital for which it has been established. To that end, the CEO is assisted by the following established structures:

a) Hospital Management Board: Appointed by the Minister responsible for Health through by Act of Parliament, the board formulates policies for the efficient operations of the hospital for which it is established; and to administer the affairs of the hospital for which it is established (REF: Medical Services Act 1990).

b) Senior Management Team (SMT): Comprise of Heads of Departments/Units within the hospital. It is chaired by the CEO. The SMT meets at least once every month with the cardinal goal of attaining high quality health service delivery in the hospital with the aim to attain better health outcomes for our patients.

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c) Clinical Management Committee: Comprising of all heads of clinical wards/units. This committee’s aim to enhance effective and efficient clinical service delivery in the hospital and meets monthly. Chaired by the Principal Nursing Officer, this committee meets a week before SMT so that decisions taken by the former can filter to the latter.

d) Procurement Committee: Comprise of the two heads of department (Principal

Accountant and Administrator), CEO and principal stores officer. Chaired by the CEO, the committee among other things ensures that the procurement processes are consistent with established national guidelines and protocols with the ultimate aim of attaining the principle of “Value for Money” in the procurement of goods and services by the hospital.

e) Blood Bank Committee: Tasked with the responsibility of transfusion blood availability within the hospital for speedy emergency health service delivery, this committee comprise of key unit heads of the hospital. Membership also included community members with demonstrated active roles and interest. The committee among other things reaches out to communities to conduct blood harvesting exercises.

f) Donation and Auction Committee: Charged with the responsibility of the coordination of donation activities as well as the conduct of auction exercises within the hospital. They are responsible for all the formalities leading to the conduct of actual auction and ensuring that the proceeds are banked as required.

1.2 Clinical Services

The clinical departments of the hospital are Internal Medicine, Pediatrics, Ophthalmic, Surgery, Obstetrics and Gynaecoloy, provided on “In and out patients” basis 24/7. These departments are supported by the Pharmacy, diagnostic units (Laboratory and X-Ray) and physiotherapy unit. The institutional arrangements for patients needing medical services in this hospital are practically as follows. First, the patient report to the cashier to get prescription pad with ticket (if required), then proceed to the outpatients for consultation and treatment. At the outpatients there are at least two stationed medical doctors between 9:00 am – 02:00 pm from Mondays to Fridays to offer medical care to patients needing the attention of a doctor. Initial screening of patients is done by a nurse. Should the patient clinically need the services of a doctor he/she is referred internally. In case a patient needs expert medical attention i.e. the services of a consultant, he/she is referred internally. The patient may physically go to the consultant or the latter come to review the patient at the outpatients. Upon screening a patient may be treated as an outpatient, admitted in the hospital or referred out. During the screening process a patient may be subjected to further diagnostic screening including laboratory investigations and/or an X-Ray. However, for admission of patients in this hospital, referral of patient out of the hospital and request for X-Ray services are exclusively the mandate of medical doctors. Finally, upon being handed with prescription, the patient goes straight to the pharmacy for the prescribed drugs before going home.

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Table 1 shows the service delivery areas of the different clinical department while table 2 the bed capacity by ward.

Table 1: Service Areas by Clinical Department

Clinical Department Service Areas

General In-patients Consultant

OPD Service Clinic

Internal Medicine Yes Yes Yes

Obstetrics & Gynecology Yes Yes Yes

Pediatrics Yes Yes Yes

Ophthalmic Yes Yes No

Surgery Yes Yes No

Emergency Medicine Yes Yes No

Table 2 : Bed Capacity

Clinical Department Available

Beds

Medical Ward 21

Maternity Ward 22

Pediatrics Ward 32

Ophthalmic Ward 20

Surgical Ward 15

Accident & Emergency Ward 5

Chest Ward 10

TOTAL 125

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2.3 Human Resources

The hospital is comprise of a multi-disciplinary team of health workers including medical doctors (all Cubans); Nurses and Midwives; laboratory and pharmacy staff and other allied health workers and support staff. Table 3 shows the staffing pattern of the hospital. Worthy to note is that of the 327 overall staff as per pay roll 46.2% are in the clinical department. There is no much difference in sex ratio among the overall staff of the hospital as the proportion of males to females is 50.3% and 49.7% respectively.

Table 3: Staffing of the Hospital

DEPARTMENT/UNIT SEX TOTAL

Male Female

Clinical Medical Doctors1 9 4 13

Registered Nurses 5 3 8

Enrolled Nurses 6 4 10

Certified Midwives 1 3 4

Enrolled Midwives 3 6 9

Nurse Attendants 24 63 87

Laboratory Personnel 5 3 8

Radiograhy Personnel 5 1 6

Physiotherapy Personnel 1 1 2

Pharmacy Staff 8 5 13

Dental Staff 1 3 4

Administrative Administration 5 5 10

Accounts 7 8 15

Security Personnel 17 1 18

Drivers 7 0 7

Medical Records 16 4 20

Stores Personnel 4 0 4

Watchmen 3 0 3

Domestic

Orderlies 25 34 59

Laundresses 0 10 10

Cooks 0 11 11

Refuse Collectors 5 0 5

Tailors 4 0 4

Maintenance

Generator Operators 7 0 7

Maintenance Personnel 6 0 6

TOTAL 174 169 340

Proportion 49.0 51.0 100.0 1All are Cuban Doctors;

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2. SERVICE DELIVERY STATISTICS For the year under review, service delivery statistics for all units and service areas (where possible) are provided in the subsequent pages.

2.1 Out-Patients Department

The Out Patients Department (OPD), is the unit that serves as the first point of call for patients seeking medical care from the hospital. It is operational 24/7. For the year 2012, a total of 28,730 patients were attended of which 4.7% (1,360), 3.6% (1,029), 29.9% (8,603) and 61.7% (17,738) were individuals 0 – 1 year old; 2 – 4 years old; 5 – 14 years old and 15 years and older respectively (table 4). Figure 1 shows trend in 2012 OPD attendance.

Table 4 : 2012 Out-patients Attendance

MONTH AGE - GROUP TOTAL

0 - 1 yr 2 - 4 yr 5 - 14 yr > 15 yr

January 47 17 332 690 1086

February 102 69 662 1222 2055

March 81 59 744 1170 2054

April 53 38 797 823 1711

May 61 34 912 949 1956

June 179 129 941 1452 2701

July 92 69 919 2017 3097

August 247 176 918 2290 3631

September 125 108 411 1447 2091

October 174 185 743 2416 3518

November 134 99 736 1861 2830

December 65 46 488 1401 2000

TOTAL 1360 1029 8603 17738 28730

Figure 1: 2012 Out-Patients Attendances (Trend)

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Key Points to Note a) With an overall total OPD clinic attendance of 28,730, the average monthly and daily

clinic attendance for 2012 was 2,394 and 79 respectively; b) The majority (61.7%) of OPD attendants were people 15 years and above. This is

because children under-five report to routine reproductive health clinics provided by health centres;

c) The peak OPD attendance was in the month of August while the lowest was in the month of January;

d) Total OPD attendance in 2011 was 12,393 compared to 28,730 in 2012 giving an increase of 131.8% between 2011 and 2012.

2.2 Referrals

Referrals constitute patients formally sent in by other health institutions to this facility or those sent out by hospital to another for management. Often, the principle in referral is that a patient is sent to a higher level health care facility.

2.2.1 In-Referrals

As the only hospital in the North Bank Region (NBR) and owing to its proximity coupled with the river crossing points, this hospital serve as a referral destination for many health facilities including those in the NBR, Lower River Region (LRR), and part of Central River Region (CRR). For the year 2012, a total of 1,187 patients were referred to the AFPRC General Hospital, of which 68.7% (816) were directed to the OPD and 31.3% (371) were maternity cases (i.e. pregnancy or delivery complications). For the OPD referrals the peripheral health facilities that sent referrals most were Soma Major Health Centre, Farafenni Clinic, Kaur and Illiassa Health Centers accounted for 19%, 15.6%, 12.7% and 10.7% respectively (Table 5).

Table 5 : 2012 OPD In-Referrals

MON HEALTH FACILITY TOTAL

K'wan S'kene N/Sanjal F/RCH Kaur Chamen Illiassa N/Kunda Soma S/Kunda Essau Others1

Jan 4 4 4 6 2 3 5 0 10 1 0 0 39

Feb 6 3 8 8 3 1 6 2 14 2 0 0 53

Mar 12 1 3 14 4 2 5 6 14 2 0 0 63

Apr 15 1 7 5 19 2 7 9 14 2 0 0 81

May 11 0 5 9 8 2 6 1 15 1 0 0 58

Jun 3 2 5 5 5 2 6 4 14 0 0 0 46

Jul 5 21 1 4 9 0 2 2 4 0 0 0 48

Aug 1 2 2 14 11 4 8 1 16 0 0 0 59

Sep 3 4 5 26 9 7 11 5 17 2 0 16 105

Oct 8 3 10 8 6 5 13 7 9 2 0 9 80

Nov 6 2 8 18 18 5 7 3 14 7 0 6 94

Dec 8 2 8 10 10 5 11 6 14 2 0 14 90

TOTAL 82 45 66 127 104 38 87 46 155 21 0 45 816

% 10.0 5.5 8.1 15.6 12.7 4.7 10.7 5.6 19.0 2.6 0.0 5.5 100.0 K’wan = Kerewan; S’Kene = Salikene; N/Sanjal = Ngayen Sanjal; N/Kunda = Njaba Kunda; S/Kunda = Sara Kunda; 1Includes Village Health services.

For the received maternity referrals for the year 2012, the facilities that sent in the most were again Soma, Kaur, Illiassa and Farafenni Clinic accounted for 20.5%; 12.9%, 10.2% and 9.7% of the referrals (table 6).

Table 6: 2012 Maternity In-Referrals

MON HEALTH FACILITY TOTAL

K'wan S'kene N/Sanjal F/RCH Kaur Chamen Illiassa N/Kunda Soma S/Kunda Essau K'Tair Njaw B'Sang Others

Jan 4 0 2 4 4 4 3 2 7 2 2 0 0 0 0 34

Feb 2 0 2 3 0 0 0 3 5 3 1 0 0 0 0 19

Mar 2 2 4 0 3 2 5 3 1 0 4 1 0 0 0 27

Apr 3 3 0 7 3 2 4 3 6 0 0 0 1 0 0 32

May 5 1 5 3 3 4 4 0 7 3 0 0 0 2 0 37

Jun 4 1 3 6 5 0 1 1 6 2 0 0 1 0 0 30

Jul 1 4 3 3 8 2 3 3 7 1 1 0 0 0 0 36

Aug 4 2 6 0 8 2 4 1 8 3 1 0 0 0 0 39

Sep 4 3 3 6 1 4 7 2 17 2 6 0 0 0 0 55

Oct 2 0 3 2 3 1 2 3 3 0 0 0 0 0 1 20

Nov 2 2 1 1 9 2 5 0 7 1 2 0 0 0 0 32

Dec 1 1 2 1 1 0 0 1 2 0 0 0 1 0 0 10

TOTAL: 34 19 34 36 48 23 38 22 76 17 17 1 3 2 1 371

% 9.2 5.1 9.2 9.7 12.9 6.2 10.2 5.9 20.5 4.6 4.6 0.3 0.8 0.5 0.3 100.0 K’Tair = Kuntair; B’Sang = Bansang

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Figure 2: 2012 Maternity and OPD In-Referrals Comparison

Key Points to Note a) Total In-Referrals to the hospital increased from 727 (2011) to 1,187 (2012) i.e. a

percentage increase of 63.3%; b) The referrals’ data demonstrates the pivotal referral centre role this hospital has and

continue to play.

2.2.2 Out-Referrals

During the year 2012 a total of 273 patients were referred out from the hospital to the Edward Francis Small Teaching Hospital (EFSTH) then Royal Victoria Teaching Hospital. Of those out-referrals, 59% (161) were emergency cases. 64.1% (175) of all out-referrals were provided free ambulance services (table 7).

Table 7: 2012 Out-Referrals

MONTH REFERRAL OUT

CONDITIONS & DEPARTMENT TOTAL EMERGENCY AMBULANCE

Surg Med Paed Mat OPD/A&E EYE Others REFERRALS USE

Jan 2 7 1 5 11 0 0 26 17 18

Feb 1 9 11 6 8 0 0 35 15 18

Mar 2 6 3 1 10 0 1 23 12 12

Apr 2 10 3 2 12 0 0 29 15 16

May 4 6 4 0 9 0 0 23 13 15

Jun 3 5 2 3 9 0 0 22 14 17

Jul 2 4 4 0 9 0 0 19 9 12

Aug 1 3 5 2 7 0 0 18 13 13

Sep 1 0 4 4 11 0 0 20 14 14

Oct 1 0 3 1 17 3 0 25 14 15

Nov 1 0 2 5 6 0 0 14 13 13

Dec 0 2 2 3 9 3 0 19 12 12

TOTAL 20 52 44 32 118 6 1 273 161 175

% 7.3 19.0 16.1 11.7 43.2 2.2 0.4 100.0 59.0 64.1

The Accident and Emergency Department effected the highest out-referrals accounted for 43.2% (118), then medical 19% followed by the Paediatric or children’s wing 16% (table 7).

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The highest number of out-referrals was in the month of February (35) while the lowest was in November with 14 cases only (figure 3).

Figure 3: 2012 Out-Referrals (Trend)

Key Points to Note a) On average 23 referral-outs were effected every month; b) Total Out-referrals increased from 214 (2011) to 273 (273) i.e. an increase of 27.6%; c) With a recorded 161 emergency cases and 175 cases provided ambulance services

implies that all emergency referrals were accorded ambulance services free of charge.

2.3 In-Patients

In-patients are those admitted in the hospital for management and close monitoring. Of the 3,312 total admissions for the year 2012, 41.2% (1,366) were at the children’s wing; 26.2% (865) were maternity cases; 21.4% (708) were at the medical ward. The surgical and chest wards recorded the lowest number of admissions – 3.7% (121) and 2.5% (84) respectively (figure 4).

Figure 4: In-Patients By Ward – Proportion

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Furthermore, 79.7% (2,639) of admissions in 2012 were discharged home alive, 5.5% (182) transferred to another hospital. The overall recorded mortality for the year 2012 in the hospital was 9.4% (312). Some patients absconded (0.8%) or opted for alternative treatment (0.6%) – (table 8).

Table 8: 2012 In-Patients by Ward

WARD/UNIT ADM DISCH T/OUT DEATHS ABSCOUNDS DAMA

Surgical 121 80 17 3 2 0

Medical 708 494 56 117 3 11

Ophthalmic 168 149 33 0 0 0

Paediatrics 1366 1099 42 174 13 10

Maternity 865 810 29 12 2 0

Chest 84 7 5 6 8 0

TOTAL 3312 2639 182 312 28 21

%

79.7 5.5 9.4 0.8 0.6 Adm = Admissions; Disch = Discharges; T/Out = Transfer out; DAMA = Discharge Against Medical Advice.

Figure 5 shows the trend of admissions. The highest number of admission was in the month of March (325) and the lowest was in February (184). The average monthly admission was 276.

Figure 5: 2012 Monthly Admissions

Key Points to Note a) 80% of the patients admitted during the year 2012 were successfully managed; b) Pediatrics, Maternity and Medical wards accounted for the highest number of

admissions. This is because these units have specialist doctors available; c) The total number of admissions have reduced from 3,610 (2011) to 3,312 (2012) i.e.

a reduction of 8.3%.

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Assessing the conditions of patients admitted by ward, the following were noted: Medical ward. The five most common conditions were pneumonia (27.6%), Hypertension (18.5%), Diabetes (11.3%), Heart Conditions (9.6%) and Cardio-Vascular Accident (9.1%), highlighting the heavy burden non-communicable diseases poses. It accounted for 48.5% of all admissions at the medical ward. Paediatric/Children’s Ward. The five most common conditions for admission were Pneumonia (22.2%), Anemia (9.8%), Neonatal Sepsis (8.6%), Malaria (8.8%) and Malnutrition (8.2%). Maternity Ward. The most common condition for admissions was Severe Anemia i.e. hemoglobin level below 7 g/dl (18.4%), Pregnancy Induced Hypertension (16.9%), Bleeding during pregnancy (11.2%) and obstructed labor (8.3%).

2.4 Surgical Operations

With a operating theatre that is operational 24/7, a total of 496 surgical operations were performed in 2012. Of the surgical operations performed 36.9% (183), 35.3% (175), 17.1% (85) and 10.7% (53) were eye, caesarean section (C/S), hernia and other operations respectively (figure 6).

Figure 6: 2012 Surgical Operations By Conditions

The surgical operations can be categorized into general and eye. Of the 313 general surgeries performed, 55.9%, 27.2% and 17.1% were caesarean section, hernia and other gynae related operations respectively. With regards to the 183 eye surgeries 82.5%, 10.9% 6.6% were for cataract, lid and pterygium excision respectively. Table 9 shows the general surgeries performed of which 61% (191) were emergencies, 66.5% (208) were major surgeries and 72.5% (227) were for gynae/obstetric conditions. Hernia operations constitutes 27.2% (85) cases overall.

Table 9: 2012 General Surgical Operations

MONTH TOTAL URGENCY CATEGORY CLASSIFICATION

Elective Emergency Major Minor C/S BTL Ectopic Abd. Hyst. Ovarian T. Molar Preg. Hernia Fistula Others

January 26 0 26 25 1 24 1 1 0 0 0 0 0 0

February 3 0 3 3 0 3 0 0 0 0 0 0 0 0

March 34 9 25 27 7 23 8 1 1 1 0 0 0 0

April 26 5 21 26 0 21 3 1 0 1 0 0 0 0

May 21 2 19 19 2 18 1 0 0 1 1 0 0 0

June 10 4 6 10 0 7 2 0 1 0 0 0 0 0

July 21 7 14 19 2 14 5 0 0 0 2 0 0 0

August 22 5 17 17 5 15 1 0 0 1 5 0 0 0

September 33 4 29 32 1 25 2 1 2 1 1 0 0 1

October 17 2 15 17 0 13 1 0 2 1 0 0 0 0

November 46 39 7 6 40 5 1 0 0 0 0 40 0 0

December 54 45 9 7 47 7 0 0 0 0 2 45 0 0

TOTAL 313 122 191 208 105 175 25 4 6 6 11 85 0 1 C/S = Caesarean Section; BTL = Bilateral Tubal Ligation; Abd. Hyst. = abdominal Hysterectomy; Ovarian T. = Ovarian Tumor

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Figure 7: 2012 General Surgeries (Trend)

Figure 7 depicts the trend of general surgical operations performed for the year 2012. Between the year 2010 and 2012 there is a progressive increase in the number of surgical operations performed in the hospital (figure 8).

Figure 8: Surgical Operations 2010 - 2012

Key Points to Note a) General surgical operations increased by 52.7% i.e. from 205 (2011) to 313 (2012);

In 2012 a total of 85 hernias surgical operations were performed compared to zero in 2011. These operations were performed by Operation Hernia Teams from United Kingdom and Germany who has established a cooperation with the AFPRC General hospital;

b) The number of performed caesarean sections increased from 111 (2011) to 175 (2012) i.e. an increase of 57.7%.

2.5 Maternity Care

2.5.1 Deliveries

For the year 2012, a total of 1954 babies were delivered in the hospital. In the same year 54 sets of twins were delivered (table 10) implying that 2.8% of births in the hospital for 2012 were multiple.

Table 10: 2012 Deliveries

MONTH TOTAL TWINS OUTCOME BIRTH WEIGHT (Kg) DELIVERY ATTENDANT

DEL. SETS LB FSB MSB

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Figure 9: 2012 Deliveries (Trend)

On delivery outcomes, 91.8% (1793) of all births were alive. Stillbirths i.e. those not born alive accounted for 8.3% (161). Birth weight of babies delivered indicated that 80% (1563) were in normal range (equal to or above 2.5 kilogram’s), 15.4% (300) were low birth weight (between 1.5 and

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Figure 11: 2012 Deliveries By Attendant

At the maternity OPD clinic, the most common reason for attendance were: to confirm pregnancy (54%), treatment for urinary tract infection (17.7%), missed menstruation (8.9%), or bleeding (5.9%) – figure 12.

Figure 12: Maternity OPD Clinic Attendance

2.5.2 Maternal Deaths

During the year 2012, fifteen (15) maternal deaths were recorded – including both those that died in the hospital and those brought in dead. In the same corresponding period a total of 1793 live births were recorded giving an institutional maternal mortality ratio of

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837 per 100,000 live births. In 2011, with a recorded maternal deaths of 16 and live births of 1387 the maternal mortality ratio was 1154 per 100,000 live births. The medical causes of the recorded 2012 maternal deaths are highlighted in table 11.

Table 11: Medical causes of 2012 Maternal Deaths

MEDICAL CAUSES N (%)

Haemorrhage (Heavy Bleeding) 6 (40.0)

Severe Anemia (HB < 7 g/dl) 4 (26.7)

Eclampsia (High BP & Fitting) 3 (20.0)

Sepsis (Infection) 2 (13.3)

TOTAL 15 (100)

Of the 2012 deaths, 9 (60%) occurred shortly after delivery and 10 (66.7%) of the 15 women that died were indeed severely anemic. Key Points to Note a) Between 2011 and 2012, the number of institutional deliveries in this hospital

increased by 24.1% i.e. from 1574 to 1954; b) Equally and importantly, the number of multiple births attended to increased from

34 (2011) to 54 (2012) – an increase of 58.8%. The proportion of multiple births in the hospital for the year 2012 was 2.8%;

c) Live births proportion was good, above 90%. However macerated still birth rate was a concern 4.7%;

d) The proportion of Low birth weight babies was 19.1% of all births recorded. This uncovers among other things poor maternal nutrition before and during pregnancy;

e) The hospital’s maternal mortality ratio reduced by 37.9% between 2011 and 2012. This is very impressive and significant.

2.6 Dental & Eye Health Services

2.6.1 Dental Services

Dental services in this hospital are limited due to staffing and equipment challenges. The services provided are mainly extraction and management of minor ailments of the teeth. During the year 2012 a total of 2100 cases were seen of which 52.4% (1100) were dental abscesses, 35.6% (747) was toothache, 12% (251) gingivitis (inflammation of the gums) and 0.1% (2) was oral thrust. Trend analysis indicates an average monthly clinic attendance of 175 (range between 144 and 205). Of the total Dental OPD clinic attendance, 23% (484) undergone tooth extraction, implying that almost 1 in 4 had tooth extraction (figure 13).

25

Figure 13: Dental OPD Clinic Attendance & Extractions

2.6.2 Eye Health Services

The eye health services provided at this hospital includes OPD for the management of minor ailments relating to the eye, optical services including diagnosis and correction of visual defects and surgical operations. For OPD services for the year 2012, a total of 3299 cases were seen. Of those, 38.9% (1284) were bacterial conjunctivitis, 14.6% (482) cataract, 7.5% (247) vernal conjunctivitis, and 3.1% (103) was glaucoma. On optical services for the year 2012, a total of 153 patients registered for refraction (children 23 and adults 130) of which 102 (20 children and 82 adults) were issued with prescription for a pair of glasses and 31 of those (30.4%) were given a pair of glasses that match the prescription. Regarding Eye Surgery a total of 183 was performed. Of those 82.5% (151) were for cataract, 10.9% (20), trabut and 6% (12) was for pterygium excision. Of the cataract operations conducted 60.3% (91) were on females and 70% (14) of the trabut operations were again on women. Key Points to Note a) Dental OPD attendance increased from 2008 (2011) to 2584 (2012) i.e. a percentage

increase of 28.7%; b) Eye health services particularly operations improved from 2011.

26

2.7 X-Ray Services

Due to staffing and equipment challenges limited X-Ray services and imaging are offered. Figure 14 depicts the cases that had X-Ray investigation for the year 2012. The average monthly attendance was 95 (range between 61 and 140).

Figure 14: X-Ray Services 2012

A thorough scrutiny of the 2012 X-Ray examinations revealed that of the 1144 cases seen with only 40.1% (459) paid the user-fees while the rest are in the exemption category. Furthermore, 38.2% (437) of cases seen were children (table 12).

Table 12: X-Ray Examinations 2012

MONTH PAID EXAMINATIONS TOTAL

EXEMPTIONS

Child TB Cases HIV Cases Security Staff Disabled RTA

January 53 35 4 8 4 5 0 4 60 February 29 26 1 3 0 3 2 1 36 March 30 29 0 4 2 4 3 3 45 April 31 28 0 3 2 6 3 3 45 May 39 52 5 7 6 3 3 2 78 June 46 41 4 5 2 4 2 1 59 July 39 43 5 4 0 10 1 2 65 August 44 40 0 7 3 19 2 1 72 September 40 60 3 3 2 30 1 1 100 October 50 40 1 5 2 8 3 5 64 November 28 24 0 2 5 2 0 0 33 December 30 19 0 2 1 3 2 1 28

TOTAL 459 437 23 53 29 97 22 24 685 TB Cases = Tuberculosis Cases; RTA = Road Traffic Accidents

27

Key Points to Note a) Cases seen for X-Ray services reduced from 2454 (2011) to 1144 (2012) i.e. a

percentage reduction of 53.4%; b) 60% of X-Ray service beneficiaries in 2012 were in the exemption category.

2.8 Laboratory Services

During the year 2012, a total of 43,511 documented laboratory investigations were performed. Blood test for malaria was the most frequent accounted for 41.8% (18,197). Of those malaria related tests, 32% (13,908) were through Rapid Diagnostic Test (RDT) and 9.9% (4,289) by Blood Film (BF). Blood grouping, Hemoglobin estimation and HIV/AIDS screening accounted for 15.9% (6,898), 11.6% (5035) and 3.8% (2113) respectively (table 13).

Table 13: 2012 Laboratory Investigations

LABORATORY TEST N %

Blood Film (>5 yr) 3571 8.2

Blood Film (< 5 yr) 718 1.7

Rapid Diagnostic Test (>5 yr) 7509 17.3

Rapid Diagnostic Test (5 yr) 649 1.5

Sickle Cell Test (5 yr) 581 1.3

White Blood Count (

28

difference was found between sex in BF positivity results overall (males 13% and females 12%). However, stark variance exist between age-groups. Positivity test results was 8.4% (32) among male children 5 years or less compared to 14.1% (235) among male children above 5 years. The same pattern was noted for females too as 7.7% (26) were found positive among females 5 years or less as against the 12.8% (244) of females above five years old. Overall positive test results was 8.1% for children 5 years or less compared to 13.4% for those above 5 years (table 14).

Table 14: 2012 Malaria Screening – Blood Film

AGE MALE TOTAL FEMALE TOTAL G/TOTAL G/TOTAL

Negative Positive(%) TESTED Negative Positive(%) TESTED TESTED POSITIVE(%)

>5 Yrs 1433 235 (14.1) 1668 1659 244 (12.8) 1903 3571 479 (13.4)

5 Yrs 2502 512 (17.0) 3014 4114 381 (8.5) 4495 7509 893 (11.9)

29

2.8.2 HIV Screening

Pregnant Women Overall 1235 pregnant women were screened voluntarily in the quest to prevent Mother-To-Child-Transmission (MTCT), of which 1.5% (19) tested positive (table 16).

Table 16: 2012 HIV Screening Pregnant Women

MONTH TEST RESULTS TOTAL

Negative Positive TESTED

January 0 0 0

February 73 3 76

March 159 4 163

April 195 3 198

May 142 1 143

June 138 2 140

July 122 0 122

August 0 0 0

September 0 0 0

October 45 2 47

November 157 1 158

December 185 3 188

TOTAL 1216 19 1235

Of the 527 patients counseled and consented to HIV screening, 126 were adult males, 327 adult females, 29 male children and 45 female children. Overall positive HIV test was 19.4% (102). Positivity test results for adult male, adult female, male children and female children was 19.8%, 16.5%, 20.7% and 37.8% respectively (table 17).

Table 17: 2012 HIV Screening – General Patients

MONTH MALES TOTAL FEMALES TOTAL MALE (Children) TOTAL FEMALE (Children) TOTAL G/TOTAL G/TOTAL

Negative Positive TESTED Negative Positive TESTED Negative Positive TESTED Negative Positive TESTED TESTED POSITIVE

January 1 0 1 3 1 4 0 0 0 0 0 0 5 1

February 14 1 15 27 2 29 2 1 3 0 2 2 49 6

March 5 1 6 33 4 37 1 1 2 2 4 6 51 10

April 11 0 11 32 9 41 3 0 3 0 9 9 64 18

May 10 5 15 16 4 20 2 0 2 2 0 2 39 9

June 11 5 16 11 5 16 3 1 4 1 0 1 37 11

July 6 1 7 9 7 16 1 0 1 3 0 3 27 8

August 10 3 13 8 4 12 0 0 0 2 0 2 27 7

September 12 2 14 19 1 20 2 1 3 1 0 1 38 4

October 6 4 10 12 6 18 1 1 2 2 1 3 33 12

November 9 0 9 23 8 31 3 1 4 3 1 4 48 10

December 6 3 9 80 3 83 5 0 5 12 0 12 109 6

TOTAL 101 25 126 273 54 327 23 6 29 28 17 45 527 102 % 19.8 16.5 20.7 37.8 19.4

2.8.3 Screening for Sexually Transmissible Infection

Screening for sexually transmitted infection is performed on selected patients including pregnant women in a quest to control its spread. Of the 1,521 pregnant women that went through the VDRL test, only 0.5% (8) was found to reactive (table 18). For the other group (non-pregnant women and men), 1701 were screened of which in 2.1% (35), test results was reactive. Men were found to be more likely to have reactive test than women – 3.9% compared to 1.8% (table 19).

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Table 18: VDRL Screening (Pregnant Women)

*No Reagents for the test

Table 19: VDRL Screenings (Men & Non-Pregnant Women)

MONTH MALES TOTAL FEMALES TOTAL G/TOTAL G/TOTAL

Non-React Reactive TESTED Non-React Reactive TESTED TESTED POSITIVE

January 5 0 5 199 5 204 209 5

February 7 0 7 180 3 183 190 3

March 11 1 12 198 4 202 214 5

April 20 4 24 170 2 172 196 6

May 31 0 31 195 3 198 229 3

June 42 1 43 149 4 153 196 5

July 33 1 34 164 2 166 200 3

August 22 0 22 240 5 245 267 5

September* 0 0 0 0 0 0 0 0

October* 0 0 0 0 0 0 0 0

November* 0 0 0 0 0 0 0 0

December* 0 0 0 0 0 0 0 0

TOTAL 171 7 178 1495 28 1523 1701 35 % 3.9 1.8 2.1

*No reagents for the test

2.8.4 Blood Transfusion

Blood transfusion is a life saving health care intervention. Often patients needing surgery, victims of road traffic accidents and most particularly pregnant and women giving birth need urgent blood transfusion. Thus, consistent availability of transfusion blood in a health care institution particularly in a referral hospital like AFPRC Hospital cannot be over emphasized.

MONTH TEST RESULTS TOTAL

Non-Reactive Reactive TESTED

January 199 2 201

February 198 1 199

March 198 2 200

April 170 0 170

May 195 0 195

June 149 1 150

July 164 2 166

August 240 0 240

September* 0 0 0

October* 0 0 0

November* 0 0 0

December* 0 0 0

TOTAL 1513 8 1521

Table 20: 2012 Blood Transfusions by Ward

MONTH MEDICAL WARD TOTAL PAEDIATRIC WARD TOTAL OPERATING THEATRE TOTAL A & E WARD TOTAL MATERNITY G/TOTAL

Male Female Male Female Male Female Male Female

January 5 6 11 1 4 5 2 4 6 0 0 0 60 82

February 4 1 5 3 1 4 0 0 0 2 1 3 28 40

March 3 12 15 5 2 7 1 3 4 4 2 6 64 96

April 5 6 11 8 4 12 1 10 11 1 2 3 47 84

May 3 4 7 8 3 11 1 2 3 1 1 2 43 66

June 4 9 13 4 9 13 2 0 2 0 0 0 53 81

July 9 2 11 11 2 13 7 0 7 1 0 1 64 96

August 2 8 10 4 5 9 0 2 2 0 1 1 50 72

September 2 8 10 6 5 11 0 7 7 0 1 1 72 101

October 1 6 7 7 3 10 0 7 7 0 2 2 38 64

November 5 5 10 5 6 11 0 3 3 0 2 2 40 66

December 4 3 7 5 5 10 0 0 0 0 0 0 19 36

TOTAL 47 70 117 67 49 116 14 38 52 9 12 21 578 884

% 13.2 13.1 5.9 2.4 65.4 100.0

During the year 2012 a total of 884 transfusions were done of which 13.2%, 13.1%, 5.9% and 65.4% occurred at the medical, children, operating theatre and maternity wards respectively. The maternity ward by far did the highest number of blood transfusion. It is also important to explain how transfusion blood was acquired leading to the actual transfusion. In total 936 pints of transfusion blood was harvested during the year under review with 64.4% (603) from relative donor and 35.6% (333) from a voluntary blood donor. On average every month the hospital attend to 93 relative donor and 51 voluntary donors. 99% of our donors were males (table 21).

Table 21: Blood Donors 2012

MONTH DONOR CATEGORY G/TOTAL

RELATIVE TOTAL VOLUNTARY TOTAL

Male Female

Male Female

January 45 0 45 41 1 42 87

February 32 0 32 36 0 36 68

March 52 0 52 30 1 31 83

April 64 0 64 25 0 25 89

May 45 1 46 35 1 36 82

June 51 0 51 20 1 21 72

July 67 0 67 41 0 41 108

August 52 2 54 37 0 37 91

September 65 1 66 17 0 17 83

October 59 0 59 26 5 31 90

November 39 0 39 6 0 6 45

December 28 0 28 10 0 10 38

TOTAL 599 4 603 324 9 333 936

% 64.4 35.6

To understand the high proportion of transfusion among pregnant or recently pregnant women we explored the prevalence of anemia among a cohort of pregnant women visiting the hospital. Table 22 outlines the hemoglobin level estimation among pregnant women referred to the hospital for the routine screening test. A grand total of 5,035 pregnant women were tested. Of those 66.9% (3369) were “Moderately Anemic”, 16.8% (845) were with “Severe Anemia” and 1.5% (75) were “Very Severely” anemic as per World Health Organization established standard. As per national guidelines and standards, 18.3% (920) whose hemoglobin level is below 7 g/dl needed blood transfusion (table 22).

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Table 22: Hemoglobin Results for 5035 Pregnant Women

MONTH HAEMOGLOBIN LEVEL (g/dl) TOTAL

35

3. FINANCIAL MATTERS This chapter will cover subventions received (Personnel Emoluments [PE], Other Charges [OC] and development), revenue generated from user-fees and expenditures for the year 2012.

3.1 User-Fees

With the adoption of Drug Revolving Fund (DRF) scheme in 1988 by the ministry of health, patients pay a highly subsidized fee for selected services. During the year 2012 an overall collection of Two Hundred and fifty Thousand and nine hundred and thirty-nine Dalasis (D250,939.00) was collected. Table 23 shows the 2012 DRF collections while Figure 15 trend in monthly collections.

Table 23: DRF Collections 2012

MONTH AMOUNT

January 18000.00

February 17550.00

March 20675.00

April 22000.00

May 17650.00

June 16750.00

July 19850.00

August 14000.00

September 20560.00

October 21249.00

November 23234.00

December 39421.00

TOTAL 250939.00

Figure 15: DRF Collections 2012 (Trend)

3.2 Subventions

As a non-profit-making public health care institution providing social and essential services to the general public, the hospital is wholly funded by the government through monthly subventions. Table 24 outlines the subventions and expenditures in 2012.

Table 24: 2012 Subventions (Monthly Income and Expenditure)

ROW SUBVENTION Dec 2011 MONTHS 2012

JAN FEB MARCH APRIL MAY JUNE JULY AUG SEPT OCT NOV DEC G/TOTAL 1 Personnel Emuluments (PE) 653280.93 653280.93 653280.93 653280.93 773009.09 753280.00 850000.00 850000.00 850000.00 850000.00 950000.00 900000.00 9,389,412.81

2 Other Chareges (OC) 500000.00 750000.00 750000.00 750000.00 650000.00 650000.00 750000.00 750000.00 750000.00 750000.00 600000.00 850000.00 8,500,000.00

3 TOTAL INCOME 1153280.93 1403280.93 1403280.93 1403280.93 1423009.09 1403280.00 1600000.00 1600000.00 1600000.00 1600000.00 1550000.00 1750000.00 17,889,412.81

EXPENDITURES

4 Salaries

485661.00 486158.80 509453.04 492748.24 461960.50 449240.33 453794.33 456216.00 478530.00 475590.35 471405.00 453499.00 5,674,256.59

5 Allowances

283161.35 303912.31 279121.06 301403.25 275782.63 327290.03 297121.58 287089.72 314119.76 315569.06 287165.65 272882.53 3,544,618.93

6 Wages

105080.62 84812.48 88808.88 85984.40 85917.20 83386.00 84671.36 84971.36 80736.80 81929.68 77739.20 80283.84 1,024,321.82 7 TOTAL EXPEND. (PE)

873902.97 874883.59 877382.98 880135.89 823660.33 859916.36 835587.27 828277.08 873386.56 873089.09 836309.85 806665.37 10,243,197.34

8 Travelling Expenses

5000.00 5000.00 5000.00 5000.00 5000.00 5000.00 5000.00 7800.00 7800.00 8800.00 7800.00 10600.00 77,800.00

9 Telecomm. Expenses

0.00 30000.00 6000.00 16000.00 16000.00 33000.00 26000.00 54000.00 29000.00 18250.00 19000.00 25000.00 272,250.00

10 Rent & Furniture

48000.00 23000.00 76100.00 35000.00 109200.00 176400.00 54500.00 156500.00 76500.00 58500.00 44025.00 89000.00 946,725.00

11 Support to TACS

14600.00 14600.00 13100.00 9100.00 9100.00 9100.00 9100.00 9100.00 11100.00 11100.00 11100.00 11100.00 132,200.00 12 Uniforms

0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 23850.00 0.00 0.00 0.00 23,850.00

13 Drugs & Dressings

0.00 0.00 0.00 0.00 0.00 25500.00 26304.00 0.00 15556.00 0.00 0.00 0.00 67,360.00

14 Misc. Office Expenses

40000.00 78650.00 64390.00 113500.00 83949.30 50000.00 73750.00 70250.00 117800.00 147320.00 45000.00 144530.00 1,029,139.30

15 Other Medical Stores

53760.00 113859.00 69825.00 55525.00 52000.00 73650.00 105000.00 108963.00 35001.09 58120.00 40350.00 0.00 766,053.09

16 Patient Food

126330.00 73000.00 25000.00 5000.00 159000.00 45850.00 165000.00 117250.00 79900.00 172875.00 100450.00 147050.00 1,216,705.00

17 Oper. & Maintenance (Fuel) 88500.00 79650.00 72570.00 102350.00 79335.50 54000.00 84165.00 89512.50 115395.00 69375.00 98170.00 87880.00 1,020,903.00 18 Oper. & Maintenance (Maint) 0.00 0.00 53884.00 20982.00 21781.00 7500.00 30000.00 22400.00 29355.00 47820.00 39550.00 2450.00 275,722.00

19 Maint. of Generators

0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 18000.00 0.00 30000.00 0.00 48,000.00

20 Maintenance of Hospital

6000.00 5000.00 35275.00 59259.00 80000.00 85650.00 113800.00 72823.00 110525.00 8400.00 86698.00 143098.55 806,528.55

21 Maint. of Equipment

0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00

22 Bank Charges

17000.00 5638.34 4753.95 1429.04 5763.91 4766.64 13234.73 10351.08 9751.35 8114.46 5438.59 5984.10 92,226.19 23 TOTAL EXPEND. (OC)

399190.00 428397.34 425897.95 423145.04 621129.71 570416.64 705853.73 718949.58 679533.44 608674.46 527581.59 666692.65 6,775,462.13

24 G/TOTAL EXPENDITURE 1273092.97 1303280.93 1303280.93 1303280.93 1444790.04 1430333.00 1541441.00 1547226.66 1552920.00 1481763.55 1363891.44 1473358.02 17,018,659.47

25

-119812.04 100000.00 100000.00 100000.00 -21780.95 -27053.00 58559.00 52773.34 47080.00 118236.45 186108.56 276641.98 26 BANK BALANCE -701766.35 -821578.39 -721578.39 -621578.39 -521578.39 -543359.34 -570412.34 -511853.34 -459080.00 -412000.00 -293763.55 -107654.99 168986.99

37

The hospital receives three categories of subventions - PE and OC (on monthly basis) for the payment of salaries and wages; and purchase of goods and services respectively and development (one-off annually) towards development works within the hospital. Table 24 highlights the income received (PE and OC) as well as expenditure for the year 2012. As per Estimates of Revenue and Expenditure 2012, the approved for OC was D8,500,000.00 and that of development was D250,000.00. As for PE, the approval as per our submitted 2012 was D12,400,917.60 (salaries D8,212,300.00; allowances D3,410,000.00 and wages D778,617.60) annually. During year under review the total sum of D9,389,412.81 was received as PE giving an overall deficit of D3,011,504.79. Unlike PE, the approved D8,500,000.00 for OC was received. However, no development vote was received during the year 2012 even though a written request was made. In terms of overall expenditure 60% of the income was spent of personnel (salaries, wages and allowances), 7.1% on feeding of patients and their escorts, 6% on stationery (patients recording tools and materials), 5.9% of fuel for the generators and on transport. Expenditure on staff accommodation attracted 5.6% of total expenditure. Worthy to note is that as at 31st December 2011 the hospital’s bank balance was in the negative of D701,766.35 (table 24, row 26) increased to D821,578.38 (table 24, row 26 under under January) by end of January 2012. From then on started to decline consistently. These negative amount does not include the monies owed to suppliers of goods and services to the hospital. For example by end of July 2012 the sum of owed to vendors amounted to D496,943.00. Implying that the hospital’s total liabilities was D1,008,786.34 (D511,843.34 overdraft and D496,943.00) owed to vendors end July. By end of December 2012 the overdraft and all monies owed were settled leading to a bank balance of D168,986.99 (table 24, row 26 under December). Thus, by 1st January 2013 the hospital for the first in many years graduated from overdraft. Figure 16 outlines the hospital balance by month.

Figure 16: Hospital Account Bank Balances 2012

38

Key Points to Note a) Revenue collection through DRF increased by 13.8% from D220,461.00 (2011) to

D250,939.00 (2012); b) The under-subvention of PE is among the main factors that dragged the hospital into

an overdraft situation over the years. Worthy of noting is the monthly bank charges are not taken into account during calculation of subvention to the hospital. In the year under review the overall bank charges was D92,226.19. This naturally is directly deducted by the bank from the hospital accounts;

c) No development funds received in 2012. This hinders development works in the hospital;

d) Prudent financial management is the main driving force that paid dividend in the hospital settling all her debts by end year 2012;

e) Though the hospital have for now graduated from an overdraft situation if the under-subvention of PE is not address it might in the future lead back to it.

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4. DONATIONS As a public institution serving the general public, the hospital has traditional partners who support the efforts of the board, management and staff in various ways including in the form of donations. During the year 2012 the hospital received the following support from individuals, groups and institutions as catalogued below. Date Donor Items Rationale

25/01/12 Office of The President 30 boxes of sacrificial meat. Towards in-patients feeding.

26/01/12 Jammeh Foundation for

Peace

139 pieces of Bedsheets, 29 Hand towels In support of their adopted ward

– Chest Ward. 08/02/12 Jaliba Kuyateh & Kumareh

Band

20 armless chairs, 115 pieces of uniforms

and assorted drugs

In support of their adopted unit –

the Pharmacy Department.

23/02/12 Hand in Health 4 cartons of assorted surgical materials Support of the hospital

management’s efforts.

01/03/12 National Malaria Control Programme

250 pieces of Bednets Prevention and control of malaria within the hospital.

06/03/12 Stick Hand to Hand 1 piece Autoclave, 4 cartons syringes and needles

Support of hospital’s efforts.

19/06/12 National Nutrition Agency

(NaNA)

7 cartons plummy nuts Rehabilitation efforts of severe

malnourished children in

hospitals.

20/06/12 Malak Chemist 3 cartons Ampicillin capsules, 2 cartons

multivitamin tablets

Support of hospital’s efforts.

25/07/12 H.E. The President – Shiekh

Prof. Alh. Dr. Yahya A J J

Jammeh

Sugar 7 bags/50 kg each Annual Rammadan Gift accorded

to all and sundry.

25/08/12 Social Security and Housing

Finance Corporation (SSHFC)

Solarization of their adopted ward – OPD

& Accident and Emergency Unit in the

tune of D158,700.00.

To ensure power supply

availability 24/7.

24/09/12 Oustass Omar Mbye 24 packets of dates Rammadan gift to staff and

patients.

17/11/12 National Nutrition Agency 100 packets laundry soap, 40 packets baby pads, 7 gallons bleach, 15 pieces of

baby stool potters.

Support on Baby Friendly Hospital Initiative (BFHI).

20/11/12 Trust Bank Gambia Limited A desk-top computer and printer,

refrigerator, electric kettle, 10 pieces of wiper blades, 10 pieces of soft brooms, 10

pieces of ceiling brushes, 20 pieces of

air-freshners, 100 bottles of cottol, 5 pieces of extention adopters, 10 bags

Omo, 144 cakes laundry soap, 100 bottles

bleach, an executive table and executive chair, 5 pieces of rain boots, 10 pieces of

iron buckets, 2 roll of bale for bedsheets,

30 meters protective curtains – worth

D112,950.00.

In support of their adopted ward

– Maternity Ward. It should be mention that this is an annual

event dating back in 2001.

27/12/12 Hon. Bala Garba Jahumpa – Minister of Health & SW

4 Dell computers each with printers and UPS

For enhanced communication, recording and data management.

40

During the year 2012 these individuals and institutions have accorded donations and services to the hospital on numerous occasions as catalogued below.

Donor Items Rationale

2nd Infantry Batallion – Farafenni They are since 1999 the key partner and ally of the hospital providing among others – Firewood

towards cooking for patients, main “Voluntary

Blood Donors” often at odd hours, clearing of

the bushy grasses within and out of the

hospital during rainy season, assigned to the

hospital for every “Operation Clean the Nation” – monthly setsetal, and even assist some

plumbering maintenance work in the hospital

To support the vision of their Commander-In-Chief

and saving lives.

Serigne Njie Actively participate in all Setsetal in the

hospital and often provide all the tools required

Contributing his quota to

national development and

supporting the efforts of the hospital

Gambia Ports Authority/Gambia Ferry Services

Not only are they crossing ambulances free of cost, giving them priority crossing they on

many occasions have to recall the ferry or ask

it to wait for an ambulance carrying an

emergency referral.

Contributing to the health sector’s efforts to saving

lives.

Farafenni NAWEC Station Prioritise electricity supply to the hospital

whenever their generator is on. Assisted on

several occasions in addressing electrical

problems within the hospital

Contributing to the health

sector’s efforts to saving

lives.

Hon. Ousman Bah of Sabah Sanjal District On several occasions bring donations of

assorted medical items to the hospital

Supporting the efforts of

the hospital.

Kemo Dibba – Farafenni

Sadibou Hydara – Farafenni

Kajali Jafuneh – AFPRC Hospital

Sulayman Jarra – Army Camp

Comm. Cherno Nyassi – Immigration Lang Dala Marong – Baddibou India

Adama Keita – Daru Yallal

These are regular voluntary blood donors who

are frequently reverted to whenever the need

arises. They are very dependable donors.

Saving lives of people.

Arfang Jerreh Jadama – Jumansarr Have every year donated from his farm

pumpkins and water mellon to the hospital towards in-patient feeding for the past years

Supporting the efforts of

the hospital.

Africa Muslim Agency Have every year donated a bull to the hospital

for in-patient during the Muslim feast of Eid-Ul-Adha (Tobaski) for the past years

Supporting the efforts of

the hospital.

Quality Print Enterprise Have on several times printed free of cost

hospital recording tools and T-shirts for the

blood bank

Support of hospital’s

efforts.

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5. INTERVENTIONS During the year 2012 management has taking certain initiatives and interventions with the aim to enhance effective and efficient tertiary health service delivery. Being a referral hospital it is important that the hospital at all times aims to provide quality health care services. In that direction the table below outlines the interventions.

Area/Dormain Intervention/Initiative Rationale

Human Resource

Management

- Internal staff audit was conducted to establish

the physically existent staff; - Staff on daily wages for the past years were

appointed on permanent basis where vacant

position exists;

- Deserving staff were promoted where vacant

positions exists; - A system of internal rotation of some general

staff introduced; - Attendance registry for all shifts (morning,

afternoon and night duties) strengthened.

- Set of uniforms provided to each clinical staff

- To get rid of ghost workers and

habitual absenteeism; - To motivate staff;

- To motivate staff;

- To encourage polyvalency in

health care delvery; - To ensure punctuality.

- For idenfication and meeting

professional standards.

Clinical Care Services - Patient triage system strengthened at the OPD;

- A trained nurse identified to serve a

management head while doctor as clinical head

of ward;

- All “In-Referrals” must be seen by a doctor on

arrival. Equally, doctors must sanction any “Out-

Referrals”;

- Ward rounds by doctors assured Mondays –

Fridays (except on public holidays);

- Essential support units such as Pharmacy, X-

Ray, Operating Theatre are operational 24/7;

- At least 2 doctors are always stationed at the

OPD and Emergency ward Mondays – Fridays (9 am – 2 pm);

- After 2 pm a doctor is on call to attend to all

emergencies in the hospital; - 3 consultant clinics have been established

during the year 2012;

- The Infectious Disease Unit has been integrated

into the medical clinic;

- Duty Room coverage 24/7 to coordinate all clinical activities after normal working hours;

- Maternal Death Review/Audit institutionalized; - Monthly meetings held;

- Proactive approach to transfusion blood harvesting initiated;

- To reduce waiting time;

- Towards quality improvement

and attainment;

- Ensure quality and to regulate

clinical practice;

- To ensure admitted patients

have the attention of a doctor;

- To avoid delays in clinical

service delivery;

- To facilitate prompt access to medical attention;

- To ensure access to expert care

and attention;

- To reduce stigma and

discrimination;

- To monitor and supervise clinical division;

- To improve clinical practice and

patient outcomes; - For improved performance;

- To facilitate prompt delivery of

emergency clinical care;

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Area/Dormain

Intervention/Initiative

Rationale

Infrastructural

development and maintenance

- Massive rehabilitative works have and continue

to be embarked upon: o Fixing of leaking water pipes and roof;

o Changing of faulty toilets, wash hand basins and taps;

o Changing of dysfunctional ceiling fans

and air-conditioners with new ones;

o Ensuring that lockable doors are

provided locks;

- The security lights of the hospital both in and

out are repaired and functional;

- Both the inside and out side of the hospital are

repainted with all wards now green-belt painted;

- A programme of changing from florescent to

energy saving bulbs have been embarked upon; - An abandoned old kitchen have been rehabilited

to standard now used as a clinic;

- New air-conditioners installed in most places

including at:

o X-Ray department;

o Each of the 3 Consultant clinics;

o Duty-Room;

o Board Room;

o Staff Canteen and Conference Hall

- Leather curshioning of hospital mattresses have

started;

- Changing wooden doors and windows to metal-

glasses have started

- For enhanced performance,

hygiene and sanitation;

- Staff motivation and ease of

working condition;

- Enhanced security;

- Enhanced security and improved

visiblity;

- In compliance with national call;

- Staff motivation and ease of

working condition;

- Towards reduction of

nosocominal infection;

- Towards reduction of

nosocominal infection

Transport Asset Management

- 2 of our fleet of stranded vehicles rehabilitated and now on the road;

- Only drivers authorised to drive the hospital

vehicles;

- A separate vehicle is dedicated for ambulance;

- A vehicle is always put on standby as utility 24/7;

- All drivers provided with uniforms

- To facilitate mobilility and transportation of goods and

services.

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Area/Domain Intervention/Initiative Rationale

Water &

Electricity

- The 30 KVA generator, dysfunctional for over two years

was repaired and serve as back-up to the functional 40 KVA generator;

- With frequent water shortage hitting Farafenni, the generator pumps water to hospital water tank to ensure

water availability in the hospital;

- With NAWEC electricity supply on scheduled times, the

hospital generators provide electricity when NAWEC is off

and during emergencies;

- The hospital settled accommodation rental arrears & that

of 2012 by December 2012

- For assured electricity

availability; - To support clinical services

for better patient outcomes.

- For staff motivation and

ensured trust with landlords.

Domestic - Ward/unit scrubbing is a routine in all three shift duties;

- Hard plastic covered dustbin provided to each ward/unit to

facilitate refuse collection;

- In addition to the national monthly Operation Clean the Nation, the hospital orderlies took it upon themselves to

organize general cleaning and scrubbing exercise every

Saturday of the month;

- Medical waste has a designated dump site where it is

incinerated;

- Three square meals provided/day to in-patients and their

escorts;

- Each ward provided with at least two sets of bed sheets for

in-patient use;

- Laundry of hospital linens done daily;

- To ensure cleanliness;

- Prevent and control

nosocominal infection;

- In compliance with national

humanitarian gesture;

- To ensure patient comfort;

Records and

Data

Management

- The culture of documentation of transactions particularly

that related to patient management improved significantly;

- Monthly service delivery statistics collated by the fifth day

of the following month making trend analysis feasible;

- Public presentation of the hospital 2012 service delivery

statistics staged in July 2013; - Service delivery records from 1999 – date available;

- Retrieval of hospital kept patient records very easy

- For enhance accountability;

- For planning and informed

decision-making;

- Raise awareness on the

performance of the hospital.

Drugs & Medical Supplies

- For decades the main drug store was also serving as an office. The two are now separated;

- Two 18 BTU split air-conditioners installed at the drugs store;

- Drugs issued to patients only on prescription;

- Supplies to wards now on weekly basis rather than daily. All

requisition must be endorsed by management before issue;

- Doctors now do all the prescriptions during ward rounds.

- For increase security of drugs and supplies;

- For enhanced drug efficacy;

- To avoid delays in patient

management;

- A quality assurance approach.

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Area/Domain Intervention/Initiative Rationale

Financial Management - A one-sheet summary financial transaction is

prepared every month to gauge expenditure, - “Value for Money” is a guiding principle in all

transactions in the purchase of goods and services;

- Payments for the purchase of goods and

services effected only upon satisfactory

completion of work;

- All procured goods are first sent to the stores

for documentation before issue out using a

standard requisition book;

- All supporting documents for any financial

transactions are collated on the payment

voucher before payments are endorsed and

signed; - Reconciliation of bank transaction print-out

against summary transactions is done at the

end of every month

- For ease of reconciliation;

- Right and best thing to do;

- Adherance to the principle of

“Value for Money”;

- For enhanced accountability;

- To exclude multiple payments

and ease auditing process;

General Management - Regular meetings of established committees

has been ongoing e.g.:

o Board meetings held at least every

two months;

o Senior Management Meeting held

every month;

o Clinical Division meeting held every

two months;

o Blood harvesting exercises carried

out in different communities

monthly;

- Clinical Division developed a comprehensive

checklist to monitor among other things staff punctuality, patient care and management,

equipment and supplies availability and use

during all three shift duties; - Monthly Senior Management team-up to round

the entire hospital; - A Close-User-Group cell phone facility entered

into has been expanded

- To keep abreast with issues

in the hospital;

- Discuss and explore solutions

to challenges and problems

collectively;

- Towards continuous quality

improvement in clinical care and services.

- To facilitate communication

between and among staff.

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6. CHALLENGES & CONCLUSION

6.1 Challenges

A lot has been achieved during the year 2012 in all spheres including that related to patient management and patient outcomes. However, some issues poses as a formidable challenge to management. Clinical Care There is no general surgeon among the doctors in the hospital. Thus, any patient

needing general surgery is referred out to the main referral hospital in Banjul. Importantly, as all our current doctors are Cubans who do not complete medical

reports on legally involved cases. Thus, all such cases are referred to Edward Francis Small Teaching Hospital in Banjul.

There are far more untrained nurses compared to the trained ones (ratio of 3:1

respectively). The reliance on nurse attendants compromise the aspired quality of care for our clientele.

There is urgent need for the replacement of some of the current set of equipments in

the hospital; Accommodation Unlike other public hospitals with their owned accommodation facilities for her staff,

this hospital is without and as such spend huge sum of money annually on rentals for accommodation;

Utility Electricity supply from NAWEC is on scheduled times/day and not 24/7 leaving the

hospital with no option to use her generator for electricity during emergencies and other times. With the increasing fuel prize it is a tough challenge;

Like electricity, water supply in the Farafenni town is also erratic, thus, the hospital rely on her generator to pump water for hospital use. The concrete water tank leak profusely;

Procurement of Goods & Services In compliance with established national standards and protocols, all goods and

services are procured from the Greater Banjul Area given the limited number of suppliers and/or service providers in this area registered with the Gambia Public Procurement Authority.

Financial The deficits in the monthly PE subvention coupled with the bank charges (often not

taken into account when calculating subventions) are the main factors that led the hospital into entering an overdraft situation. This if not address may drag the hospital back into that situation;

46

Not receiving the hospital’s development funds (though approved) hinders

development within the hospital. Patient Feeding Unlike urban located public hospitals, in rural located hospitals the in-patients and

their escort or escorts rely heavily on the hospital provided food for their survival. Thus, instead of providing food to a patient/bed we actual providing food (three meals/day) to at least two people to a bed.

6.2 Conclusion

The numbers provided herein are about people and diseases and should be viewed in that context. It is only then the reader can appreciate the important roles health systems play in overall national development. The data herein further demonstrates how health systems anywhere in the globe is impacting on the lives of individuals, families and communities of nations. Increasing health care coverage now coined as “Universal Health Coverage” is the single most powerful concept that public health has to offer. The AFPRC General Hospital came into being in a quest to improve availablity, access and utilization of tertiary medical care services in the North Bank Region and beyond. “What would it have it been for these patients if this hospital was not in existence”? Because of its strategic location, it is referral centre to health facilities in at least three regions in the country. Thus, it is visionary to conceive the idea of constructing this hospital in the first place not to mention the demonstrated commitment to actually construct it. Good health is not only a consequence of economic development, but also a driver of it, since healthier people can do more. Good health not only enhances these benefits by improving health but also yield additional economic benefits. It is in that direction that the current management of the AFPRC General Hospital is thinking and doing everything possible to ensure the delivery of quality tertiary health care services at all times.