Access to health care is a big issue here in Lubutu. Congo is divided into Health Districts. Our district is centered on Lubutu, its largest town. Lubutu sits at a crossroads, with four routes leading to the cardinal directions. These roads are called “Axe” (axis) followed by the name of the town at their termination. Thus Axe Walikale is the road loading out from Lubutu to Walikale . This is the paved road I take to the Centre de Santé at Mungele. Two of the Axes are good paved roads, one is a passable dirt road, but the fourth is terrible. This is Axe Maiko.
The ability for a population to access health care can be measured several ways. One is to determine the difference between the expected number of patients who reach a health facility with a particular diagnosis versus the actual number of cases seen. In an emergency health situation, the average person makes four visits to a primary health care facility (Centre de Santé) per year. If the target population is 10,000 people, you would expect 40,000 visits per year. If there are only 10,000 visits per year, you have a problem. That problem can either be that you have an incredibly healthy population (unlikely), your census was wrong (perhaps only 2500 people live in the area, so the 10,000 visits experienced is right on target) or there is a problem with access to care. The sick cannot reach a health care facility.
The MSF project in Lubutu started three years ago. An inquiry at the time revealed that mortality rates in this area of Congo were extraordinarily high. One measures mortality rates as the number of deaths per 10,000 population per day. In an emergency (refugee or displaced person) setting, this number should be under 2 deaths per 10,000 people per day. At the time of the inquiry in Lubutu, the mortality rate was about 5 per 10,000 per day. Even though this was not an emergency situation (no war, famine, or natural disaster) MSF chose to intervene. At the time there were twenty-one Centres de Santé in the Lubutu Health District, all run by the Congolese government with the aid of Merlin, a British NGO (non-governmental organization). If there was a complicated case in one of these primary care Centres de Santé, there was no place where more intensive care could be provided. There was no referral hospital.
So the first thing MSF did was take an old government owned hospital, completely rehabbed it, and opened it as a Hôpital Générale du Référence. They let the word out to all of the Merlin/Congolese government Centres de Santé that the referral hospital was open for business and would happily accept their patients. Patients are cared for completely free of charge at the MSF hospital so there was no financial barrier to referral.
At the same time, MSF decided to take over four of the Merlin/Congolese government Centres de Santé and reopen them as MSF facilities. Two are open already, Kalibabete and Mungele. These are where I work. Merlin/Congolese government facilities charge a fee to see the Consultant and for medications. All care and medicines are free of charge at MSF facilities. This was done in order to try to remove any financial barriers to access.
Unfortunately, the number of patients referred to the hospital remained low, possibility indicating an access gap. In order to increase referrals, a free ambulance service was set up. Consultants at any of the Merlin/ Congolese government Centres de Santé can radio this service at any hour. Transportation for non-emergency cases is on an availability basis. If an MSF vehicle (like the car that takes us to Mungele each day) is travelling by a Centre de Santé and there is a non-emergency patient who needs a ride to the hospital, we give them one.
The results of these efforts are mixed. In the three years since the Lubutu project opened, mortality rates have decreased eighty percent in this Health District. This is amazing. It is likely due to a number of factors including the absence of war and the economic stimulus of having a large NGO-funded hospital in a small town. Whatever the cause, the decrease is wonderful news. At the same time, outside of the immediate area around Lubutu town, access to care remains a problem. The rate of hospitalizations and procedures (such as Caeserian sections) remains much lower than expected. This problem is not symmetrical across the district. Along the two Axes with the best roads, access to care is better. The biggest gap lies along Axe Maiko, heading north.
How to improve access further? Patients at the non-MSF Centres de Santé pay for services and medication. How about asking everyone to stop charging for care? Surprisingly, it is unclear if this would help. At Mungele, most of the patients live close to the Centre de Santé. The majority of those living two villages away choose to get their primary care from the nearer government run clinic. Patients prefer to stay in their own village and pay a fee rather than travel (by foot, bicycle, or motorbike) to Mungele, where services and medications are free of charge. So if we eliminated charges everywhere, would that improve access?
How about starting a patient bus service along the three Axes where the roads are decent? That might help. Statistics show that access along Axe Walikale, the road we take to Mungele, is best. One or two MSF vehicles drive on Axe Walikale each day, picking up and dropping off patients from all of the Centres de Santé . Patient transportation appears to have helped. Bus MSF is not a public transportation company. Who is going to start a bus service here?
The biggest gap in access lies along Axe Maiko, the road leading north out of Lubutu. It's infamous as being difficult, full of deep potholes. MSF's Toyota Landcruisers cannot traverse it. The obvious thing to do is make Axe Maiko into a real road, right? Right, except that MSF doesn't build roads. Currently the only way that patients living along this route can get to Lubutu for care is to walk, pedal a bicycle, or ride on the back of a motorcycle.
Last weekend I took a long walk up Axe Maiko. It is not a road. In many spots it is little more than a footpath through the bamboo jungle. When there are two parallel tracks they are often at different elevations, one two feet higher than the other. No wonder access stinks. If patients have an illness requiring hospitalization they must either have the money to pay for a motocycle ride or get to Lubutu on their own power. Not likely if you need a Caeserian section.
This all came together today. Before clinic was open, one of the people working in triage came to see me. A man was seated in the waiting area with two bandages on his leg. A dozen flies circled the gauze. The smell was horrible and the other patients were complaining. We took him into an exam room, cut off the bandages, and cleaned his wounds. Above his left ankle was a deep infected hole, the bone clearly visible. A tract of infection led all the way up to his knee. This man lived on Axe Maiko, sixty kilometres from Lubutu. The original injury was a year ago, a cut from a machete. It got infected. He went to the local Centre de Santé where antibiotics were prescribed. They didn't help. The wound became deeper and the sinus tract appeared. Even if the Centre de Santé phoned the ambulance, the vehicle could not traverse Axe Maiko. The patient could not walk or pedal a bicycle. His family could not pay for a motorcycle ride. So he sat in his village until he got the worst infection I have ever seen.