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Table of Content

1. INTRODUCTION ................................................................................................................... 8

1.1 Organization, Management & Administration ........................................................................................ 8

1.2 Hospital Department............................................................................................................................. 10

1.3 Human Resources ................................................................................................................................. 12

2. CLINICAL SERVICE DELIVERY STATISTICS ............................................................................ 14

2.1 Out-Patients Department ...................................................................................................................... 14

2.2 Road Traffic Accidents ........................................................................................................................... 15

2.2 Referrals ............................................................................................................................................... 17 2.2.1 In-Referrals ......................................................................................................................................... 17 2.2.2 Out-Referrals ...................................................................................................................................... 20

2.3 In-Patients ............................................................................................................................................ 23

2.4 Surgical Operations ............................................................................................................................... 27

2.5 Maternity Care ...................................................................................................................................... 30 2.5.1 Deliveries............................................................................................................................................ 30 2.5.2 Maternal Deaths ................................................................................................................................ 34

2.6 Dental & Eye Health Services ................................................................................................................ 36 2.6.1 Dental Services ................................................................................................................................... 36 2.6.2 Eye Health Services ............................................................................................................................ 38

2.7 X-Ray Services ....................................................................................................................................... 40

2.8 Laboratory Services ............................................................................................................................... 42 2.8.1 Malaria Screening .............................................................................................................................. 42 2.8.2 HIV Screening ..................................................................................................................................... 43 2.8.3 Screening for Sexually Transmissible Infection .................................................................................. 46 2.8.4 Blood Transfusion .............................................................................................................................. 48 2.8.5 Transfusion Blood Mobilization ......................................................................................................... 50 2.8.6 Hemoglobin Estimation ...................................................................................................................... 50

3. FINANCIAL MATTERS ......................................................................................................... 53

3.1 Consolidated Financial Statement ......................................................................................................... 53

3.2 Subventions .......................................................................................................................................... 55

3.3 Drug Revolving Fund ............................................................................................................................. 56

4. DONATIONS....................................................................................................................... 58

4.1 Donations ............................................................................................................................................. 58

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4.2 Ward Adoptees’ Donations ................................................................................................................... 59

5. INTERVENTIONS ................................................................................................................ 60

5.1 Human Resources for Health ................................................................................................................. 60

5.2 Clinical Care Services ............................................................................................................................. 60

5.3 Records Management ........................................................................................................................... 61

5.4 Maintenance of Structure and Equipment ............................................................................................ 61

5.6 Maternal Deaths Review/Audits (MDR/A) ............................................................................................ 61

5.7 Environmental Management ................................................................................................................ 61

5.8 Performance Review Meeting ............................................................................................................... 61

5.9 Blood Replacement Policy ..................................................................................................................... 62

6. CHALLENGES AND CONCLUSION ....................................................................................... 63

6.1 CHALLENGES ......................................................................................................................................... 63 6.1.1 Human Resources .............................................................................................................................. 63 6.1.2 Access Ramp ...................................................................................................................................... 63 6.1.3 Mortuary Refrigerators ...................................................................................................................... 63 6.1.4 Subventions........................................................................................................................................ 63 6.1.5 Equipment .......................................................................................................................................... 64

6.2 CONCLUSION ......................................................................................................................................... 64

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FORWARD

On behalf of the Hospital Management Board, the people of the North Bank Region and on my own behalf let me again register our profound gratitude to His Excellency the President of the republic of The Gambia – Sheikh Professor Alh. Dr. Yahya A J J Jammeh - BABILI MANSA, for his continuous support to this strategically located tertiary hospital. This is the third annual report since 2012 and it attempts to provide detailed narratives of the activities of this noble institution in my administrative region – North Bank Region. I therefore urge all and sundry to take time to read this important and educative report. Alh. Lamin S.I. Jammeh GOVERNOR NBR CHAIRMAN, HOSPITAL MANAGEMENT BOARD

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ACKNOWLEDGEMENT

On behalf of the Senior Management Team, Staff and on my own behalf, I would like to thank the Hospital Management Board and the people of North Bank Region for their support. To the staff of the hospital, your commitment and dedication is the engine that made the preparation of this report possible. Without your work there would be no statistic to report on in the first place. To His Excellency the President of the republic of The Gambia - Sheikh Professor Alh. Dr. Yahya A J J Jammeh, BABILI MANSA, I would like to express on behalf of the entire staff of this great hospital our profound appreciation and gratefulness for the assured funding towards effective and efficient operation of the hospital. To my Esteem Readers, it is my pleasure to present to you the AFPRC General Hospital’s 2014 Report. The data contained herein highlights the achievements registered in 2014 with trends from 2012. The report attempts to capture service statistics at all delivery points with the aim to inform policy and decision-making. The report also highlights challenges that warrant attention. I would conclude by thanking once again the staff for being steadfast in collecting service delivery data. You are cognizant of the adage “What is not recorded cannot be counted” which have motivated you all to be doing what you have already done. The spirit behind the preparation of this comprehensive report is "team work" where every member is valued and cherished. Dr. Mamady Cham (PhD) CHIEF EXECUTIVE OFFICER

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SUMMARY

With the primary function of delivering tertiary medical services to the population, the AFPRC General Hospital in 2014 recorded an overall OPD attendance of 18,769. 78.9% of which are 15 years and older. Forty-two separate Road Traffic Accident events were recorded involving 112 persons in total. In 2014 the hospital received 1,021 referrals sent in by peripheral health facilities. The majority of the in-referrals were from Soma Major Health Centre accounted for 24.3%. In the same period the hospital effected 311 out-referrals to EFSTH. 248 of those cases were emergencies and all were accorded free ambulance services. A total of 2,585 admissions occurred in 2014 with 31.7% as pediatric cases, 24.7% at the maternity and 21.2% as medical cases. Overall 78% of the admitted patients were successfully managed and discharged home alive. The overall mortality was 10.8% in 2014. Surgical operations performed was 517, the majority as cesarean section followed by eye surgeries. With a recorded number of 1,593 deliveries in 2014, 91.7% were livebirths, 82.3% of babies’ birth weight was within normal range while for a significant proportion (17.3%) weight was below normal. Skilled birth attendant rate was 63.4% of which midwife attended deliveries was highest (33.6%). Nurse Attendant attended deliveries accounted for a significant proportion, 32.1%. Sadly, 6 maternal deaths were recorded, 4 of which was as a result of hemorrhage. With a recorded 45,178 individual laboratory investigations performed in 2014, hemoglobin estimation accounted for the highest (40.2%). Overall malaria positive test was 8.2% (microscopy) and 6.9% using RDT. HIV positive test result was 1.2% among screened pregnant women. Of the 861 blood transfusion performed in 2014, 51.8% was at the maternity, 18.5% at the operating theatre and 11.3% at the medical ward. With 864 pints of transfusion blood donated, 81.7% was through relative donor. Anemia among pregnant women was very high as of the 5,304 pregnant women screened, only 27.6% were with normal hemoglobin level. With regards to finances, the revenue generated through Drug Revolving Fund was D1,090,345.50 in 2014. Overall the sum of D21,515,766.28 was received as subvention in 2014. No Development Fund was received in 2014. Donations in cash and kind were received from individuals, institutions and public agencies. All donations were geared towards complimenting government’s efforts towards delivering quality health services to the general population.

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Acronyms

BF Blood Film

CEO Chief Executive Officer CS Cesarean Section DRF Drug Revolving Fund HMB Hospital Management Board MMR Maternal Mortality Ratio NBR North Bank Region OPD Out Patients Department RDT Rapid Diagnostic Test RTA Road Traffic Accident SMT Senior Management Team VDRL Venereal Disease Research Laboratory

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1. INTRODUCTION The Armed Forces Provisional Ruling Council (AFPRC) General Hospital located in Farafenni in the North Bank Region of The Gambia, is the “first health facility among many” built after the 22nd July, 1994 revolution in a quest to improve access to and quality of tertiary medical services. Though officially inaugurated by His Excellency, the President of the republic of The Gambia – Sheikh Professor Alhagi Dr. Yahya A J J Jammeh – Babili Mansa, on the 21st January 2003, the hospital started operations in 1999. The 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 primary roles and functions of the hospital are:

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

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

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

d) To serve as a public health research center, undertake and/or participate in public health research for improved health outcomes for the population.

This report outlined the services and activities of the hospital for the period 1st January 2014 – 31st December 2014. The specific objectives of this report are:

a) To outline the management and administrative structures within the hospital; b) To describe the types of clinical services offered in the hospital; c) To detail the 2014 service delivery statistics with comparative analysis from the

year 2012; d) To chart out initiatives/interventions implemented during the period under

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

2014; f) To enlist recommendations towards improving performance and better health

outcomes for our patients.

1.1 Organization, Management & Administration The hospital headed by the Chief Executive Officer (CEO) who is responsible for the overall day-to-day management of the hospital, works closely with the established hospital structures for the effective and efficient operation of the hospital and for which the hospital has been established. To that end, the CEO work with and/or through the following established structures:

a) Hospital Management Board: Appointed by the Minister responsible for Health through by an Act of Parliament, the board formulates policies for the efficient

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operations of the hospital for which it is established and administers the affairs of the hospital for which it is established (REF: Medical Services Act 1990). The current board was inaugurated in December 2013 and comprise of Alhagie Lamin Queen Jammeh Governor NBR (as Chairman), Ebrima A T Jammeh Chief of Illiassa, Alhagie Jim Fatma Jobe Chief of Jokadou, Jainaba Sonko Community Representative of Nuimi, Baturu Secka Community Representative Sabah Sanjal, Chief Executive Officer AFPRC Hospital, Magistrate (posted in NBR), Regional Director of Health Services, Director of Health Services and Hospital Administrator as secretary. The Board convened four (4) regular meetings in 2014 (30/02/14; 05/06/14; 19/07/14; and 20/11/14). The current board is however, without a financial advisor.

b) Senior Management Team (SMT): Comprises of Heads of Departments/Units within the hospital. It is chaired by the CEO. The SMT meets at least once every two months were possible. It is the second highest decision-making body of the hospital. Its main responsibility is to ensure that high quality tertiary health care services delivery in the hospital at all times. The SMT convened seven (7) meetings in 2014 (27/02/14; 27/03/14; 14/05/14; 18/06/14; 07/08/14; 24/09/14; and 22/10/14). A core SMT also exists consisting of CEO, Administrator, Accountant and Principal Nursing Officer who meets when and where necessary to discuss/decide on key issues.

c) Clinical Division Committee (CDC): The CDC comprises of all heads of clinical wards/units (units that directly provide clinical services). This committee meets at least once every two months with the aim to enhance effective and efficient clinical service delivery in their respective clinical units at all times. Chaired by the Principal Nursing Officer, the committee meets before the SMT meeting so that decisions and/or challenges can be filtered to the latter for possible redress. The clinical division convened in 2014 meetings on 05/04/14; 19/06/14; 11/07/14 and 10/12/14.

d) Procurement Committee: Comprising of the Principal Accountant, Administrator,

Principal Stores Officer and CEO who is the chair. The committee among other things ensures that the procurement processes are consistent with established national guidelines and protocols with the aim to attain “Value for Money” in the procurement of goods and services for the hospital.

e) Blood Bank Committee: Tasked with the responsibility of mobilizing transfusion blood availability within the hospital for prompt response to emergencies. The committee comprise of key unit heads of the hospital with membership also includes community members with demonstrated active role and interest. The committee conducts community outreach bleeding sessions to harvest blood from voluntary donors. In 2014, the committee through its outreach activities harvested a total of 67 units of blood (see section on blood transfusion for details).

f) Donation and Auction Committee: Charged with the responsibility of the

coordination of all donation and auction activities within the hospital. The committee is responsible for all the formalities leading to the conduct of actual

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auction and ensuring that the proceeds are banked as required. For the period under review no auction was done in the hospital. However, some donations were received as detailed at section on donations.

g) Social Committee: Considering the important role staff welfare play in overall staff performance, the hospital management constituted this committee with the aim to coordinate all social functions including the organization of hospital parties and other social events. The conduct of the annual “Performance Review Meetings” and staff parties were effectively coordinated by this committee for the past three years.

h) Infection Prevention and Control Committee: Cognizant of the risk of infection in health care settings, an Infection Prevention and Control (IPC) committee has been set-up to ensure adherence to infection prevention and control protocols and guidelines. On its second year of existence the committee has instituted some very impressive interventions including ensuring 24/7 cleanliness of the hospital, introduced the recommended approach to health care setting scrubbing using the recommended detergents and chemicals. The committee is also in the process of developing a local infection prevention and control guidelines and protocol for the hospital. Importantly, the committee consists of clinical staff including nurses, doctors and other para-professionals. An Infection Prevention and Control unit has been established to coordinate IPC activities.

i) Therapeutic Committee: In an effort to strengthen the quality of clinical services particularly drug prescription within the hospital a therapeutic committee has been constituted with the aim to direct patient management particularly drug prescriptions within the hospital. The committee comprise of Medical Doctors, Midwives, Trained Nurses, Pharmacy staff and management. To control prescription, the committee has identified and issue code numbers to limited staff who are allowed to prescribe for patients. This approach not only minimizes poly-pharmacy but enhances accountability and rational use of essential drugs.

1.2 Hospital Department

The hospital is departmentalized into three, namely Administration, Accounts and Clinical.

1. Administration: Consist of the Secretarial, Maintenance, Security, Domestic (cooks and Tailors), and Generator Operators. The general and pharmacy stores are under administration for obvious reasons. The division is headed by the Hospital Administrator.

2. Accounts: The units under this department are the general accounts and Drug

Revolving Fund units. Headed by a Principal Accountant the department has a delegated responsibility of coordinating and implementing all accounts and accounting matters of the hospital.

3. Clinical: Consisted of all units and sub-units directly providing clinical services. It

includes the Nursing and medical divisions, Laboratory, admission wards, X-Ray,

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Physiotherapy and Pharmacy units. The head of the division is the Principal Nursing Officer.

Within the clinical division are different service delivery areas or clinical units as outlined in table 1?

Table 1: Service Areas by Clinical Department

Clinical Department Service Areas

General In-patients Special

OPD Service Clinic

Internal Medicine Yes Yes Yes

Obstetrics & Gynecology Yes Yes Yes

Pediatrics Yes Yes Yes

Ophthalmic Yes Yes Yes

Surgery Yes Yes Yes

Emergency Medicine Yes Yes Yes

Table 2 outlines the bed capacity by admission wards within the hospital which has increased from 120 (2013) to 142 (2014) i.e. an increase of 18%.

Table 2: Bed Capacity

Clinical Department/Sponsor Available

Beds

Medical/Gambia Port Authority Ward 28

Maternity/Trust Bank Ward 18

Pediatrics/Gamtel Ward 24

Ophthalmic Ward 21

Surgical Ward 18

Accident & Emergency/SSHFC Ward 6

Chest/Jammeh Foundation for Peace Ward 24

Operating Theatre 3

TOTAL 142

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1.3 Human Resources

The hospital is comprised of a multi-disciplinary team of health professionals and support staff including medical doctors (mostly Cubans); Nurses and Midwives; laboratory and pharmacy staff and other Para-professional health workers and support staff. Table 3 shows the staffing pattern of the hospital in 2014. Worthy to note that of the 329 overall staff, 46.2% are in the clinical department. There is no much difference in sex ratio among the staff of the hospital as the proportion of females to males is 49.2% and 50.8% respectively. Table 3: Staffing Situation in 2014

DEPARTMENT/UNIT SEX TOTAL

Male Female

Clinical Medical Doctors 7 3 10

Registered Nurses 9 4 13

Enrolled Nurses 8 5 13

Certified Midwives 1 1 2

Enrolled Midwives 3 3 6

Nurse Attendants 13 57 70

Laboratory Personnel 6 6 12

Radiograhy Personnel 6 0 6

Physiotherapy Personnel 3 0 3

Pharmacy Staff 5 8 13

Dental Staff 1 2 3

Administrative Administration 7 4 11

Accounts 7 7 14

Security Personnel 15 1 16

Drivers 9 0 9

Medical Records 6 5 11

Stores Personnel 4 0 4

Watchmen 2 0 2

Domestic

Orderlies 28 38 66

Laundresses 0 9 9

Cooks 0 7 7

Refuse Collectors 7 0 7

Tailors 4 0 4

Maintenance Generator Operators 6 0 6

Maintenance Personnel 10 0 10

TOTAL 167 162 329

Proportion

50.8 49.3 100.0

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Table 4: Status of Key Professiona/Technical Positions

POSITIONS ESTABLISHED AVAILABLE %

General Nurses 52 26 50.0

Midwives 24 8 33.3

Medical Officers 8 3 37.5

Laboratory Tech. 9 1 11.1

Radiographic Tech. 5 0 0.0

Table 4 depicts the acute staffing shortage situation in the hospital which no doubt inhibits performance and quality of services. Overall, there is a shortage of >60% in professional/technical staffing.

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2. CLINICAL SERVICE DELIVERY STATISTICS This section attempts to provide an analytical data of the 2014 service statistics of all units and service delivery areas within the hospital.

2.1 Out-Patients Department Serving as the first point of call for patients to the hospital, the Out Patients Department (OPD), is operational 24/7. During the year 2014, a total of 18,769 patients were attended to at the OPD. Of those 3.2% (592), 3.1% (572), 14.8% (2,790) and 78.9% (14,815) were individuals 0 – 1 year old; 2 – 4 years old; 5 – 14 years old and 15 years and older respectively (table 5). A drop of 36.8% in OPD attendance was registered between 2013 and 2014. Figure 1 highlights the trend in OPD attendance from 2012 to 2014. Table 5: 2014 Out-patients Attendances

MONTH AGE – GROUP TOTAL 0 - 1 yr 2 - 4 yr 5 - 14 yr > 15 yr Jan 65 55 684 1693 2497 Feb 18 22 175 1260 1475 Mar 44 36 204 1376 1660 Apr 43 47 199 1107 1396 May 16 24 157 1269 1466 Jun 95 76 238 1223 1632 July 88 79 172 1060 1399 Aug 68 76 191 1176 1511 Sept 50 53 255 1256 1614 Oct 50 58 204 1326 1638 Nov 40 33 188 1233 1494 Dec 15 13 123 836 987 TOTAL 592 572 2790 14815 18769

Figure 1: OPD ATTENDANCE 2012, 2013, 2014 (Trend)

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Figure 2: OPD Attendance 2012, 2013 & 2014

Figure 2 compares the overall OPD attendance for the years 2012 to 2014. Key Points to Note a) With an overall total OPD clinic attendance of 18,769 in 2014, the average daily and

monthly clinic attendance was 52 and 1,564 patients respectively; b) The majority (78.9%) of OPD attendants were people 15 years and above. This is

because children under-five are seen only on weekends and after day sessions of reproductive health clinics delivered by health centers;

c) The peak OPD attendance was in the month of January while the lowest was in the month of December in 2014;

d) A drop of 36.8% in OPD attendance was recorded between 2013 and 2014.

2.2 Road Traffic Accidents

Road Traffic Accidents (RTA) is an important health event as often victims need “emergency” medical Attention. Good road network is sadly associated with frequent accidents not because of the road but as a result of over-speeding. Given the excellent road networks available in The Gambia particularly in the NBR, the hospital is frequently a recipient of RTA victims and as such keep records of those events with the aim to influence policy and decision-making. During the year 2014, a total of 42 separate RTA events whose victims reported at the hospital were recorded. Of that, a total of 112 individuals were involved. Of the 112 individuals, 1.8% (2) people died and another 74.7% (80) people were treated and discharged. 23.3% (22) of the 107 patients were referred-out to EFSTH for further management (table 6). RTA incidents we noted has increased from 34 to 42 between 2013 and 2014. An increased in the number of victims registered (from 57 to 112) between 2013 and 2014;

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representing an upsurge of 87.7%. Statistically, RTA case/incident was recordedd every 9 days in 2014. Table 6: 2014 Road Traffic Accidents

Accident No Date No. of people involved

Rx & Discharged

Death

Referred Out

1. 21/02/14 7 7 2. 24/02/14 2 2 3. 26/02/14 1 1 4. 28/02/14 4 3 1 5. 02/03/14 10 8 2 6. 05/03/14 1 1 7. 23/03/04 1 1 8. 30/03/04 4 4 9. 01/04/04 3 3 10. 20/04/04 6 6 11. 24/04/14 3 2 1 12. 28/04/14 1 1 13. 30/05/14 1 1 14. 15/06/14 1 1 15. 25/06/14 1 1 16. 26/06/14 3 3 17. 04/07/14 3 3 18. 07/07/14 1 1 19. 15/07/14 1 1 20. 16/07/14 1 1 21. 20/07/14 1 1 22. 30/07/14 1 1 23. 01/08/14 1 1 24. 16/08/14 4 4 25. 19/08/14 1 1 26. 01/09/14 1 1 27. 11/09/14 1 1 28. 15/09/14 1 1 29. 17/09/14 1 1 30. 02/10/14 1 1 31. 24/10/14 3 3 32. 26/10/14 7 7 33. 30/10/14 1 1 34. 31/10/14 3 1 2 35. 25/11/14 1 1 36. 26/11/14 5 1 4 37. 27/11/14 1 1 38. 08/12/14 3 3 39. 13/12/14 1 1 40. 17/12/14 1 1 41. 20/12/14 1 1 42. 31/12/14 12 12

Total (%)

112 63* (70.0%)

2 (2.2%)

21 (23.3%)

RX = Treatment; *22 of the 2014 cases outcomes were not documented

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2.2 Referrals

Referrals constitute patients formally sent by one health facility to another for better management. Often, the principle in referral is that a patient is sent to a higher level facility or where the patient’s condition is effectively manageable.

2.2.1 In-Referrals

“In-Referrals” are those patients received by this hospital i.e. sent in from other health facilities. As the only hospital in the North Bank Region (NBR) and owing to its proximity and coupled with the river crossing points, this hospital serve as a referral center to many health facilities including those in the NBR, Lower River Region (LRR), and part of Central River Region (CRR). During the year 2014, a total of 1,021 patients were referred to this hospital, of which 78.5% (802) were directed to the OPD and 21.4% (219) as maternity in-referrals (i.e. pregnancy and/or childbirth related complications). Of the OPD in-referrals, the peripheral health facilities that sent referrals most were Soma Major Health Centre, Kaur, Farafenni RCH Clinic, and Illiassa Health Centers which accounted for 24.3%, 15.3%, 14% and 11.3% respectively (Table 7).

Table 7: 2014 OPD In-Referrals

MONTH HEALTH FACILITY TOTAL

K'wan Salikene N' Sanjal F/RCH Kaur Chamen Illiassa

N' Kun Soma S'Kun Essau K'Tay Njaw Bsg Others

Jan 9 5 11 4 17 3 15 1 17 6 0 1 1 0 5 95

Feb 9 4 4 6 9 1 12 5 23 2 0 0 1 0 13 89

Mar 1 1 5 10 9 1 11 0 15 1 0 0 0 0 4 58

Apr 5 4 1 5 18 0 16 2 20 1 1 0 1 0 0 74

May 2 1 4 4 12 2 11 2 12 2 0 0 2 1 5 60

Jun 3 1 2 12 8 1 3 3 13 3 0 0 1 0 2 52

Jul 5 1 7 11 9 1 5 7 10 4 0 0 0 2 5 67

Aug 3 0 2 4 13 2 1 3 13 4 0 0 0 0 1 46

Sep 0 1 2 18 5 2 6 5 13 3 1 0 1 0 1 58

Oct 3 1 4 9 6 2 3 1 7 3 0 0 0 0 8 47

Nov 4 2 3 16 7 3 5 2 21 7 0 0 0 0 4 74

Dec 4 3 4 13 10 0 3 4 31 3 0 0 1 0 6 82

TOTAL: 48 24 49 112 123 18 91 35 195 39 2 1 8 3 54 802

% 6.0 3.0 6.1 14.0 15.3 2.2 11.3 4.4 24.3 4.9 0.2 0.1 0.9 0.3 6.7 99.8

K’wan = Kerewan; N/Sanjal = Ngayen Sanjal; N/Kunda = Njaba Kunda; S/Kunda = Sara Kunda; K'Tay = Kuntaya; Bsg = Bansang

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Of the Maternity In-Referrals in 2014, the facilities that sent in the most referrals were again Kaur, Illiassa, Ngayen Sanjal, Essau and Soma health centers which accounted for 24.7%; 12.3%, 9.6%, 9.1% and 8.7% of the referrals respectively (table 8). Table 8: 2014 Maternity In-Referrals

MONTH HEALTH FACILITY TOTAL

K'wann S,Kene N. Sanjal F/RCH Kaur Chamen Illiassa N, Kun Soma S,Kund Essau Kuntaya Njaw BSG Others

Jan 2 0 0 2 6 0 2 3 2 1 1 2 1 0 1 23

Feb 0 0 1 0 9 1 3 0 0 0 3 0 1 0 1 19

Mar 1 1 1 1 8 2 2 0 1 1 2 0 2 0 1 23

Apr 2 0 2 0 2 2 0 1 0 1 1 0 1 0 0 12

May 0 0 3 0 4 2 2 1 0 0 0 0 1 0 0 13

Jun 0 0 5 4 2 2 1 6 0 1 0 0 0 0 21

Jul 0 1 1 0 5 2 0 1 8 1 0 0 0 0 0 19

Aug 1 1 1 0 5 1 3 2 1 0 2 0 0 0 0 17

Sept 0 1 3 0 6 1 1 2 0 1 0 1 0 0 0 16

Oct 2 0 2 0 1 0 2 0 0 0 2 0 0 0 4 13

Nov 3 1 2 0 4 0 4 4 1 1 7 0 0 1 0 28

Dec 2 2 0 1 0 0 6 3 0 0 1 0 0 0 0 15

TOTAL: 13 7 21 4 54 13 27 18 19 6 20 3 6 1 7 219

% 5.9 3.2 9.6 1.8 24.7 5.9 12.3 8.2 8.7 2.7 9.1 1.4 2.7 0.4 3.2 100.0

Figure 3 depicts the trend of OPD and Maternity In-referrals in 2014 while figure 4 compares the overall total In-referrals in 2012, 2013 and 2014.

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Figure 3: 2014 Maternity and OPD In-Referrals Comparison

Figure 4: In-Referrals 2012 – 2014 (Comparison)

Key Point to Note a) Between 2013 and 2014, “In-Referrals” dropped from 1118 to 1,021 i.e. a drop of

8.7%; b) Soma Major Health Centre as in previous years accounted for the highest In-

referrals; c) Overall average monthly in-referrals was 85 but for OPD was 67 and maternity 18.

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2.2.2 Out-Referrals

“Out-referrals” are those patients sent out by this hospital to another for further management. During the year 2014 a total of 311 patients were referred out from the hospital to the Edward Francis Small Teaching Hospital (EFSTH). Of those out-referrals, 79.7% (248) were emergency cases. 84.2% (262) including all emergency cases were provided free ambulance services. In 2014 the Accident and Emergency Unit effected the highest Out-Referrals 42.4% (132), then surgical ward and Eye unit with 15.4% (48). Overall Out -Referrals in 2014 reduced by 6.9% from 2013 (table 9). Table 9: 2014 Out-Referrals

MONTH REFERRAL OUT TOTAL EMERGENCY AMBULANCE

CONDITIONS & DEPARTMENT

REFERRALS USE

Surg Med Paed Mat OPD/A&E EYE Others

Jan 7 5 1 0 20 4 0 37 30 31

Feb 1 2 2 1 113 7 0 26 19 20

Mar 0 3 3 3 11 5 0 25 20 20

Apr 2 1 5 1 10 2 0 21 16 18

May 5 1 0 1 3 8 0 18 10 10

Jun 9 3 1 6 10 4 0 33 30 30

Jul 11 1 1 5 5 5 0 28 20 23

Aug 1 0 3 10 8 4 0 26 21 21

Sep 1 3 2 0 20 0 0 26 25 25

Oct 3 2 1 7 12 2 0 27 22 27

Nov 5 2 2 0 9 3 1 22 17 18

Dec 3 1 3 0 11 4 0 22 18 19

TOTAL 48 24 24 34 132 48 1 311 248 262

% 15.4 7.7 7.7 10.9 42.4 15.4 0.3 100.0 79.7 84.2

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Figure 5 highlights the trend in out-referrals while figure 6 outlines Ambulance usage as against emergency referrals. The highest number of out-referrals was in the month of January (68) while the lowest was in May (10) as in figure 5.

Figure 5: 2014 Out-Referrals (Trend)

Figure 6: Out-Referrals & Ambulance Use 2014

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Figure 7 provides a comparison of the total out-referrals between 2012 and 2014.

Figure 7: Out-Referrals 2012 – 2014 (Comparison)

Key Points to Note a) On average 26 Out-Referrals were effected every month in 2014 compared to 28 in

2013; b) Total Out-referrals dropped by 6.6% between 2013 and 2014; c) All emergency referrals were provided free ambulance services.

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2.3 In-Patients

In 2014 a total of 2,585 admissions were recorded at the hospital of which 31.6% (818) were at the children’s wing; 212% (548) at the medical ward; 1376% (353) at the surgical ward; 24.3% (628) as maternity cases. The Ophthalmic and chest wards recorded 5.2% (121) and 4% (104) of admissions respectively (figure 8). Figure 8: In-Patients By Ward (Proportion)

During the year under review, 77.7% (2009) of the in-patients were effectively managed and discharged home alive. The overall recorded deaths were 10.8% (279) for the year 2014. However, a negligible proportion, 0.3% (8) absconded and 1.5% (38) opted for alternative treatment (table 10).

Table 10: 2014 In-Patients by Ward

WARD/UNIT ADM DISCH DEATHS ABSCOUNDS DAMA

Surgical 353 270 8 2 5

Medical 548 352 99 0 14

Ophthalmic 134 1341 0 0 0

Paediatrics 818 568 143 5 15

Maternity 628 592 7 0 4

Chest 104 93 22 1 0

TOTAL 2585 2009 279 8 38

%

77.7 10.8 0.3 1.5 Adm = Admissions; Disch = Discharges; DAMA = Discharge Against Medical Advice.

Figure 9 shows the trend in admissions. The highest number of admission was in the month of January (264) while the lowest was in June (198). The average monthly admission in 2014 was 215 patients compared to 222 in 2013.

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Figure 9: 2014 Monthly Admissions

Figure 10 shows the management outcomes of admissions by ward/unit in 2014. Similar to 2013, the Ophthalmic (Eye) and Maternity wards attained ≥ 90% success rate in 2014.

Figure 10: Successfully Managed of Patients by Ward 2014

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Figure 11 compares admissions between 2012 and 2014.

Figure 11: Admissions 2012 – 2014 (Comparison)

Analysis of the conditions of patients admitted by ward in 2014, revealed the following: Medical ward: The five most common conditions for admission were Hypertension (12.6%), Anemia (11.1%), Pneumonia (10.4%), Heart Conditions (8.7%) and Cardio-Vascular Accident (8.1%). Non-communicable diseases assumed the top five most common conditions admitted. However, admissions due to Diabetes has significantly dropped registering 2.8% of all admissions in 2014. Pediatric (Children’s) Ward: The five most common conditions for admission were Pneumonia (26.0%), Neonatal Sepsis (15.3%), Anemia (11.6%), Malaria (10.3%) and Malnutrition (6.2%). Maternity Ward: The most common conditions for admission was severe anemia i.e. hemoglobin level below 7 g/dl (10.1%), Pregnancy Induced Hypertension (10.9%), obstructed labor (8.3%) and bleeding during pregnancy (5.9%) Key Points to Note a) Overall admissions have reduced from 2659 (2013) to 2585 (2014) i.e. reduction of

2.7%; b) 78% of the patients admitted in 2014 were successfully managed compared to

76.4% in 2013; c) The common conditions for admission in 2014 follows similar trend as in 2013;

Pneumonia, Non-Communicable diseases (hypertension, heart conditions and etc.), severe anemia to name but a few;

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d) Pediatrics, Medical and Maternity wards like in 2012 and 2013 accounted for the highest number of admissions.

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2.4 Surgical Operations

In 2014, a total of 517 surgical operations were performed. Of those 52.2% (270), 27.0% (140), 7.3% (38) and 13.3% (69) were caesarean section (C/S), Eye, Hernia and other operations respectively (figure 12). 38 Hernia cases were operated in 2014 following the posting of a Gambian Medical Officer compared to none in 2013 when there was no Doctor to do surgery. Figure 12: 2014 Surgical Operations by Type

Of the 415 general surgeries performed, 65.1%, 9.2% and 25.8% were caesarean section, hernia and other surgeries (excluding eye) respectively. With regards to the 140 eye surgeries 84.3%, 2.1%, and 13.6% were for cataract, lid and pterygium excisions respectively. Table 11 shows the surgeries performed excluding eye operations. Of those 80.9% (305) were emergencies, 89.9% (339) as major surgeries. 71.6% (270) of the general operations were cesarean section.

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Table 11: General Surgical Operations in 2014

MONTH TOTAL URGENCY CATEGORY CLASSIFICATION

Elective Emergency Major Minor C/S BTL Ectopic EVAC Ovarian Cy Molar Preg Hernia Fistula Others

Jan 23 1 22 23 0 22 0 1 0 0 0 0 0 0

Feb 26 6 20 24 2 20 2 0 0 1 1 0 0 2

Mar 34 6 28 33 1 26 1 0 0 0 0 5 0 2

Apr 34 11 23 30 4 20 1 0 0 0 0 7 0 6

May 37 9 28 34 3 24 2 0 0 0 1 5 0 5

Jun 35 6 29 31 4 26 1 0 1 0 0 4 0 3

Jul 39 7 32 35 4 24 1 1 1 0 0 6 0 6

Aug 29 7 22 21 8 17 2 0 0 0 1 3 0 6

Sept 27 2 25 26 1 25 1 0 0 0 1 0 0 0

Oct 22 3 19 21 1 18 1 0 0 0 0 1 0 2

Nov 37 5 32 34 3 26 1 1 1 0 0 3 0 5

Dec 34 9 25 27 7 22 0 0 0 0 1 4 0 7

TOTAL 377 72 305 339 38 270 13 3 3 1 5 38 0 44

19.1 80.9 89.9 10.1 71.6 3.4 0.8 0.8 0.3 1.3 10.1 0.0 13.0

C/S = Caesarean Section; BTL = Bilateral Tubal Ligation; EVAC= Evacuation of the Uterus; Ovarian C. = Ovarian Cyst

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The trend on general surgical operations in 2014 is depicted in figure 13.

Figure 13: 2014 General Surgeries (Trend)

Between 2012 and 2014, observed is a progressive increase in the number of surgical operations performed in this hospital (figure 14). Figure 14: Surgical Operations 2012 – 2014 (Comparison)

Key Points to Note a) Overall surgeries increased by 28.6% between 2013 and 2014;

The number of Eye operations reduced from 226(2013) to 140 (2014) i.e. a decrease of 38%.

b) The number of caesarean sections increased from 156 (2013) to 270 (2014) i.e. an increase of 70.1%.

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2.5 Maternity Care

2.5.1 Deliveries

In 2014, a total of 1,593 babies were delivered in the hospital among 1504 parturient women. Of those, were 44 sets of multiple births including a set of triplets (table 12) implying that 2.7% of babies delivered in 2014 were from multiple pregnancies. Table 12: Institutional Deliveries in 2014

MONTH TOTAL TWINS OUTCOME BIRTH WEIGHT (Kg) DELIVERY ATTENDANT

DEL SETS LB FSB MSB <1.5 1.5 - <2.5 ≥2.5 Not Weigh Doctor Midwife G/Nurse Nurse Att BBA

Jan 156 5 143 8 5 4 18 134 0 21 41 49 38 7

Feb 131 2 123 6 2 9 11 111 0 15 41 28 40 6

Mar 151 4 137 11 3 4 10 137 1 24 45 0 77 5

Apr 93 3 84 5 4 3 14 74 2 16 25 13 37 2

May 105 3 94 5 6 7 12 84 2 25 25 29 21 5

Jun 91 2 76 8 7 7 13 70 1 25 14 25 24 3

Jul 112 3 108 2 2 6 17 89 0 30 28 3 44 7

Aug 97 2 84 6 7 4 14 78 1 19 40 4 31 3

Sep 150 3 136 8 6 7 24 119 0 27 43 33 40 7

Oct 171 7 158 8 5 6 23 142 0 24 68 14 55 10

Nov 164 5 159 2 3 5 22 137 0 29 78 3 48 6

Dec 172 5 158 8 6 13 23 136 0 19 87 0 57 9

TOTAL 1593 44 1460 77 56 75 201 1311 7 274 535 201 512 70 LB = Live birth; FSB = Fresh Still Birth; MSB = Macerated Still Birth; G/Nurse = General Nurse; Nurse Att. = Nurse Attendant; BBA = Birth Before Arrival; C/S = Caesarean Section. Figure 15 highlights the trend in deliveries by month. While the lowest number of deliveries was recorded in June (91) the highest was in December (172). The average monthly deliveries in 2014 was 163.

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Figure 15: 2014 Deliveries (Trend)

On the outcomes of deliveries, 91.7% (1460) of all births were live births. Stillbirths (i.e. those not born alive) were 8.3% (133). 4.8% (77) of babies were fresh stillbirths (figure 16). Figure 16: Birth Outcomes of Deliveries in 2014

Exploring birth weight of babies delivered indicated that 82.3% (1311) were within normal range (≥ 2.5 kilogram’s), 12.6% (201) were low-birth-weight babies (i.e. between 1.5 and <2.5 kilogram’s), and 4.7% (75) were in the category of very low-birth-weight babies (weigh below 1.5 kilogram’s (figure 17).

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Figure 17: Birth Weight of 2014 Deliveries

Deliveries by Birth Attendant revealed that 17.2% (274) of all births were by a medical doctor, 33.6% (538) by a midwife, 12.6% (201) by a trained nurse and 32.1% (512) by a nurse attendant, indicating a Skilled Birth Attendant rate of 63.4% (figure 18). In 2014, Birth-Before-Arrival was 4.4% (70) of all deliveries.

Figure 18: 2014 Deliveries By Delivery Attendant

In 2013, an obstetrics and gynecology OPD clinic was established. During the year 2014, of the 1031 patients seen at that clinic the most common conditions were: confirming pregnancy 52.8% (544), urinary tract infection (UTI) 5.1% (53), uterine bleeding 3.6% (37) and amenorrhea 3.5% (36) – figure 19.

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Figure 19: Obstetrics & Gynecology OPD Clinic Attendance 2014

In 2014, 734 women with obstetric complications were managed at the hospital (figure 20). Of those hemorrhage accounted for 10.9% (APH 5.9% and PPH 5%); Pregnancy induced hypertension and/or eclampsia 10.9% (PIH 7.8% and Eclampsia 3.1%); Obstructed labor and/or uterine rupture 11.4% (dystocia 7.6% and ruptured uterus 3.1%); anemia 10.1%. Figure 20: Obstetric Complications Managed in 2014

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Figure 21 provide a trend in obstetric complications managed by month in 2014 with the peak was in July (95 cases). Figure 21: Trend of Obstetric Complication in 2014

2.5.2 Maternal Deaths

In 2014, six (6) maternal deaths were recorded (including those brought in dead). Table 13 outlined the 2014 medical causes of the recorded maternal deaths. Of the 2014 maternal deaths, 4 (66.6%) died of severe bleeding. In the same corresponding period a total of 1460 live births were recorded giving an institutional maternal mortality ratio of 411 per 100,000 live births. This indicates a significant reduction in maternal deaths in this hospital from 973/100,000 LB (2013) to 311/100,000 LB in 2014 (table 14). Table 13: Medical causes of 2014 Maternal Deaths

MEDICAL CAUSES N (%)

Haemorrhage (Heavy Bleeding) 4 (66.6)

Dystocia (Obstruction) 1 (16.6)

Others 1 (16.6)

TOTAL 6 (100)

Table 14: Maternal Deaths 2012 – 2014

VARIABLE YR 2012 YR 2013 YR 2014

Maternal Deaths

15

15

6

Live Births

1793

1542

1460

Maternal Mortality Ratio

837

973

411

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Figure 22: Institutional Deliveries 2012 – 2014 (Compared)

Key Points to Note a) Overall, a reducing trend in institutional deliveries is observed between 2012 and

2014. Between 2013 and 2014, a reduction of 6.5% in institutional deliveries is noted (figure 22);

b) Equally and importantly, the number of multiple births increased by 15.7% between 2013 and 2014;

c) The proportion of live births in 2014 was 91.7% compared to 90% in 2013. Overall, stillbirth rate has also reduced from 9.5% in 2013 to 8.3% in 2014;

d) The proportion of Low birth weight babies was 17.3% in 2014 compared to 16.7% in 2013. This revealed among other factors that maternal nutrition continues to be an important challenge among parturient women;

e) On average 61 women with obstetric complications were managed in a month at the hospital in 2014;

f) The hospital’s maternal mortality ratio have reduced impressively by 50.8% between 2013 and 2014; and

g) The skilled birth attendant rate was 63.4% in 2014 compared to 70.5% in 2013. This uncovers the limited number of midwives in the hospital.

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2.6 Dental & Eye Health Services

2.6.1 Dental Services

Dental services in this hospital continue to face challenges due to inadequacies relating to staffing, supplies and equipment. Thus, limited services are being provided mainly tooth extraction and/or management of minor oral conditions. In 2014 a total of 1158 dental cases were seen. Of those 65.9% (764) were dental abscess, 30.2% (350) was toothache and 3.7% (44) gingivitis (inflammation of the gums). Figure 23 show the trend in dental cases seen. Trend analysis indicated an average monthly dental clinic attendance of 97 (ranged between 63 and 143) (figure 23). Figure 24 provides a comparison of overall dental OPD cases seen between 2012 and 2014. Noted is that there is a declining trend in dental OPD attendance.

Figure 23: Dental OPD Clinic Attendance & Extractions

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Figure 24: Dental OPD Attendance 2011, 2012, & 2013

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2.6.2 Eye Health Services

Eye health services are provided on both out and in-patient basis with a state of the art refraction services available since April 2013. Due to the successful piloting of the One Sight supported refraction project in this hospital, it was rolled out to Bansang Hospital, Basse and Brikama Major Health Centers and Sheikh Zeid Regional Eye Care Centre. For OPD Eye services in 2014, a total of 3196 cases were seen. Of those, 24.7% (791) were bacterial conjunctivitis, 16.8% (537) as cataract, 6.3% (203) vernal conjunctivitis, 3.6% (116) glaucoma and 0.18% (6) were ophthalmic neonatarum (table 15). Table 15: 2014 Eye Unit OPD Cases

Month Cataract Conjunct Trachoma Glaucoma Opht. Neo

Verna Conjunct Others TOTAL

Jan 55 42 0 7 0 13 93 210

Feb 52 96 0 11 1 13 155 328

Mar 56 85 0 9 2 22 103 277

Apr 53 83 0 16 0 20 153 325

May 66 87 0 12 1 35 149 350

Jun 56 106 0 2 0 14 136 314

Jul 29 46 0 6 0 21 142 244

Aug 43 56 0 12 0 14 132 257

Sept 23 77 0 7 1 9 136 253

Oct 28 46 0 9 0 5 125 213

Nov 38 31 0 16 0 24 114 223

Dec 38 36 0 9 1 13 105 202

TOTAL 537 791 0 116 6 203 1543 3196

On Eye Surgeries, a total of 140 were performed. 83.9% (110) were cataract, 3.0% (4) Trabut and 12.9% (17) were pterygium excision. On cataract operations, 54.5% (60) were on males and 45.4% (50) on females. Females continue to constitute the higher proportion for Trabut operations; 3:1. For optical services and refraction in particular, a total of 1602 patients underwent refraction (children 282 and adults 1320). Of those, 70.7% (1132 [children 117 and adults 1015]) received prescription for glasses. Of those with prescription for a pair of glasses only 36.0% (408 [children 19 and adults 389]) actually bought a pair of glasses (table 16).

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Table 16: 2014 Refractive Services

MONTH REG. REFRACTION TOTAL PRESCRIPT ISSUED TOTAL RECEIVED GLASSES TOTAL

Children Adults Children Adults Children Adults

Jan 83 161 244 13 97 110 6 48 54

Feb 12 137 149 7 104 111 1 41 42

Mar 28 143 171 16 115 131 4 36 40

Apr 13 179 192 6 134 140 1 122 123

May 6 165 171 1 109 110 1 29 30

Jun 5 150 155 2 124 126 1 29 30

Jul 9 70 79 0 53 53 3 20 23

Aug 57 90 147 35 76 111 1 27 28

Sept 42 103 145 19 86 105 0 16 16

Oct 5 20 25 1 21 22 0 12 12

Nov 22 102 124 17 96 113 1 9 10

Dec 0 0 0

TOTAL 282 1320 1602 117 1015 1132 19 389 408

A reduction in the number of refractions and order for glasses was noted in 2014. It is assumed that the rolled out of the optical services to other centers around the country explains the reason for the drop. Figure 25 compares refraction services done in 2013 and 2014. Figure 25: Refractive Services 2013 and 2014 Compared

Key Points to Note a) Dental OPD attendance reduced by 27.4% between 2013 and 2014; b) Cataract surgeries continue to dominate among eye surgeries performed - 83.9% of

all eye surgeries in 2014 c) Uptake for refractive services has dropped by 3.6% between 2013 and 2014.

Similarly glasses sold has also dropped by 26% for the same period (figure 25).

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2.7 X-Ray Services

Lack of skilled staff (only available are radiographic assistants) coupled with frequent breakdown of equipment continue to impact negatively on X-Ray/imaging services in this hospital. Figure 26 shows the trend in X-Ray investigations in 2014. The average monthly attendance was 68 (range between 41 and 111). However, no X-Ray services was recorded for the month of September due to faulty machine.

Figure 26: X-Ray Services 2014

A review of the 2014 X-Ray investigations revealed that of the 820 screenings, 56% were within the exemption category implying that only 44% actually paid for services. The exemption category included children, HIV, Tuberculosis patients, Staff, RTA, Security personnel and people with disability (table 17).

Table 17: X-Ray Examinations 2014

MONTH EXAMINATIONS TOTAL

PAID EXEMPTED

Adult Child TB Cases HIV Cases Security Staff Disabled RTA

Jan 33 14 7 8 4 9 0 8 83

Feb 26 12 4 17 1 2 0 5 67

Mar 38 21 8 19 3 4 1 6 100

Apr 61 20 3 5 5 7 1 9 111

May 42 37 9 1 6 9 0 0 104

Jun 28 20 5 1 4 6 0 1 65

Jul 15 20 5 2 3 2 0 2 49

Aug 19 13 0 3 2 4 0 0 41

Sep 0 0 0 0 0 0 0 0 0

Oct 26 10 13 6 1 1 0 7 64

Nov 27 7 4 6 4 5 0 7 60

Dec 38 17 3 3 9 4 0 2 76

TOTAL 353 191 61 71 42 53 2 47 820

% 43.0 23.3 7.4 8.7 5.1 6.5 0.2 5.7 100.0

TB Cases = Tuberculosis Cases; RTA = Road Traffic Accidents

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Figure 27 compares the X-Ray screenings performed between 2012 and 2014 indicating a progressive decline over the years. Figure 27: X-Ray Services 2012 – 2014 (Comparison)

Key Points to Note a) A reduction of 3% in X-Ray services was registered between 2013 and 2014; b) 56% of X-Ray service beneficiaries in 2014 were in the exemption category, implying

that only 44% paid for the services. c) No X-Ray investigations were performed in the month of September 2014 due to

faulty X-Ray machine.

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2.8 Laboratory Services

In 2014, a total of 45,178 individual laboratory tests were documented in this hospital. Table 18 details the tests performed. The most performed test in 2014 was hemoglobin estimation (40.2%), RDT (20.6%), blood grouping (8%) and BF (7.4%). Culture and sensitivity test are still not possible in the hospital for logistic reasons. Table 18:2014 Laboratory Investigations

TEST N %

Blood Film < 5 yrs 2471 5.5

Blood Film > 5 yrs 878 1.9

Blood Grouping < 5 yrs 82 0.2

Blood Grouping > 5 yrs 3623 8.0

Blood Transfusion 861 1.9

Fasting Blood Sugar 933 2.1

Hemoglobin < 5 yrs (Inpatients) 788 1.7

Hemoglobin > 5 yrs (Inpatients) 2681 5.9

Hemoglobin ANC (Only) 5304 11.7

Hemoglobin OPD 9441 20.9

Hepatitis B 730 1.6

HIV Screenings 711 1.6

PMTCT 1725 3.8

Rapid Diagnostic > 5 yrs 6747 14.9

Rapid Diagnostic Test < 5 yrs 2555 5.7

Sickle Cell < 5 yrs 73 0.2

Sickle Cell > 5 yrs 155 0.3

Sputum 564 1.2

Stool 539 1.2

Urine 1288 2.9

VDRL (Antenatal) 1810 4.0

VDRL (General) 200 0.4

WBC < 5 yrs 122 0.3

WBC > 5 yrs 612 1.4

White Blood Count 285 0.6

TOTAL 45,178 100.0

2.8.1 Malaria Screening

Malaria prevention and control is an important policy goal for the ministry of health, thus, it is mandatory to confirm malaria through screening before treatment. Two malaria screening approaches: microscopy - Blood Film (BF) and Rapid Diagnosis Test (RDT), the former being the gold standard were applied. A total of 3349 BF tests (45%

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less than in 2013 [6,103]) were performed. 73.8% (2471) of those were individuals above 5 years of age. Of the overall BF tests performed, 8.2% (273) were found to be positive. Gender wise 10.1% (147) of males and 6.7% (126) of females tested positive. However, stark variance exists between age-groups as positive test results was 6.3% (30) among male children 5 years or less compared to 12.0% (117) among male children above 5 years. Similar pattern was noted for females as 4.8% (19) were found positive among females 5 years or less against 7.2% (107). This finding uncovers the consistent higher positivity test result among individuals above 5 years. Table 19 details all findings. Table 19: 2014 Malaria Screening – Blood Film

AGE MALE TOTAL FEMALE TOTAL G/TOTAL G/TOTAL

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

>5 Yrs 861 117 (12.0) 978 1386 107 (7.2) 1493 2471 224 (9.1)

<5 Yrs 449 30 (6.3) 479 380 19 (4.8) 399 878 49 (5.6)

TOTAL 1310 147 (10.1) 1457 1766 126 (6.7) 1892 3349 273 (8.2)

Using the RDT screening approach, an overall total of 9302 individual tests were performed, 39.4% less than in 2013. Of those RDT tests performed 6.9% (641) were found to be positive. Significant difference was noted between sex and age-group. The proportion of positive test result was higher among those above 5 years than those below as evidenced in table 20. However, the proportion of positive test results was similar among those below 5 years of age. Table 20: 2014 Malaria Screening – Rapid Diagnostic Test

AGE MALE TOTAL FEMALE TOTAL G/TOTAL G/TOTAL

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

>5 Yrs 2617 320 (10.9) 2937 3580 230 (6) 3810 6747 550 (8.2) <5 Yrs 1386 56 (3.9) 1442 1078 35 (3.1) 1113 2555 91 (3.6)

TOTAL 4003 376 (8.6) 4379 4658 265 (5.4) 4923 9302 641 (6.9)

Table 21 provides a snapshot of malaria screening test results in 2013 and 2014, indicating an overall decline in 2014. Table 21: Malaria Screenings 2013 & 2014 Compared

Test Type 2013 2014

Tests Done Positives Tests Done Positives

BF 6103 513 (8.4%) 3349 273 (8.2%)

RDT 15347 1510 (9.8%) 9302 641 (6.9%)

2.8.2 HIV Screening

Pregnant Women Overall 1736 pregnant women were voluntarily screened for HIV in a quest to prevent and control Mother-To-Child-Transmission (MTCT) as per national protocol. Of those 0.6% (11) tested positive (table 22). Noted also is that overall, the proportion of pregnant women with positive HIV test result have increased from 0.6% (2013) to 1.5% (2014) - table 23.

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Table 22: 2014 HIV Screening among Pregnant Women

MONTH TEST RESULTS TOTAL

Negative Positive (%) TESTED

Jan 85 1 86

Feb 60 1 61

Mar 85 1 86

Apr 95 0 95

May 142 5 147

Jun 149 4 153

Jul 146 0 146

Aug 271 6 277

Sep 193 1 194

Oct 142 1 143

Nov 184 1 185

Dec 152 0 152

TOTAL 1704 21 (1.2) 1725

Table 23: HIV Screening (Pregnant Women) 2013 & 2014 Compared

2013 2014

Tests Done Positives Tests Done Positives

1736 11 (0.6%) 1725 21 (1.2%)

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General Patients Of the 711 general patients (OPD Cases) counseled, consented and subsequently tested for HIV, overall positivity rate was 13.4% (95). The proportion of positive test result for adult male, adult female, male children and female children in 2014 were 15.3%, 23.3%, 0.9% and 20% respectively (table 24). The proportion of HIV positive tests among the general population increased from 19.4% (2012) to 23.2% (2013) – table 25. These statistics should be treated with caution as there is selection bias. Table 24: HIV Screening Tests (General) in 2014

MONTH MALE TOTAL FEMALE 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

Jan 17 4 21 14 5 19 3 0 3 3 1 4 47 10

Feb 10 4 14 18 4 22 0 0 0 0 1 1 37 9

Mar 18 3 21 13 4 17 1 0 1 2 0 2 41 7

Apr 21 2 23 29 7 36 0 0 0 0 0 0 59 9

May 14 3 17 12 4 16 0 0 0 0 0 0 33 7

Jun 10 3 13 14 3 17 0 0 0 1 0 1 31 6

Jul 13 2 15 18 3 21 0 1 1 0 0 0 37 6

Aug 9 1 10 9 6 15 0 0 0 2 0 2 27 7

Sep 11 2 13 6 3 9 0 0 0 0 1 1 23 6

Oct 47 6 53 20 6 26 153 1 154 2 0 2 235 13

Nov 6 1 7 15 7 22 74 0 74 2 0 2 105 8

Dec 12 3 15 16 4 20 0 0 1 0 0 0 36 7

TOTAL 188 34 222 184 56 240 231 2 234 12 3 15 711 95

Table 25: HIV Screening (General) 2013 & 2014 Compared

2013 2014

Tests Done Positives Tests Done Positives

457 106 (23.2%) 711 95 (13.4%)

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2.8.3 Screening for Sexually Transmissible Infection

Screening for sexually transmitted infection is routine for targeted patients including pregnant women. This is to prevent and control its spread. Of the 1810 pregnant women that underwent VDRL test in 2014, only 0.4% (8) was found to be reactive (table 26). Table 26: VDRL Screening (Pregnant Women)

MONTH FEMALE TOTAL

Non-React Reactive TESTED

Jan 302 3 305

Feb 185 0 185

Mar 219 0 219

Apr 155 1 156

May 217 1 218

Jun 299 1 300

Jul 91 1 92

Aug 69 0 69

Sep 90 0 90

Oct 44 1 45

Nov 32 0 32

Dec 99 0 99

TOTAL 1802 8 1810

The number of individual VDRL screening performed reduced by 18.6% between 2013 and 2014 mainly because of intermittent shortages of reagents (table 27).

Table 27: VDRL Screening (Pregnant Women) 2013 & 2014 (Compared)

2013 2014

Tests Done Positive Tests Done Positive

2223 18 (0.8%) 1802 8 (0.4%)

Among the 200 general patients screened for VDRL, 3% (6) were reactive (table 28) suggesting a fairly very low infection rate.

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Table 28: VDRL Screenings (Other Category of Patients Women)

MONTH MALE TOTAL FEMALE TOTAL G/TOTAL G/TOTAL

Non-

React. Reactive TESTED

Non-

React. Reactive TESTED TESTED REACTIVE

Jan 12 1 13 14 0 14 27 1

Feb 15 1 16 20 2 22 38 3

Mar 7 0 7 11 0 11 18 0

Apr 5 1 6 16 0 16 22 1

May 3 0 3 6 0 6 9 0

Jun 5 0 5 9 0 9 14 0

Jul 4 0 4 8 0 8 12 0

Aug 5 0 5 9 0 9 14 0

Sep 3 0 3 2 0 2 5 0

Oct 8 0 8 9 0 9 17 0

Nov 4 0 4 5 1 6 10 1

Dec 8 0 8 6 0 6 14 0

TOTAL 79 3 82 115 3 118 200 6

*No reagents for the test

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2.8.4 Blood Transfusion

Blood transfusion is a life-saving health service intervention, thus, form an essential component of emergency obstetric care package. Therefore, blood is a critical health system commodity so its continuous availability should be assured at all times. Often patients undergoing surgery, victims of RTA and most particularly pregnant and parturient women need urgent blood transfusion. Thus, consistent availability of transfusion blood in a health care institution particularly in a referral hospital like ours cannot be over emphasized.

Table 29: 2014 Blood Transfusions by Ward

MONTH Medical Paediatric Theatre A & E Maternity Surgical Chest TOTAL

Jan 18 14 15 5 42 0 0 94

Feb 4 6 12 1 31 0 1 55

Mar 8 2 15 2 36 0 0 63

Apr 11 15 9 1 26 2 2 66

May 5 1 8 0 41 2 0 57

Jun 7 4 13 3 35 0 3 65

Jul 13 17 20 0 39 11 0 100

Aug 6 10 8 0 62 4 0 90

Sep 8 7 9 1 47 5 0 77

Oct 10 6 15 3 23 2 0 59

Nov 4 5 21 1 32 3 1 67

Dec 3 6 14 1 32 7 5 68

TOTAL 97 93 159 18 446 36 12 861

% 11.3 10.8 18.5 2.1 51.8 4.2 1.4

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During the year 2014, a total of 861 transfusions were performed of which 51.9%, 18.5%, 11.3% and 10.8% occurred at the maternity, operating theatre, medical, pediatric wards respectively (table 29). The maternity ward by far performed the highest number of blood transfusion. This elucidates the importance of blood in maternal health care. Also worth explaining is how transfusion blood was acquired in 2014. In total 864 pints of transfusion blood were donated. Of that 81.7% (706) were from relative donors and 18.3% (158) from voluntary blood donors. On average every month the hospital received 59 relative and 13 voluntary donors (table 30). Table 30: 2014 Blood Donors by Category

MONTH DONOR CATEGORY G/TOTAL

RELATIVE TOTAL VOLUNTARY TOTAL

Male Female Male Female

Jan 75 0 75 10 0 10 85

Feb 41 0 41 15 0 15 56

Mar 54 0 54 6 0 6 60

Apr 63 0 63 6 0 6 69

May 53 0 53 5 0 5 58

Jun 53 0 53 34 0 34 87

Jul 71 0 71 6 0 6 77

Aug 84 0 84 8 0 8 92

Sep 61 0 61 15 0 15 76

Oct 46 0 46 14 0 17 63

Nov 56 0 56 7 0 7 63

Dec 49 0 49 29 0 29 78

TOTAL 706 0 706 155 0 158 864

Worryingly, observed is the reducing trend in voluntary blood donations. In 2013 they constituted 32% but only 18% in 2014 (table 31). This has negative implications on patients’ outcomes in general as voluntary donation is far more reliable and sustainable for the health system. Table 31: Blood Donors 2013 & 2014 (Compared)

Donor Type 2013 2014

Relative 547 (68.1%) 706 (81.7%)

Voluntary 256 (31.9%) 158 (18.3%)

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2.8.5 Transfusion Blood Mobilization

During the year 2014, the hospital’s Blood Bank Committee carried out a series of outreach blood harvesting exercises in an effort to mobilize transfusion blood for the hospital. In total 67 pints were harvested within communities of the NBR and LRR (table 32). This quantity is 58% less than that harvested in 2013. This again points out the general apathy in voluntary blood donation.

Table 32: 2014 Blood Harvesting Exercise

MONTH COMMUNITY BLOOD UNITS OBTAINED

Jan Kossi Village - NBR 9

Jun M/konko Military Barracks LRR 13

Oct M/Konko CHN School - LRR 21

Dec NACUUF – Soma LRR 24

TOTAL 67

2.8.6 Hemoglobin Estimation

As the main approach to gauge anemia among people, HB is a routine for pregnant women and selected patients. The section that follows outlines the tests and results among selected cohort. To understand the high proportion of transfusion among pregnant or recently pregnant women we explored the prevalence of anemia among pregnant women that visited the hospital. Table 33 outlines the hemoglobin level estimation among 5304 pregnant women referred to the hospital for routine hemoglobin test. Of those 75.3% (3783) were

Table 33: Hemoglobin Results of 5304 Pregnant Women Screened 2014

MONTH HAEMOGLOBIN LEVEL (g/dl) TOTAL

<4 4 - 6.9 7 - 10.9 11 ≥

Jan 1 3 245 89 338

Feb 0 1 203 80 284

Mar 0 5 254 100 359

Apr 0 5 232 82 319

May 0 2 252 117 371

Jun 0 3 294 101 398

Jul 0 6 304 161 471

Aug 0 5 495 154 654

Sep 0 7 452 115 574

Oct 0 9 378 76 463

Nov 0 3 386 163 552

Dec 0 4 289 228 521

TOTAL 1 53 3783 1466 5304

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“Moderately Anemic”, 1% (53) were with “Severe Anemia” and 0.002% (1) were “Very Severely Anemic" as per World Health Organization established standard. As per national guidelines and standards, 1% (54) hemoglobin level was below 7 g/dl thus, needed blood transfusion.

Table 34: Hemoglobin Results Screened Pregnant Women 2013 and 2014

MONTH

HAEMOGLOBIN LEVEL (g/dl)

<4 g/dl 4 - 6.9 g/dl 7 - 10.9 g/dl 11 ≥ g/dl TOTAL

2013 11 (0.2%) 61 (1.2%) 3574 (25.8%) 1269 (25.8%) 4915

2014 1 (0.002%) 53 (1.0%) 3783 (75.3%) 1466 (27.6%) 5304

Table 34 provides a comparison of hemoglobin level of pregnant women that visited the hospital in 2013 and 2014. The picture is almost similar.

Table 35 details the HB results of OPD attendees in 2014 with stark difference obtained in the level of moderate anemia among >5 years (25.1%) compared to 57.5% for <5 years. There is 2.3 folds difference.

Table 35: Hemoglobin Results of 12,659 OPD Attendees Screened 2014

MONTH

HAEMOGLOBIN LEVEL (g/dl)

<4 g/dl

4 - 6.9

g/dl 7 - 10.9 g/dl 11 ≥ g/dl TOTAL

> 5 years 49 (0.5%) 143 (1.5%) 2370 (25.1%) 6879 (72.9%) 9441

< 5 years 11 (0.3%) 42 (1.3%) 1850 (57.5%) 1315 (40.9%) 3218

TOTAL 60 185 4220 1466 12659

Though not a routine test but for selected patients, however, the proportion of positive test results is high as shown in table 36.

Table 36: Sickle Cell Test Screenings 2014

GROUP TESTED POSITIVE (%)

Male < 5 yrs 27 7 (25.9)

Female < 5 yrs 22 6 (27.3)

Male > 5 yrs 73 9 (12.3)

Female > 5 yrs 115 17 (11.0)

TOTAL 237 39 (16.5)

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Table 37 depicts the Hepatitis B tests carried out in 2014 with a positive results of 8.5%. This test is mandatory before any blood transfusion is effected.

Table 37: 2014 Hepatitis B Screenings

MONTH > 5 Years G/TOTAL G/TOTAL

Male TOTAL Female TOTAL TESTED Pos.

Neg. Pos. Neg. Pos.

Jan 27 0 27 2 0 2 29 0

Feb 16 0 16 4 0 4 20 0

Mar 74 9 83 14 1 15 98 10

Apr 52 6 58 15 0 15 73 6

May 57 4 61 23 0 23 84 4

Jun 90 9 99 15 0 15 114 9

Jul 40 8 48 0 1 1 49 9

Aug 62 7 69 11 0 11 80 7

Sep 81 8 89 7 0 7 96 8

Oct 52 7 59 22 1 23 82 8

Nov 0 0 0 0 0 0 0 0

Dec 3 1 4 1 0 1 5 1

TOTAL 554 59 613 114 3 117 730 62

Key Points to Note a) Hemoglobin estimations accounted for 40.2% of all laboratory tests in 2014; b) Overall malaria positivity test using RDT method was 6.9% compared to 8.2% using

the microscopy – BF; c) As in previous years the highest number of transfusion performed was at the

maternity ward constituted 52% overall. This again uncovers the increasing burden of anemia among pregnant and recently pregnant women;

d) The proportion of voluntary blood donors has declined considerably in 2014. This is a worrying situation for women’s health and reproductive health in general;

e) The hospital’s laboratory can perform only limited category of tests for lack of capacity relating to staffing, equipment, reagents to name but a few.

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3. FINANCIAL MATTERS This chapter outlines the financial matters of the hospital including subventions received (Personnel Emoluments [PE], Other Charges [OC]), revenue generated from user-fees i.e. Drug Revolving Funds (DRF) as well as expenditures incurred during the year 2014.

3.1 Consolidated Financial Statement

Table 38 details the hospital’s financial statement for the year under review. Table 38: 2014 Summary Consolidated Financial Statement (All Accounts)

Receipts GMD

Opening balance 926,578.89

Subventions 21,515,766.28

Drug Revolving Fund 1,090,354.50

Other Income 4,213.50 Total 23,536,913.17

Salaries 9,816,763.46

Allowances 1,146,202.00

Wages 505,152.72

Travelling Expenses 49,200.00

Telecomm. Expenses 190,027.50

Utilities- Electricity, Water & Sewage 390,970.00

Rent & Furniture 627,260.00

Purchase of Fuel & Lubricants 1,392,172.60

Purchase Of Vehicle 465,000.00

Maintenance Of Vehicle 290,046.30

Maint. Of Building & Facility 2,175,889.00

Maint. Of Equipment & Generators 32,848.50

Purchase Of Small Office Equipment 63,050.00

Stationery 460,050.00

Misc. Office Expenses 1,738,055.87

Expenses On TAs 87,750.00

Drugs & Dressings & Medical Supplies 1,104,950.00

Uniforms & Protective Clothing 134,710.00

Food & Food Services 1,000,550.00

Furniture & Fittings 295,608.00

Bank Charges 92,666.38

TOTAL EXPENDITURES 22,058,923.33

Surplus of Receipts over expenditure for the period Jan -Dec 2014

1,477,989.84 Represent as per Bank Statement Balances:- Subvention Drug revolving fund Development fund

923,052.13 551,677.43

3,260.28 1,477,989.84

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In total D23, 536,913.17 were income/receipts (D926,578.89 as balance of accounts by December 31st 2013; D21,515,766.28 as total subventions received [PE and OCs] in 2014; D1,090,354.50 as revenue generated through user-fees and D4,213.50 as other incomes). Overall expenditure in 2014 was D22,058,923.03 giving an account balance of D1,477,989.84 (table 38).

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3.2 Subventions

Table 39: Analysis of 2014 Subventions

P.E. Subventions O.C. Subventions MTH REQUIRED RECEIVED REMARKS ACTUALS REQUIRED RECEIVED REMARKS ACTUALS Jan 1,063,747.00 1,063,747.00

1,063,747.00 750,000.00 750,000.00

750,000.00

Feb 1,063,747.00 1,063,747.00

1,063,747.00 750,000.00 750,000.00

750,000.00 Mar 1,063,747.00 886,424.80

886,424.80 750,000.00 750,000.00

750,000.00

Apr 1,063,747.00 950,000.00

950,000.00 750,000.00 750,000.00

750,000.00 May 1,063,747.00 975,085.90

975,085.90 750,000.00 750,000.00

750,000.00

Jun 1,063,747.00 925,085.90

925,085.90 750,000.00 750,000.00

750,000.00 Jul 1,063,747.00 1,025,085.90

1,025,085.90 750,000.00 750,000.00

750,000.00

Aug 1,063,747.00 1,150,000.00

1,150,000.00 750,000.00 1,085,000.00 D335,000.00 as refund. 750,000.00 Sep 1,063,747.00 1,556,840.20 D543,093.20 (1 X 6 Advances) 1,013,747.00 750,000.00 1,149,000.00 D399,000.00 as refund. 750,000.00 Oct 1,063,747.00 1,063,747.00

1,063,747.00 750,000.00 750,000.00

750,000.00

Nov 1,063,747.00 1,063,747.00

1,063,747.00 750,000.00 -

- Dec 1,063,747.00 1,063,747.00 1,063,747.00 750,000.00 - -

TOTAL 12,764,964.00

12,787,257.70

12,244,164.50

9,000,000.00

8,234,000.00 7,500,000.00

UNDERSUBVENTIONS 520,799.50 1,500,000.00

Table 39 provides a detailed account of the subventions received, both PE and OC. Given that D543,093.20 was 1 by 6 advances (which was refunded) gives an actual PE subvention of D12,244,164.50 implying that there was an under-subvention of D520,799.50 on PE. In the same vein, during the year under review, the hospital undertook activities on behalf of the ministry of Health and Social welfare (D335,000.00 as rehabilitation cost on Medical Officers residence and D399,000.00 as payment of Hardship allowances to doctors). This implies that the OC subventions was actually short by D1,500,000.00 in 2014. Overall, the under-subvention in 2014 was D2,020,799.50. Like in 2013, no development fund was received in 2014.

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3.3 Drug Revolving Fund

Through user-fees, Revolving Fund an overall revenue collection of D1,090,354.50) was made in 2014 at the hospital i.e. 187% greater than in 2013. Table 40 shows the monthly collections while Figure 26 the trend for the year under review. The average monthly collection was D90,862.00.

Table 40: DRF Collections 2014

MONTH AMOUNT IN DALASIS

Jan 48,911.50

Feb 70838.00

Mar 85,445.00 Apr 78,265.00

May 85,075.50

Jun 94,900.00

Jul 74,775.00

Aug 126,850.00

Sep 92,775.00

Oct 108,145.00 Nov 107,000.00

Dec 117,375.00

TOTAL 1,090,354.50

Figure 28: 2014 Monthly DRF Collections 2013 (Trend)

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Table 41: DRF Financial Statement for 2014

RECEIPTS AMOUNT

Balance as of 31st December 2013 83,659.43

Total Revenue Collected 1,090,354.50

Interest 4,213.50

Total 1,178,227.43

EXPENDITURES

Purchase of Drugs & Supplies 422,050.00

Purchase of DRF Materials 204,500.00

TOTAL EXPENDITURE 626,550.00

Surplus of Receipts Over Expenditure Jan 14 - Dec 14 551,677.43

Represent as per Bank Statement 551,677.43

Figure 28 depicts the trend in revenue collection while table 41 provides a summary financial statement of the DRF Account for the year under review. Figure 29 compares the overall revenue collection through DRF between 2012 and 2014.

Figure 29: DRF Collections 2012, 2013 & 2014 Compared

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4. DONATIONS During the course of 2014, the hospital received gifts and/or donations from individuals, institutions and well-wishers to compliment the efforts of government towards the delivery of quality health services to the population. Donations/gifts upon receipt are handed over to the general stores for documentation before its final issuance to the intended user. All transactions are documented using the prescribed recording tools. This approach enhances accountability and transparency.

4.1 Donations

Table 42 outlined the donations received in 2014 excluding those of ward adoptees. Table 42: 2014 Received Donations

Date Donor Items

02/01/14 Office of The President 20 kg Sacrificial meat. 24/01/14 Modou Jobe – Farafenni 600 Multivitamin tablets. 20/02/14 Fatou Jobarteh Disposable Gloves. 24/03/14 GRA Farafenni Office 10 Bags Irish Potatoes. 27/03/14 Wassu Kafo – Gambia 4 cartons of assorted surgical items.

30/04/14 B B Electrical Company 234 kg of Coos. 28/04/14 School for the Gambia 18 cartons of assorted Medical and

surgical items. 03/07/14 Gaye Njoro Skills Centre 10 mouse pads, 15 uniform shirts & 45

caps. 02/09/14 Catholic Relief Service 300 pieces of Insecticide Treated Nets. 31/10/14 Epidemiology and Disease

Control Unit 17 Bottles of Hand wash Gel.

2nd Infantry Battalion Regularly provide the hospital with transfusion blood, clean the hospital environment and other support.

In addition to the above, management recognizes the contribution of the community Yallal-Ba for regularly assisting in clearing the hospital environment including weeding off grasses. Equally, the community of Wallalan do also have a coos farm, yields of which is donated to the hospital to support in-patient feeding. The 2nd Infantry Battalion in Farafenni and the soldiers at the Military Barracks at Mansa Konko, community of Kossi Village and the students of the School for Enrolled Community Health Nurses always voluntarily donate blood during outreach blood harvesting exercises. They have played no small part in saving many innocent lives.

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4.2 Ward Adoptees’ Donations

Table 43 outlines the ward/unit adoptees and their support to their adopted ward during the year under review. Table 43: Support to Ward/Units By Institutions

Ward/Unit Adopted by Support Provided

Accident & Emergency

Mrs. May Winterton Over the past years have and continue to provide support to the hospital including essential drugs and medical supplies and some basic biomedical equipment.

Outpatients Department

Social Security and Housing Finance Corporation (SSHFC)

Has in 2012 solarized the ward. From then on provided support in kind. In 2014 donated 4.5 x 50 kilograms of coos to the hospital.

Maternity Ward Trust Bank Have for the past 13 years provided support to her adopted ward in the form of assorted items determined by the hospital worth D100,000.00. However, in 2014 satisfied with the way those support were utilized increased the donation to items worth D205,850.00.

Chest Ward Jammeh Foundation for Peace

Donated assorted medical items and 10 bags of maize to the hospital in 2014.

Eye Unit One Sight Installed state of the art refraction equipment in the unit in 2013.

Pediatric Ward Gamtel/Gamcel Yet to provide support. Management would also wish to thank the above institutions that adopted wards/units in the hospital and continue to provide support/donations as outlined. They have manifested long-sightedness as their corporate-social responsibilities have been extended far and wide.

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5. INTERVENTIONS

Aware of the “vision and mission” of the Ministry of health and Social Welfare, management has implemented certain interventions in various forms that have paid dividend. Among which are:

5.1 Human Resources for Health

Given the critical stake Human Resources for Health has in the attainment of our vision and mission, management implemented the following to boost staff moral and performance. Among the measures are:

a) Staff salaries, wages and allowances are always paid out not later than the 21st day of the month throughout in 2014;

b) Aware of the need for trained nurses, training and retraining of staff take center stage in management’s activities. Important to mention that management also sponsored staff for professional training at the Nurse Training institutions in the country to purse general nursing, midwifery and other courses;

c) A Continuous Education Program (monthly sessions) has been instituted with the aim to augment staff knowledge, skills and performance;

d) All professional staff are housed in a furnished accommodation paid by the hospital. The cost of utilities (water and electricity) is borne by the hospital. For heads of department/units each is accorded additional amenities including refrigerator, fan to name but a few;

e) All staff are provided with their cadre's standard uniforms free of charge.

These interventions are received well by staff and have been a talking point among health professionals in the country. Thus, the hospital attracted more trained health workers.

5.2 Clinical Care Services

Given that it is the primary function of the hospital, there is: a) 24 hours coverage of the hospital with a medical doctor. A Medical doctor is

always available to respond to emergencies including calls; b) The laboratory is operational 24/7 for emergencies and other investigations for

in and out patients; c) To ensure quality in the delivery of tertiary medical services, only medical

doctors can admit, refer and/or discharge a patient in this hospital; d) Importantly, ward rounds of inpatients is assured Mondays – Fridays. Thus, we

can confidently and proudly say that all our inpatients receive the attention and services of a medical doctor;

e) Consultant clinics at the pediatric, maternity and medical wards have been instituted and are operating satisfactorily. This innovation reduces congestions and waiting time at the OPD and enhances quality service delivery;

f) Doctors hold morning meetings daily (Monday – Fridays) to discuss clinical matters for improved patient care and management

g) An “Emergency Response Team” has been set up to respond to health emergencies including RTAs, Disease Outbreak to name but a few.

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These interventions have contributed greatly to the improved quality of care and patients’ outcome in this hospital.

5.3 Records Management

Aware of the important role records play in quality health care service delivery, management has instituted an effective data management system with improved recording, records verification, data analysis and dissemination. It is because of the availability of reliable data that our annual “Performance Review Meeting” is possible. With the availability of data, decisions in the management of this hospital is purely guided by evidence. It is worth mentioning that the hospital has a comprehensive service delivery data dating back in 1999 which is very rich to carryout comprehensive operational research to inform policy.

5.4 Maintenance of Structures and Equipment

A conducive working environment enhances better performance, thus, management invest heavily to maintain the hospital structures. Routine maintenance of structures is a regular undertaking. Thus, leaking water pipes and/or electrical problems are prevented. To enhance work environment, a preventive maintenance approach to equipment has been tried over the years.

5.6 Maternal Deaths Review/Audits (MDR/A)

MDR/A is proven to be key in the reduction of maternal deaths. Aware of that, management has made MDR/A a quarterly activity in this hospital. In our review meetings all health referring facilities to our hospital and other stakeholders are invited to attend. This approach has helped greatly in reducing maternal deaths, curb out challenges and forged a common understanding. Importantly, with the reducing trend in maternal deaths in our institution, management started the conduct or Near-Missed Reviews/audits.

5.7 Environmental Management Every weekend the orderlies have since the inception of this hospital carryout routine cleaning exercise. Additionally, on every pronounced national clean-up day (Setsetal) all hospital staff converges in the hospital to carryout general cleaning within the hospital. This have contributed greatly to the overall cleanliness of the hospital and ranked by many of our visitors as the cleanest health facility in the country.

5.8 Performance Review Meeting

In our drive to promote accountability the management since 2012 convenes a Performance Review Meeting inviting stakeholders including service users to present to them service delivery statistics of the ended year for discussion and clarification. Through this approach management is “accounting to the people” and has enhanced trust between the hospital and the community and the relationship more cemented.

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5.9 Blood Replacement Policy

In 2014 management was experiencing intermittent shortages of transfusion blood in the hospital as voluntary blood donors were not forthcoming. Management took the bold initiative to introduce a system of “Transfusion Blood Replacement” in the hospital. This simply means that emergency cases needing blood are instantly supplied the needed blood from the hospital’s blood bank and before discharge the relatives refund the blood to the bank. This has enhanced blood availability in the hospital with positive patients’ outcomes as have played an important role in this hospital’s drastic reduction of maternal deaths. The approach is being tested in other sister hospitals around the country.

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6. CHALLENGES AND CONCLUSION Despite all the achievements, the hospital is confronted with some challenges as illustrated below.

6.1 CHALLENGES

6.1.1 Human Resources

The hospital has for long been confronted with shortage of staff particularly trained Nurses and Midwives, technicians (Laboratory, Radiography and biomedical). A worrying gap in the number of trained staff availability in 2014 was experienced as indicated in table 44.

Table 44: Staffing Gap

CADRE ESTABLISHED AVAILABLE

Registered Midwife 10 3

Enrolled Midwife 12 4

Registered Nurse 23 9

Laboratory Technician 7 1

Radiographic Technician 5 0

The gap highlighted above explains part of our staffing problems.

6.1.2 Access Ramp

The main operating theatre upstairs cannot be routinely utilized mainly because of the lack of an access ramp. Instead the minor theatre at the ground floor is being used. Given the increasing trend in the performed surgical operations, it would make a huge difference in terms of service delivery if an access ramp to the operating theatre upstairs is constructed.

6.1.3 Mortuary Refrigerators

Given the widen catchment area and the expanding nature of the hospital, patients come from far and wide. Often, corpses cannot spend longer time at the mortuary before burial. Additionally, management has observed that residents of Farafenni often bring their corpses for safe keeping in the hospital. With the availability of mortuary refrigerators, the hospital would be able keep dead bodies longer and in the most ideal way. Currently, the hospital mortuary is without mortuary refrigerators but air conditioners only.

6.1.4 Subventions

During the year under review Other Charges (OC) monthly subventions were irregular and inconsistent as outlined above. This affects effective and efficient operations of the

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hospital, patients care and management and indeed patients’ outcomes. Thus, a more reliable approach of subventions to hospitals should be explored.

6.1.5 Equipment

Given the increasing demand for tertiary medical services and the expanding nature of services in this hospital, there is compelling need for additional bio-medical equipment and the replacement of old ones including but not limited to X-Ray and anesthetic machines, Ultra-Sound Scanners, Operation Lamps and tables, Nebulizers, laboratory and dental equipment to name but a few. Availability of these equipment will enhance quality of services, improves patient outcomes and importantly cut down out referrals..

6.2 CONCLUSION This report is a follow-up to that of the 2012 and 2013, which all detailed services and activities of the hospital using numerical numbers. The numbers used in these reports are indeed human health and in particular diseases affecting human-beings. Thus, the statistics herein should be viewed in that context. It is only through that one will appreciate the work invested herein and the outcomes realized. The 2014 report have enlisted numerous achievements including the successfully documentation of RTA incidents and victims’ outcomes; referrals (in and out) received and sent-out, in-patients (number, condition and outcomes), surgical operations (by type and category) carried out, maternal health services including deliveries conducted and obstetric conditions managed, laboratory services with emphasis on diagnostic tests, blood transfusion activities, finances of the hospital, donations received to but a few. The report also provided statistical data to measure trend in all these areas with the aim to enable the reader to make an informed judgement on how the hospital has performed over the years. The report further highlighted interventions implemented successfully towards better patient outcomes. Not with standing, this report outlines key challenges that hinder progress and as such warrants urgent attention. Cognizant to the fact that Health is a basic Human Right, the hospital management also subscribes to the fact that “Good Health is not a consequence of Economic Development, but also a driver of it”. Thus, in this hospital we all (management and staff) aspire to inspire others to continually deliver “High Quality Health Care Services at all times. This will yield better patient outcomes. Our focus is always the “Patient”, “Client” and/or the “Sick”.

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Table 45: SUMMARY DATA: 1999 - 2014

INDICATOR 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 TOTAL

OUTPATIENT 32,859 36,034 35,542 29,962 11,889 18,403 22,718 24,826 20,338 20,225 24,714 17,724 12,393 28,730 29,709 18,769 384,835

ACCIDENT&EMERGENCY 5,048 12,221 14,740 11,461 10,645 9,187 10,540 9,828 7,065 8,308 14,616 13,307 6,864 1,551 1,666 137,047

INPATIENTS 3,691 4,830 4,959 4,091 4,224 3,585 3,387 5,133 2,639 2,851 2,960 3,379 3,610 3,312 2,659 2,585 57,895

SURG. OP PERFORMED 1,595 2,401 2,180 677 217 169 401 417 305 284 301 159 205 313 402 517 10,543

DENTAL CASES 346 1,188 2,024 1,248 1,113 1,082 1,033 1,537 1,527 1,735 1,862 2,034 2,008 2,584 2,433 1,158 24,912

DEATHS (ALL CASES) 338 285 283 198 231 171 180 294 204 200 222 307 318 312 250 279 4,072

IN-REFERRALS 191 264 491 249 223 262 338 368 430 485 481 842 727 1,187 1,118 1,039 8,695

OUT-REFERRALS 145 68 47 42 64 82 54 85 54 93 106 125 214 175 334 311 1,999

Normal Deliveries 884 1,072 1,130 945 1,043 1,168 1,102 1,160 1,320 1,481 1,458 1,462 1,439 1,779 1,552 1,323 20,318

Live Birth 779 1,156 1,449 945 943 1,150 1,058 1,097 1,281 1,347 1,450 1,412 1,387 1,793 1,542 1,460 20,249

Caesarian Section 56 54 124 94 40 54 73 70 45 90 99 98 76 175 151 270 1,569

Fresh Still Birth 38 49 81 75 83 80 40 67 74 110 90 93 48 70 78 77 1,153

Macerated Still Birth 40 26 37 38 - 64 79 63 63 75 81 58 89 91 83 56 943

Birth Before Arrival 71 30 31 17 - 19 42 31 12 25 37 64 15 93 90 70 647

Multiple Births - - - - - 45 45 21 26 22 28 34 34 54 38 44 391

Maternal Deaths 4 12 11 18 23 7 13 18 18 17 18 20 16 15 15 7 232

Maternal Mortality Ratio 513 1,038 759 1,905 2,439 609 1,229 1,641 1,405 1,262 1,241 1,416 1,154 837 973 479

Cesarean Section RATE 6 5 9 8 3 4 6 5 3 6 6 6 5 9 9 17