On a humid morning with soaring temperature, Rogers Kusemererwa, a refugee from the Democratic Republic of Congo who has been in Kyaaka II Refugee Settlement since 2008 goes about his work with utmost alertness and strictness, typical of a security guard who loves his job. At one point he pauses to offer an opinion about the services at Bujubuli Health Centre.

“I rarely fall sick, but as the security guard of the health centre, I have witnessed many successful deliveries and provision of mosquito nets and other services at this centre,” he says. “The only time I fell sick, I was treated until I recovered, free of charge,” he adds.

In many ways, Kusemererwa’s testimony is the epitome of what Bujubuli health centre is all about. Situated within the settlement, the health center is meant to offer free quality health services to the over 28,000 refugee residents in the camp. It is not an easy task.

Established in 2005, Kyaaka II refugee settlement is one of the many settlements managed by the UNHCR and the Office of the Prime Minister of the Republic of Uganda. It covers 81.5 square kilometres in three sub-counties of Kyegegwa district, in the west of the country. Over 80% of the refugees in Kyaka II are from the Democratic Republic of Congo (DRC). Others are from Burundi, Ethiopia, Kenya, Malawi, and Rwanda.

High Malaria Burden
According to Dr Patricka Erimuka, the project coordinator of the African Humanitarian Action in the settlement, Malaria is the biggest health challenge Bujubuli Health Centre. “Over 35% of outpatient consultations are due to malaria,” he says. This is compounded by poor health-seeking behaviours among the refugees with many reporting very late. “They, therefore, present with complications such as convulsions and severe anaemia”, he adds.

Blood transfusion which is critical in the treatment of severe malaria and anaemia is insufficient at Bujubuli health centre. On average, about 16 blood transfusion sessions are done on children. However, there is a recurrent shortage of testing kits, drugs and blood for transfusion. The backup facility for blood is Fort Portal Regional Referral Hospital (FRRH)- over 100km from Kyaka II which is a big challenge due to transport constraints. “To mitigate the blood shortage challenge, blood donation sessions take place once a month in the camp where we collect an average of 20-25 units from the refugees,” says Dr Erimuka.

In the recent past, Kyaka II has benefited from the free distribution of Long Lasting Treated Mosquito Nets (LLINs) by the Ministry of Health, WHO and other partners. This has resulted in a drop in the incidence of malaria cases in the settlement. But just like in any other community, LLINs have been misused by some refugees in Kyaka II. There are reported cases of nets being used in house construction, rearing of chicken, making local brew or in gardens. This is being addressed by authorities.

High Birth Rates
Bujubuli Health Centre is also grappling with a high birth rate among refugees. Records indicate that on average, over 120 babies are delivered at the facility every month. Dr Erimuka attributes this to social circumstances and reluctance by many to use modern birth control methods.

“Many say they lost their relatives in large numbers during the wars and the intention is to replace them. Some women are afraid of their spouses who do not support birth control methods,” says Dr Erimuka. Consequently, only about 24% to 30% of women of reproductive age use contraception in Kyaka II.

For those who use family planning, the preferred method is injectable or implant because of their convenience and the ability to use them without the knowledge of their spouses. This usually leads to stock-outs of these commodities compared to contraceptive pills.

Luckily, most deliveries at Bujubuli Health Centre are normal. According to Dr Erimuka, complications due to delivery are very rare at the facility. If complications were to occur regularly that would be a medical nightmare because the next points of referral such as Kyegegwa HCIV, Mubende Hospital or the usually preferred FRRH are very far.

Teenage pregnancies and defilement 
Teenage pregnancies and defilement are also worrying in Kyaka II despite interventions by local leaders supported by the Uganda Police and courts of law. For instance, in November 2016, of the 220 mothers who attended Antenatal Care (ANC) at Bujubuli Health Centre, 35 were between 10 to 19 years. In December, out of the 183 mothers who ANC, 31 were between 10 to 19 years. In February 2017, 193 mothers attended ANC and 30 were aged 10 to 19 years.

Fortunately, community members are cooperating in the fight against this problem. On average, four cases of rape, defilement or domestic violence are reported to the police in Kyaka II. Perpetrators are prosecuted and victims are screened for HIV, other Sexually Transmitted Infections and appropriately treated. They are also counselled and managed to prevent unwanted pregnancies.

Depression
Depression and post-traumatic stress disorder are high in the settlement with about 600 patients currently receiving psychiatric services. The settlement employs a fulltime psychiatric nurse and a psychiatric specialist visits the settlement monthly.

HIV/AIDS in the settlement 
HIV/AIDS prevalence among refugees is reportedly 1.4% which is considerably high in this population. “Although there is an adequate supply of ARVs, many patients do not adhere to treatment because they keep moving out of the settlement, to conduct business in DRC or visit their relatives in other settlements,” says Polycarp Byamukama the clinical officer at Bujubuli health centre. He also adds that the use of condoms use is worryingly low.

Village Health Teams lauded
The Village Health Teams (VHTs), a strategy of the Ministry of Health to deliver health services at community and household levels in Uganda, is working well in Kyaaka II. Refugees have their VHTs who do Community-Based Disease Surveillance and report to health authorities. They identify and advise sick patients to seek medical care; mobilize people for health actions such as immunization; and educate them on Ebola, nutrition and hygiene among others. Presently, there are 372 active VHTs in Kyaka II who were trained with support from WHO.

Although Rogers Kusemererwa rarely falls sick, he and other refugees are at least assured that if they do, Bujubuli Health Centre III is there for them as the first point of call. In the meantime, Kusemererwa continues with his security job which earns him UGX 200,000/= (USD 53.87) that enables him to take care of the family.