Health workers attend to a Covid-19 patient in an ICU at Mulago National Referral Hospital. PHOTO/ PROMISE TWINAMUKYE
Covid-19 has brought to light the high costs that families are burdened with and must bear to see their loved ones in Intensive Care Units (ICUs) or High Dependency Units (HDUs) survive.
In June, as the second wave of Covid ravaged the country with high infection rates, admission numbers, and deaths, the public expressed outrage against exorbitant charges for patients seeking lifesaving medical care, especially in private and for-profit health facilities.
These exorbitant charges forced several stakeholders, including health rights activists, to push for reduction in these prices.
But the spiraling charges have not come down despite the outcries and negotiations between Health ministry authorities and private medical practitioners.
The charges are expected to skyrocket, with scientists predicting the country will be hit by a third wave of Covid despite the number of infections, hospitalisation, and deaths staying low for now.
But why are ICUs facilities high-priced and what does it cost to set up one?
Only last week, the parliamentary taskforce on Covid-19 response criticised the Health ministry for running non-operational ICUs across the country. The committee, which undertook a countrywide fact-finding mission on the readiness of the ministry in tackling the Covid-19 pandemic, said all regional referral hospitals (RRHs] had only temporary housing for lCUs that did not function as ICUs.
The Health ministry had claimed it delivered 10 ICU beds, ventilators, oxygen concentrators and an assortment of ICU equipment to each RRH. But the legislators said most of these were not operational. This, the MPs said, is because of lack of adequate space, power and lack of intensivists.
“All ICUs in the public RRHs are operating as HDUs. They were able to monitor and manage moderate patients, but referred critical patients to either [St Mary’s Hospital] Lacor or Mulago [National Referral] hospitals if the oxygen saturation dropped beyond 80-85 per cent,” the MPs’ report to Parliament said.
So what happened to the government’s readiness plans for ICUs, and why hasn’t it fixed complete ICU units in its RRHs even when the country has gone through ravages of the first, second and now fears for an impending third wave of Covid-19?
Experts say intensive care medicine deals with provision of intensive and specialised medical and nursing care to critically ill patients, who require enhanced capacity for monitoring and multiple modalities of physiologic organ support to sustain life during life-threatening organ system insufficiency.
Dr Jacinta Amito, the principal of St Mary’s Hospital Lacor School of Anesthesia, says to run an ICU, one requires space, an ICU bed, and oxygen supply, among other equipment, consumables, and utilities.
“The ICU bed is quite expensive and are in grades. You need oxygen supply, then ventilators, which are fairly costly…,” Dr Amito says.
Mr George Otim, the commissioner of health infrastructure at the Ministry of Health, says the cheapest ICU bed costs Shs6m.
He says a standard ICU set up should have at least 10 beds. This means a medical investor has to part with Shs60m to buy 10 average beds for an ICU with 10-bed capacity.
One of the suppliers of medical equipment that Sunday Monitor talked to said setting up an ICU depends on the client’s budget and what they will need to be included on the list. He says ICU beds range from electric to manual, with a five-function fully electric one going for about $2,000 (about Shs7m).
The supplier said some of the equipment required in ICUs include, patient monitor, ICP monitor, cardiac tables, oxygen apparatus, mobile X-ray, and infusion pumps, among others. This means more 10 infusion pumps, 10 patients monitors are needed for a standard ICU of 10-bed capacity. In total, more than 30 equipment are required.
Mr Otim says an investor will thus spend about Shs2.7b on equipment for 10-bed capacity ICU.
He says this figure changes depending on capacity and grade of equipment one orders.
“The equipment minus consumables, you have 32 items apart from ICU beds,” he said.
A medical equipment supplier says costs of patient monitors range between $800 (Shs2.8m) and $1,000 (Shs3.5m), whereas oxygen to run the ventilators and medical air cylinders costs about $1,200 (about Shs4.2m)
Oxygen is one of the most essential items needed in ICUs, with a critical Covid patient consuming about 70 litres of oxygen per minute.
Meanwhile, the private hospitals incur both transport costs and cost to refill the oxygen cylinders that are critical in most cases to beef up the installed oxygen plants.
Interestingly, ventilators from Europe are not the same as ones from Asia or China, and range from $10,000 (Shs35m) and $40,000 (Shs141m).
But before one buys these equipment, one needs to have space, which will house both the ICUs, doctor’s office, and nurse’s space with standard buildings.
Mr Otim says a standard space measures 700 square metres, costs Shs3b.
Similarly, personal protective equipment (PPEs) such as masks, gloves and overalls, especially for Covid patients, are essential in ICUs.
A box of surgical masks with 50 pieces costs about Shs250,000.
A Covid-19 patient in an HDU at a private hospital in Kampala, he or she will have to part with at least Shs2 million for treatment every day. The patient has to pay Shs300,000 for oxygen, Shs100,000 for a physician, Shs150,000 for a doctor and Shs200,000 as risk allowance for the two acute care nurses.
The patient also pays additional Shs250,000 for the isolation room and an average Shs400, 000 for drugs administered every day.
For a Covid-19 patient in an ICU will have to part with between Shs3m and Shs6m per day.
“For critical cases in ICU, payment for personnel takes Shs150,000, medicine takes about Sh840,000 and supplies such as PPEs, laboratory test kits and other consumables take around Shs990,000,” Dr Charles Olaro, the director of clinical services in the Health ministry, says.
Mr Otim says in June, Uganda had 218 ICU beds allocated to Covid-19 patients, with 31 from seven accredited Covid-treating private health facilities. He says public health facilities have 280 ICU beds, with 187 of them dedicated to Covid patients.
The government plans for every regional referral hospital to have 10 functional ICU beds.
“The plan still holds. What we call an ICU unit is when you have at least 10 functional beds to have an economical ICU with an intensivists able to work on quite a sizeable number of patients within a space. Each ICU has an ICU bed itself, ventilators, [and] in that space where there are 10 ICU beds, you have an X-ray machine, a CT scanner, oxygen therapy apparatus and so many other small equipment. One ICU bed requires more than 30 pieces of equipment,” Mr Otim says.
Most regional referral hospitals were given 10 ICU beds, except Soroti that was given six and Gulu and Hoima getting two less.
“Of 143 ICU beds that were bought last year, 139 were installed, leaving only four pieces uninstalled because of space constraints in Gulu and Hoima. This means 139 have been installed and are functional. Of course, there are challenges of human resource,” Mr Otim says.
“This year, government wants to top them up and make sure all of them have 10 beds and we are going to construct standard facilities to house these ICUs. In this second lockdown, government will buy more 54 ICU beds,” Mr Otim said last month.
Before Covid, the country had 137 ICU beds, yet the Health ministry says the global health agency, World Health Organisation (WHO), recommends one ICU bed for every 100,000 persons. This means Uganda needs at least 420 ICU beds for her 42 million people.
Remodeling and construction of new ICU buildings will enable the equipment to be fully functional for optimal use. To be fully operational, they will require the recruitment of anesthesiologists, intensive care nurses and intensivists.
Sadly, the Uganda Medical Association (UMA) says during this second wave, several people died due to lack of oxygen, ICU and HDU beds as ambulances queued up in hospital parking lots.
The doctors under their umbrella UMA say the cost of ICU care is extremely high and government must own up and establish ICUs in all regional referral hospitals. But this would also mean government recruits and deploys critical care specialist and staff to all these centres.
“Currently, the only functional government ICUs ready to offer ventilation to critically ill patients are in Mulago and Mbarara hospitals,” reads the UMA statement issued last week.
The statement further states: “It is for this reason that we lost a highly trained paediatrician while being transported from Gulu to Kampala. We thank the anesthesiologists of Uganda who are working with the Ministry of Health to make ICUS in Fort Portal, Jinja and Lira regional referral hospitals functional.”
UMA says government needs to support private hospitals to offer affordable critical care.
They also say there is need to equip regional referrals to relive the pressure on national referral hospitals.
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