Chapter 4 - Outpatient services

Introduction

The Hospital has a separate OPD Department with two wings, one for adult and the other for children. The Building is hosting also the Ophthalmologic and the ENT service, the ANC and the Immunisation service. The Dental and Private service, though part of the OPD, are in separate buildings. The laboratory and radiological examinations are carried out in the Hospital premises, but the arrangement is such that they can be accessible from the Hospital courtyard. Here follow data focused on the curative function of OPD services. The PHC function exercised is reported in chapter 7, as global report for the Zone.

Function of the Hospital OPD

According to the its established function in the District Health System the Hospital should offer to the public Outpatient consultations of first contact (exclusively for the immediate catchment area of the hospital), Outpatient consultations of referral level (for referred patients only), Inpatient and emergency (medical and surgical) services and a package of preventive and promotive services (for the immediate catchment area). As a matter of fact things are much less clearly defined and the Outpatient Department delivers a mix of services, pertaining to different levels of care.

The Matany Hospital OPD covers two separate functions within the Health System of the District: it serves as first contact for the patients of the immediate catchment area (roughly the sub-counties of Matany, Lokopo and Lopei, which have no other dispensary), and as referral centre for patients who have first consulted elsewhere and have either been referred or decided to report to the Hospital because their problem was not solved. It also serves as first contact level for patients who bypass their first contact unit. The first two functions may be considered in line with a correct use of the health system. The third utilisation pattern (bypass of first contact near home) goes against a correct and cost-effective utilisation of the system. A study carried out in 1995 showed that about 72% of the patients seen in Matany OPD did not move correctly within the health system.

The number of referral to the Outpatient department is still low as 4.9% of the new cases of the patients “out of the system” in the first six months of 1999. As said in chapter 3 the impact of the new fees structure on utilisation was to increase the number of patients “belonging” to the system more than the patients outside the system, and the structure itself was though to improve the rational use of the Health System and therefore increase the number of referral, but this seems not yet the case.

Workload

All OPD workload data from 1993 on are reported in table 4.1. After the low ebb of 1990, OPD activity has reached a peak in 1993, dropped in 1995 and has increased again in 1996 and first semester 1997, to drop sharply after August fees (see impact of fees on utilisation in Chapter 3).

OUT-PATIENT	1993	1994	1995	FY 96/97	FY 97/98	FY 98/99
GENERAL SERVICE
New attendance	19736	18827	16282	18796	11102	15998
Adults	9845	7816	6892	8524	3757	6956
Children	9891	11011	9390	12514	7345	9042
Re-attendance	23525	22253	18458	22973	11029	18511
TOTAL	43261	41080	34470	44009	22131	34509
Table 4.1: OPD activities; workload of years 1993 – 95 and FY 96/97, 97/98, 98/99

It has been remarked that in the same period the utilisation of patients in Government and Private non profit Health Units of the zone has not increased as shown in the following graphic A:

This implies that patients who were formerly utilising Matany hospital OPD have returned to either the traditional or the western non-registered private sector and that there is a general trend in this reduction, not really related with the increment of fees of Aug 97.

As anticipated in chapter 3, the impact of the new fees had been tremendous on women and children and the overall effect on utilisation is clearly reflected by financial year 97/98 utilisation.

In the graphic B is presented the utilisation along the last three financial years. It appears that in financial year 98/99 the utilisation along the year is following the “pattern”of FY 96/97, even though not at the same level.

On the overall the utilisation seems in the last financial year on the average of the last 10 years and almost the same of 1995.

FY 96/97 FY 97/98 FY 98/99

Graphic B: Utilisation of OPD FY 96/97, 97/98, 98/99

Special Outpatient Services

Some special services are offered as part of the OPD, all runs by trained personnel (table 4.2.): primary ophthalmology, primary ENT, primary dentistry. A private service is also offered but it does not generate income. It mainly serves religious personnel and VIPs. For the first group the Hospital Management has introduced a pre-payment scheme with the diocese of Moroto.

SPECIAL OUTPATIENT SERVICES
	1994	1995	1996	1997	1998	FY 98/99
P. OPHTHALMOLOGY
Patients examined	969	494	139	812	859	990
P. DENTISTRY
Patients treated	n.a.	267	95	92	74	126
P. E.N.T.
Patients treated	n.a.	814	884	693	765	679
PRIVATE SERVICE
Patients examined	n.a.	166	149	61	122	96
Table 4.2: Special Outpatient services

Epidemiology

As far as the epidemiology is concerned the main diagnosis reported for FY 98/99 is still malaria (9666 episodes). In accordance with the points of action established in 1996, a more detailed classification of diseases in OPD has been introduced. The second most frequent diagnosis is diarrhoea (4006 episodes): with the new classification 1341 of these were due to dysentery. The third most frequent pathology reported is URTI (3985), followed by LRTI (3590) and by gastrointestinal diseases (2057). The average number of consultations resulted to be of 2.1 per patient, which is still consistent with a sufficient follow-up.

In the following graphic C, the percentage of the five top causes of attendance is compared along the years:

What it appears very clear is that there are no significant changes in the epidemiological pattern and that the more “obvious” diseases are the five tops, besides some differences in some years, concerning the fifth one and very difficult to explain, that can be trauma, worms, gastrointestinal diseases or splenomegally. What is more surprising are the differences in the number of diagnosis done per patient (shown by the fact in same years the five top causes account for 100% of all the patients). This is clearer if we analyse the number of diagnosis done per patient:

	1990	1991	1992	1993	1994	1995	1996	1997	1998
AVERAGE NUMBER OF DIAGNOSIS PER PATIENT	3.1	2.7	3.4	3.3	4.1	4	5	3.9	2.4

It is clear that 4 or 5 diagnosis per patient as in 1994,1995, 1996 and 1997 has no epidemiological sense and it poses the question of what should be the purpose of the diagnosing the patients and if our diagnoses are at all correct. In view of all these problems a meeting with the entire Medical and Clinical Officers was held in June 99. After discussion some decisions were taken, the more important of which was that a patient should received only one diagnose, the cause of the complain that has brought the patient to seek for treatment and not more than 3 if they are really relevant for epidemiological purpose (e.g. malnutrition as associated diagnosis in child who has come for malaria). As already said with the new coding system, introduced in 1996, was possible to notice that 2807 patients re-attended the OPD for the same episode of malaria (29%). This was interpreted as due to an increase chloroquine resistance. Yet according to the database of the Hospital Archive the number of patients who re-attended for the same episode of malaria were only 1394 (17%). This and all what said before shows clearly that data collection, accuracy and reproducibility are far from the reality when we consider a very busy environment and with a relatively high turnover of personnel (on average is changed every 2 years).

Quality Assurance

The above analysis comes out from the need of a better monitoring and quality assurance of the services rendered to the population.

Infact since September 98 a drugs use monitoring was established for the Outpatients Department. In the following table is presented the monthly monitoring done. The first indicators is the average diagnosis per patient and this seems in line with what said before and with the National Standard figure. Still far from the National Standard Indicators are the antibiotic prescriptions and the use of injectables. Can be noticed the positive impact of the first check of the indicators and the followed discussion with the prescribers, with a drop of one third for the antibiotic and to the National standard of injectables for adults. Several attempt and effort by the prescribers have been done but the main difficulties seem the administration in children of oral drugs and the high number of very sick children with ARI often associated with malaria or difficult to differentiate.

The monitoring of the anti-inflammatory prescription was done because was noticed that the number of anti-inflammatory prescribed was largely exceeding the number of diagnosis in which they are indicated, as trauma and muscle-skeletal disease which on average account for less then 10% of the all diagnosis.

OUTPATIENTS DEPARTMENT MATANY HOSPITAL

DRUGS USE INDICATORS 1998-1999

INDICATORS	SEPT	OCT	NOV	DEC	JAN	FEB	MAR	APR	MAY	JUN	NATIONAL STANDARD FIGURES
AVERAGE DIAGNOSIS PER PATIENT	2,5	2,4	1,9	2	1,9	1,7	1,3	1,6	1.4	1,4	1,5
% OF CASES GIVEN ANTIBIOTICS	45%	30%	41%	43%	32%	30%	28%	28%	29%	28%	<20%
% OF CASES GIVEN INJECTABLES: CHILDREN ADULTS	49% 25%				40% 12%	51% 15%	48% 4,6%	62% 4%	38% 11%	62% 9%	<15%
% OF CASES GIVEN ANTI- INFLAMMATORY DRUGS	15%	9%	10%	8%	13%	10%	10%	7%	11%	9%

An other effort in quality assurance was the monitoring of the waiting time in outpatient, defined as the time from the registration to the dispensing of the treatment. The exercise took place several times along the financial year and after each time some solutions to improve on it were established but with poor result as shown by the following table:

OUTPATIENTS DEPARTEMENT – MATANY HOSPITAL

Average waiting time in OPD Children
	“busy day” (Monday)		“Less busy day” (middle week)
	New cases	Reattendances	New cases	Reattendances
August 98 (166 children)	3hr 56min	3h 2min	2hr 6min	2h 24min
April 99 (248 children)	3hr 28min	3hr 5min	2hr 50min	2hr 53min
June 99 (222 children)	2hr 49min	3hr 27min	2hr 7min	1hr 50min

Average waiting time in OPD Adults
	“busy day” (Monday)		“Less busy day” (middle week)
	New cases	Reattendances	New cases	Reattendances
August 98 (63 adults)	2hr 12min	2h 39min	1hr 54min	2h 43min
April 99 (132 adults)	2hr 55min	3hr 32min	1hr 31min	1hr 41min
June 99 (84 adults)	2hr 34min	3hr 20min	2hr 18min	2hr 25min

The recommended waiting time for a patient in OPD should be less or equal to 1 hour. It is clear that Matany OPD is far from this average waiting time. The main reason is the high workload, considering the average of 108 visits per working day and that the majority of the patients are seen in the morning hours from 9a.m. to 1-2 p.m. The other reasons are that the OPD can use laboratory and X-ray service of the Hospital even for the new cases and that the reattendances/referral are preferably seen by a Medical Officer who do not arrive in OPD before 11 a.m. when he/she has ended the Ward Round.

In conclusion the average waiting time is high, but on the other side the services offered by Matany OPD are higher from the quality point of view. This does not mean that no effort in improving the efficiency should be done.

As points of action for the ongoing financial year 99-00 can be envisaged:

· More effort on the accuracy of the data “production”, collection and analysis should be made in view to have epidemiological data to plan better the future.

· Improvement and updating of guidelines and standard of diagnosis and treatment.

· More effort on the organisational structure of OPD to improve in efficiency.

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