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A letter from Barbara Nagy in Malawi

October 2011

Nkhoma Hospital Update

Dear friends,

Nkhoma Hospital had a very busy last year, partly due to increased patient numbers generated by Service Level Agreements (SLAs) with the Malawi government that have removed cost barriers for many pregnant women and children seeking care, as well as the general deterioration of the economy that has left nearby government facilities without essential drugs and supplies.  During 2010 we saw over 47,000 outpatients and cared for 16,000 admissions.  Nearly 9,000 were pediatric patients and there were over 3,000 births. Since newborns are not generally counted as admissions, the total number of inpatients was actually closer to 20,000, cared for by a full-time nursing staff of 26. HIV medicines were provided to 304 adults and 32 children, and 46 mothers received treatment to prevent transmission of HIV to their unborn children.  Outreach clinics occurring six times each month generally saw 200–500 patients each, providing vaccinations, under 5s health and nutrition assessments, antenatal services, family planning, and HIV testing in remote areas.  Health centers supported by the hospital saw an additional 100,000 patients.  A Safe Motherhood program linked to nine health centers in our area supported lifesaving emergency obstetrical procedures and we believe contributed to decreased maternal and newborn deaths. Indoor residual spraying reached over 58,000 people (98 percent of the population in sprayed communities) and decreased the prevalence of positive malaria smears from 75 percent before spraying began to 36 percent in areas where spraying has been done for two consecutive years.

Financially the hospital’s total operating expenses for 2010–2011 were $1,825,000.00, exclusive of capital costs.  Twenty percent of these expenses were drugs and medical supplies and food for patients, 62 percent were staff expenses, 11 percent were maintenance costs, and 7 percent administrative costs.  Income for the hospital came from the following sources: 36 percent from patient fees, including 14 percent recovery of costs through the SLA agreement, 44 percent from the Malawi government for basic salaries of established staff, and 20 percent from donations.  The monthly average expense is $151,000.00.   

Support of staff has been a high priority in past years, and we were thrilled to be able to send one of our most dedicated clinicians—who started out as a gardener in one of our staff houses years ago, advancing from patient attendant to medical assistant to clinical officer—to medical school in Tanzania.  This represents not only years of hard work for this individual but years of support on the part of hospital administration.  He joins a group of highly valued and excellent administrative, technical, nursing and clinical staff who have been sponsored for further training in the past and returned to faithfully serve their community at Nkhoma.

In the midst of busy teaching and patient care programs, many areas of the hospital have been under construction.  We were fortunate to realize a newly completed nursing hostel for 60 students as well as an outpatient renovation providing a covered waiting area that coordinated with an emergency triage system for children.  Color-coded benches for children that divide emergency, urgent, and routine patients helped us decrease the inpatient pediatric mortality rate to 2 percent as opposed to Malawi government targets for improvement of 7.5 percent and have helped make children dying in line waiting to be seen a part of past history.  Surgical procedures were reduced during the year because the surgical ward and operating theaters underwent major reconstruction.  Nonetheless, 1,770 surgeries were still accomplished, primarily emergency obstetric procedures.  The new ward provides significant improvements in services, including a new burn unit.  Opened again in July 2011, it was immediately filled to capacity and hosted visiting surgical specialty teams that were able to offer and teach procedures not normally available for our patients.  Four new houses for staff were constructed during the year and renovations have been undertaken for an expanded laboratory.

During the past year we also faced many challenges, including very limited numbers of staff in all departments, nearly daily power outages that taxed every area of service, and constant financial distress.  There were several points during the year when we felt the hospital was in danger of closing due to lack of funds to purchase medicines or pay staff, but always at the critical moment God provided the needed resources.  This situation repeatedly occurred when the Malawi government failed to pay for services provided under its Service Level Agreements.  In spite of this significant problem, we want to extend Service Level Agreements to other districts served by our hospital due to the greatly improved access to care this provides the people living in those areas.  A government health administrator recently described the areas in Malawi (all mission hospitals) covered by Service Level Agreements as “islands of plenty in the midst of a sea of misery” because of the improved services and decreased mortality rates resulting from the collaboration.  Funds provided are also significantly more than the small amounts previously charged to our mostly indigent patients, so if the government pays its bills, our hospitals are much more able to meet financial goals. An additional problem posed by extending Service Level Agreements to new areas is the increased workload presented to an already severely overburdened hospital staff and infrastructure.  It is not uncommon to see four women on plastic sheets on the floor of the maternity in the process of delivering babies without even space for the staff to walk between them. Pediatrics admissions peaked at 1,200 patients in one month with three or four patients in each bed, children farmed out to all available hospital wards to provide oxygen, and a M*A*S*H style admission area in the corridors to try to get critically ill children cared for in the shortest possible time. 

In the coming year we are hoping to renovate the high-care area of the pediatric ward, enlarge the maternity ward, and remodel space for a separate nursery due to the high numbers of sick newborns seen.  The main challenge to these plans is adequate nursing staff due to the severe shortage of housing in our remote area; thus new staff housing is critical to furthering the work of Nkhoma Hospital.  Construction funds for all projects are pending approval of several grant applications, including two submitted to Presbyterian Women, and unfortunately the size of the maternity ward even with the added space will be far from adequate. We are also hoping to reduce the numbers of severely ill people coming to the hospital by increasing the number and capabilities of outreach clinics.  Finally, we face significant problems with the unexpected destabilization of the Malawi government and resultant weakening of all government services, repeated countrywide shortages of fuel (needed to run ambulances and emergency generators), lack of foreign exchange, which severely limits imports, including medicines, and an attitude of repression and irresponsibility that has seen the withdrawal of all major international aid in the past six months.

Thank you sincerely for your prayers, encouragement and support that have been vital factors in our continued work.  We pray daily to be faithful witnesses of the character and compassion of Christ as we care for the many people who pass through our doors.  This is only possible because of fellow Christians such as you who are tirelessly standing with us.

May God’s grace be with you all,
Barbara Nagy for Nkhoma Hospital

The 2011 Mission Yearbook for Prayer & Study, p. 67
The 2012 Presbyterian Mission Yearbook for Prayer & Study, p. 106

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