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Disability and Rehabilitation
ISSN: (Print) (Online) Journal homepage: https://www.tandfonline.com/loi/idre20
Evaluation of the current status of prosthetic
rehabilitation services for major limb loss: a
descriptive study in Ugandan Referral hospitals
Benedict Mulindwa, Racheal P. Nalwoga, Brenda T. Nakandi, Erisa S. Mwaka,
Laurence P. J. Kenney, Louise Ackers & Robert Tamale Ssekitoleko
To cite this article: Benedict Mulindwa, Racheal P. Nalwoga, Brenda T. Nakandi, Erisa
S. Mwaka, Laurence P. J. Kenney, Louise Ackers & Robert Tamale Ssekitoleko (2023):
Evaluation of the current status of prosthetic rehabilitation services for major limb loss:
a descriptive study in Ugandan Referral hospitals, Disability and Rehabilitation, DOI:
10.1080/09638288.2023.2188266
To link to this article: https://doi.org/10.1080/09638288.2023.2188266
Published online: 24 Mar 2023.
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ORIGINAL ARTICLE
DISABILITY AND REHABILITATION
Evaluation of the current status of prosthetic rehabilitation services for major
limb loss: a descriptive study in Ugandan Referral hospitals
Benedict Mulindwaa, Racheal P. Nalwogaa, Brenda T. Nakandia, Erisa S. Mwakab , Laurence P. J. Kenneyc,
Louise Ackersd and Robert Tamale Ssekitolekoa
aBiomedical Engineering Unit, Department of Physiology, Makerere University, Kampala, Uganda; bDepartment of Anatomy, Makerere University,
Kampala, Uganda; cCentre for Health Sciences Research, University of Salford, Salford, United Kingdom; dSchool of Health and Society, University
of Salford, Salford, United Kingdom
ABSTRACT
Purpose: Low-and-middle-income countries (LMICs) have a large burden of major limb loss. No
recent study has reported on Uganda’s state of public sector prosthetics services. This study aimed
to document the landscape of major limb loss, and the structure of available prosthetics services in
Uganda.
Methods: This study involved a retrospective review of medical records at Mulago National Referral
Hospital, Fort Portal Regional Referral Hospital, and Mbale Regional Referral Hospital, and a
cross-sectional survey of personnel involved in the fabrication and fitting of prosthetic devices across
orthopaedic workshops in the country.
Results:Upper limb amputations accounted for 14.2%, and lower limb accounted for 81.2%. Gangrene
(30.3%) was the leading cause of amputation, followed by road traffic accidents and diabetes mellitus.
Orthopaedic workshops offered decentralised services, and most materials used were imported.
Essential equipment was largely lacking. Orthopaedic technologists had diverse experience and skill
sets, but many other factors limited their service provision.
Conclusion:The Ugandan public healthcare system lacks adequate prosthetic services both in terms
of personnel and supporting resources, including equipment, materials, and components. The provision
of prosthetics rehabilitation services is limited, especially in rural regions. Decentralising services
could improve patients’ access to prosthetic services.
hIMPLICATIONS FOR REHABILITATION
• Availability and accessibility of prosthetic services are essential to the rehabilitation and reintegration
of amputees into communities in Low-and-Middle-Income countries (LMICs).
• For stakeholders to formulate effective plans to address issues within prosthetics service provision,
quality data on the current state of services is necessary.
• Service providers should prioritise the decentralisation of prosthetic rehabilitation services, especially
for patients in rural areas, to improve access and reach of these services.
• To achieve optimal limb functionality after amputation for both lower and upper limb amputees,
rehabilitation professionals working in LMICs should focus on delivering comprehensive
multidisciplinary rehabilitation services.
• Orthopaedic personnel should ensure complete and accurate documentation of patient information
following amputation to enable effective tracking and monitoring of patient care to improve
outcomes of rehabilitation.
Introduction
Major Limb Loss (MLL), defined as the partial or total severance
of an extremity when done at or proximal to the wrist or ankle,
is a widely recognised health challenge, especially in
low-and-middle-income countries (LMICs) [1–3]. A recent report
by ATscale2030 indicated that 1.5 million people are amputated
annually, with up to 65 million living with amputations globally
[4]. The leading causes of MLL worldwide are diabetes mellitus,
trauma, and peripheral vascular diseases [5–7]. In the coming
years, factors such as unhealthy diets and sedentary lifestyles will
contribute to an increase in amputations related to peripheral
vascular diseases, especially resulting from diabetes mellitus [8].
Several studies [3,9–11] have linked the burden of MLL with var-
ious adverse physical, psychological, social, and economic out-
comes of amputations that may have devastating effects on
individuals, families, and society.
Over 80% of the global MLL population is estimated to live in
low-and-middle-income countries [12]. The incidence of MLL in
LMICs has, until recently, been hugely dominated by trauma, pri-
marily due to road traffic accidents, and violence-related injuries,
especially domestic violence [8,10]. Despite the recent global drive
to improve equitable access to health services for people with
disabilities, LMICs still lag behind [13–15]. Over 30 million people
© 2023 Informa UK Limited, trading as Taylor & Francis Group
CONTACT Robert Tamale Ssekitoleko rsseki@gmail.com Biomedical Engineering Unit, Department of Physiology, School of Biomedical Sciences, College
of Health Sciences, Makerere University, Kampala, Uganda
https://doi.org/10.1080/09638288.2023.2188266
ARTICLE HISTORY
Received 8 July 2022
Revised 26 February 2023
Accepted 2 March 2023
KEYWORDS
Major limb loss;
low-and-middle-income
countries;
prosthetics services;
decentralisation;
Ugandan referral hospitals;
orthopaedic technologists
2 B. MULINDWA ETAL.
in LMICs are believed to require prosthetic services, yet in some
countries, only 3% have access to them [16]. The available
LMIC-based services are often highly dependent on donated pros-
thetic devices. Despite their well-meaning intentions, donations
have led to the underutilisation or complete abandonment of
devices because many do not meet the users’ needs and expec-
tations [17]. The situation is even worse for people with upper-limb
loss, as even in high-resource settings, rejection rates of devices
are high [18,19]. Without good quality data on the prevalence of
limb loss and the state of current services, it is difficult for stake-
holders to plan on how to address these issues effectively [20].
This study focuses on Uganda, a country of 48 million people
[21], and reports on work carried out in a collaborative research
project focused on developing improved upper limb prostheses.
Approximately 12.5% of Uganda’s population aged five and over
lives with some form of disability, with 35.3% having loss and/or
limited use of extremities and the majority living in urban areas
[22,23]. In the 1990s, Uganda suffered internal conflict concen-
trated in its north, which left many victims of limb loss [24]. Today,
the country hosts about 1.5 million refugees, especially from
war-torn neighbouring countries [25]. In Uganda and other LMICs,
the primary focus for prosthetic rehabilitation is on lower limb
amputations (LLA), and upper limb amputations (ULA) do not
receive the same attention and services. A few studies have
reported on amputee demographics in the north, post-conflict,
focused on the Acholi region [3,26], and two other studies
reported disability statistics related to road traffic accidents in
other parts of the country [27,28]. However, no study has reported
on Uganda’s state of public sector prosthetics services.
This descriptive study aims to establish characteristic data on
the landscape of major limb loss; highlighting the upper limb
and the structure of existing prosthetic services in Uganda. The
findings reported in this study provide a baseline for other stake-
holders and service providers to plan and develop prosthetics
and orthotics (P&O) programmes and services in Uganda.
Methods
Ethical considerations
Makerere University School of Biomedical Sciences Research Ethics
Committee (SBS-641) and the Uganda National Council for Science
and Technology (ADM 194/212/01) approved the study. No per-
sonal identifying information was collected on the data collection
forms to protect patient privacy. Collected data was coded to
remove identifying information and stored on a password-protected
KoboToolbox server that only the researchers had access to, and
only aggregate findings were reported.
Study design
The study used a descriptive approach and included a retrospec-
tive review of medical records [29] and a cross-sectional
questionnaire-based survey of personnel involved in the fabrica-
tion and fitting of P&O devices.
The review of medical records was conducted at three public
regional referral hospitals, including Mulago National Referral
Hospital (MNRH), Fort Portal Regional Referral (FPRRH), and Mbale
Regional Referral (MRRH) in central, western, and eastern Uganda
respectively. A secure online/offline digital data collection form
adapted from Okello etal. [3] was designed in KoBoToolbox Global
Server Version 2.022.08 and deployed at each hospital. The form
was used to assess patient demographics and details of amputa-
tions performed between 2015 and 2021.
The cross-sectional survey involved a quantitative exploration
of the technical capacity of orthopaedic centres and personnel
to provide the prosthetic services they are expected to provide.
A self-evaluation questionnaire with closed-ended questions was
designed based on WHO guidelines for training personnel in
developing countries for P&O services [30] and the AT2030 pros-
theses product narrative [4] and hosted online on KoboToolbox.
The questionnaire was used to collect data on the education and
professional backgrounds of personnel, their technical skills, and
the availability of key resources (such as equipment, materials,
and funding) necessary to deliver prosthetic services.
Sampling
During the review of patient records, a convenience sampling
approach [31] was used because there was limited information
about amputations. All patients who had undergone any level of
lower or upper limb amputation or sought prosthetic services at
MNRH, FPRRH, or MRRH orthopaedic theatre, ward or workshop
between May 2015 and December 2021 were included. Instances
where amputation-related information was “not specified” were
captured and considered during analysis. Patients who were
recorded as only having received orthotic services and any records
dated earlier than May 2015 were excluded.
Survey participants were purposively targeted [32] to ensure
that a representative sample of orthopaedic personnel working
in various orthopaedic workshops across the country was reached.
Personnel who were registered members of nationally recognised
professional bodies, namely, the Uganda Association of Orthopaedic
Technologists (UOTA)1 and the Allied Health Professionals Council2
(AHPC), were particularly targeted. To be included, participants
must have been employed as prosthetists, orthopaedic technol-
ogists3, or orthopaedic technicians4 at any public,
private-not-for-profit or private-for-profit hospitals, or private com-
panies nationwide. They also must have had a minimum of two
years of experience providing amputees with prosthetic care.
Although ISPO has changed the terms “orthopaedic technolo-
gist” and “orthopaedic technician” to “associate prosthetist/ortho-
tist” and “prosthetic/orthotic technician” [33], personnel still
referred to themselves as “orthopaedic technologist” or “orthopae-
dic technician” at the time of data collection. The eligible popu-
lation was estimated to be 500, from which a representative
sample size was calculated using the Taro Yamane formula [34].
The percentage maximum acceptable error (precision level) was
set to ±10%, the confidence level at 95%, and the percentage
occurrence was estimated at 50%. A sample size of eighty-three
participants was calculated and considered for the study.
Data collection
Retrospective medical records review
Data was collected in 2021. Patient medical records from the
orthopaedic theatres, wards, and workshops at MNRH, FPRRH, and
MRRH were reviewed by research assistants under the supervision
of the lead researcher. Administrative clearance was obtained at
each hospital to access patient records. Data was collected on
relevant demographic information, including gender, age, residen-
tial village, and amputation characteristics, including the type of
amputation (LLA, ULA), indication, and prosthesis usage. LLAs
were defined as unilateral or bilateral amputations (or
PROSTHETICS SERVICES PROVIDED BY UGANDAN REFERRAL HOSPITALS 3
disarticulations) below or above the knee, through the hip, knee,
or ankle joints, or foot and partial foot. For ULA, amputations (or
disarticulations) below or above the elbow, through the shoulder,
elbow, or wrist joints were all considered major. Although hand
or partial hand amputations were not considered major upper
limb amputations [1, 2], their incidences were recorded but
excluded from the total frequency of levels of ULA.
Patient records at MNRH were retrieved from patient registra-
tion manuscript books at the orthopaedic workshop,
hospital-issued registration books at the orthopaedic trauma
theatre, and Ministry of Health (MoH) patient database logbooks
at the trauma ward. At the time of the study, there was no
operational orthopaedic theatre or ward at FPRRH. Records were
obtained from the main operating theatre Health Management
Information System (HMIS) logbooks, and clinical notes recorded
in the general surgical ward report manuscript books. FPRRH
orthopaedic workshop records for January to December 2021
were retrieved from a computerised record system and earlier
records from an HMIS patient registration logbook. At MRRH,
information was collected from the orthopaedic workshop’s HMIS
outpatient registers, the orthopaedic ward’s clinician rounds
report manuscript books and an online reporting system imple-
mented at the orthopaedic operating theatre.
Google Maps was used to estimate and calculate the shortest
road distance in kilometres (km) from each patient’s residential
village to the orthopaedic department where they received ser-
vices. All this data was collated onto an online server hosted by
KoboToolbox via the data collection form. Latitude (Y ) and lon-
gitude (X) coordinates were obtained from Google Maps and
tabulated into spreadsheets.
Cross-sectional self-evaluation survey of orthopaedic personnel
The survey questionnaire was sectioned into three profiles: the
personnel, services and resources, and the skillset.
1. The personnel prole was used to collect data on partic-
ipants’ educational and professional backgrounds and
identify accreditation and professional development
pathways.
2. The services and resources prole explored decentralisa-
tion models of P&O services [4], funding pathways and
commonly used supplies (specically materials), and avail-
ability of essential equipment at orthopaedic workshops
(adapted from the WHO Medical Equipment List for Typical
District Hospital, Kenya [35]).
3. The skillset prole applied a 5-point Likert scale to rate
the technical capacity of personnel to perform tasks
including; clinical assessment, design, fabrication, tting
and alignment of P&O devices, among others, as prede-
termined by WHO/International Society for Prosthetics and
orthotics (ISPO) Category I, II, and III guidelines [30, 36].
Information about the survey was presented at the UOTA
Annual General Meeting in October 2021. A link to the online
questionnaire was distributed to members via the association
president, who had access to a member contact database.
Additionally, a research assistant provided paper-based question-
naires at the orthopaedic workshops during records review and
later uploaded the responses to the online KoboToolbox server.
Before enrolling in the survey, informed consent was obtained
from each respondent. Contact information of the local ethics
committee chairperson and the lead researcher was provided to
participants in case they had any questions or concerns about
the study or their rights.
Data analysis
Data was preliminarily analysed using graphs and figures in an
automated report generated by KoBoToolbox. Records review data
and returned surveys were exported from KoboToolbox and col-
lated into two separate spreadsheets. The sheets were checked
for duplicates and incomplete datasets, which were excluded from
the analysis. The data was then labelled and statistically analysed
in Microsoft Excel Version 2205. Descriptive data were used to
establish trends, presented as frequency, percentage, and graphs,
from which gaps in service provision were identified and dis-
cussed. Latitude and longitude spreadsheets were imported into
ArcGIS Pro 2.8.0, which was used to map the locations onto a
base map and shapefile obtained from the Humanitarian Data
Exchange database [37].
Results
Retrospective medical records review
A total of 634 records of patients who had undergone major limb
amputation between May 2015 and December 2021 were con-
sidered for analysis. Most patients (265; 41.8%) were in the age
range of 36–65. Male patients made up 425 (67.0%) of all patients,
with a female-to-male ratio of 2:1 (Table 1).
Upper limb amputations accounted for ninety cases (14.9%)
of all amputations, while lower limb amputations accounted for
515 cases (85.1%), giving a 6:1 ratio between LLA and ULA.
Twenty-nine patients had missing data on the type of amputation.
Nineteen of the 90 upper limb amputations were partial hand
amputations and were excluded from the total frequency of the
levels of major ULA. Seven non-specified levels of ULA were also
excluded. Of the 64 major occurrences of ULA, 38 (59.4%) were
above the elbow (including shoulder disarticulation; n = 15, and
fore quarter; n = 1), while 26 (40.6%) were below the elbow (includ-
ing wrist disarticulation; n = 8). Table 1 summarises the detailed
analysis of this dataset.
Of the 634 patients, only 266 (42.0%) had residential informa-
tion recorded, while the majority, n = 368 (58.0%), did not. Patients
travelled a mean distance of 65.4 km to any referral hospital (a
range of 0–554 km). While most of the patients, 156 (58.7%), trav-
elled between 0 and 49 km, six patients (2.3%) moved over 300 km
to access an orthopaedic service at MNRH, FPRRH, or MRRH. Figure
1 illustrates the population distribution of patients from the refer-
ral hospitals where they accessed orthopaedic services.
Indications for amputation
From the entire dataset, the indication for amputation was
recorded for 416 patients (65.6%). Amputations were predomi-
nantly caused by (30.3%), followed by road traffic accidents (RTA)
(15.9%), diabetes (12.0%), trauma (7.2%), sarcomas (6.7%), and
septic wounds (6.3%). Other indications accounted for a total of
21.6%. Trauma-related amputations were defined as those caused
by crush injuries, machine injuries, accidental falls, and bicycle
accidents, excluding RTA. While RTA is one of the major causes
of trauma, it was excluded from the overall total of trauma-related
amputations due to its substantial frequency. Osteosarcoma was
the most prevalent malignant tumour. Figure 2 shows the distri-
bution of indications. From the figure, many of the indications
(n = 218, 34.4%) were not registered in the patient records, sug-
gesting the need for improved documentation practices.
4 B. MULINDWA ETAL.
Results from self-evaluation survey of orthopaedic personnel
A total of nineteen responses were received from private and
public sector organizations, including Orthotech and Physical
Rehabilitation Limited and CoRSU Hospital, as well as MNRH,
FPRRH, MRRH, Lira RRH, Gulu RRH, school of orthopaedic tech-
nology, and Chieftaincy of Mubende rehabilitation centre: a mil-
itary rehabilitation centre. The majority (n = 17) worked in
public-sector hospitals. Fourteen orthopaedic technologists, four
prosthetists/orthotists, and one orthopaedic technician
Table 1. Distributions of patient characteristics based on recruitment, age, gender, type and level of ULA, between May 2015 and December
2021.
Frequency, f (Percentage, %)
FPRRH
f (%)
MNRH
f (%)
MRRH
f (%)
Total
f (%)
Age
Adult (36–65 years) 97 (15.3) 75 (11.8) 93 (14.7) 265 (41.8)
Youth (19–35 years) 57 (9.0) 100 (15.8) 39 (6.2) 196 (30.9)
Elderly (>65 years) 33 (5.2) 34 (5.4) 25 (3.9) 92 (14.5)
Child (1–18 years) 32 (5.0) 31 (4.9) 18 (2.8) 81 (12.8)
Total 219 (34.5) 240 (37.9) 175 (27.6) 634 (100)
Gender
Male 132 (20.8) 180 (75.0) 113 (64.6) 425 (67.0)
Female 87 (13.7) 60 (25.0) 62 (35.4) 209 (33.0)
Total 219 (34.5) 240 (37.9) 175 (27.6) 634 (100)
Type of amputation
Lower limb amputation 183 (30.2) 201 (33.2) 131 (21.7) 515 (85.1)
Upper limb amputation 36 (6.0) 37 (6.1) 17 (2.8) 90 (14.9)
Total 219 (36.2) 238 (39.3) 148 (24.5) 605 (100)
Not specieda,b 0 2 27 29
Level of amputation (ULA)
Above elbow amputation 8 (12.5) 12 (18.8) 2 (3.1) 22 (34.4)
Below elbow amputation 12 (18.8) 2 (3.1) 4 (6.3) 18 (28.1)
Shoulder disarticulation 4 (6.3) 8 (12.5) 3 (4.7) 15 (23.4)
Wrist disarticulation 2 (3.1) 5 (7.8) 1 (1.6) 8 (12.5)
Fore Quarter amputation 01 (1.6) 01 (1.6)
Total 26 (40.6) 28 (43.8) 10 (15.6) 64 (100)
Partial-Hand Amputationb,c 9 8 2 19
Not speciedb1 5 1 7
aRecorded as ‘amputation’, or only indication of amputation recorded.
bExcluded from percentage distribution calculation.
cHand or partial hand amputation was not considered major ULA.
Figure 1. A map of Uganda showing the population distribution of patients from the hospitals where they receive orthopaedic services.
PROSTHETICS SERVICES PROVIDED BY UGANDAN REFERRAL HOSPITALS 5
participated in the study. Ten participants held bachelor’s degrees
in fields unrelated to orthopaedic technology, including phar-
macy, health administration, and biomedical lab technology, eight
had diplomas in orthopaedic technology, and one had a master’s
degree in public health. The majority had more expertise in pro-
viding lower limb prosthetic services as compared to the upper
limb. Table 2 shows data on the education and professional pro-
file of the participants.
The services provided and resources available at orthopaedic
workshops are summarised in Table 3. Most of the participants
indicated that decentralised orthopaedic services were offered at
their workshops, although four said that none of the services were
provided at their workshops. Figure 3 below shows how partici-
pants self-rated their ability to perform tasks required for optimal
P&O service provision. All participants were confident in their
ability to provide essential orthopaedic services and support ser-
vices including physiotherapy, paraplegic support, fabrication of
club foot orthoses, and psychological counselling to patients.
Plaster of Paris and plastics, among other commonly used mate-
rials, were imported from Germany, India, South Africa, and others.
Ottobock (Germany), the International Committee of the Red Cross
(ICRC), and Endolite (India) were the leading international suppliers.
Some materials, such as wood, buckles, rivets, and EVA could be
purchased locally from Orthotech and Physical Rehabilitation Ltd.,
Joint Medical Stores, and Leos Orthopaedic Centre Ltd. Most of
the essential orthopaedic equipment required for P&O service
provision, including P&O kits, vacuum laminating machines, air
compressors, and PVA sealing machines were reported lacking
from the workshops. The government, through the MoH (12/19;
63.2%) and non-governmental organisations (NGOs) (10/19;
56.63%), were the primary sources of funding for the orthopaedic
workshops.
Discussion
Broadly consistent with the findings of Okello etal. [3] in Northern
Uganda, Chalya etal. [14] in Tanzania, and Yempabe etal. [15] in
Figure 2. Indications for amputation. Distribution of amputations by frequency of occurrence %. “* Sarcoma included osteosarcoma (18), brosarcoma (2), NRSTS
(1), Rhabdomyosarcoma (1), Kaposi’s sarcoma (3), STS (1), synovial sarcoma (2). ** Others were assault, human bite, foot ulcer, pathology, domestic violence,
self-injury %”.
Table 2. Characteristics of personnel providing prosthesis services.
Characteristic Frequency (%)b
Job description
Orthopaedic technologist 14 (73.7)
Prosthetist and Orthotist 4 (21.1)
Orthopaedic technician 1 (5.3)
Total 19 (100)b
Maximum level of education
Bachelor’s degree 10 (52.6)
Diploma (or equivalent) 8 (42.1)
Master’s degree 1 (5.3)
Total 19 (100)
Training school
School of Orthopaedic Technology 10 (52.6)
TATCOT 4 (21.1)
Both 4 (21.1)
Others 1 (5.3)
Total 19 (100)b
Expertise
Lower Limb prosthetics 13 (81.3)
Upper Limb prosthetics 3 (18.8)
Total 16 (100)b
Not specieda3
Years of experience
2–10 2 (12.5)
11–20 11 (68.8)
>20 3 (18.8)
Total 16 (100)b
Not specieda3
Education and professional prole of participants.
aExcluded from percentage calculation.
bPercentages have been rounded and may not total to 100%.
6 B. MULINDWA ETAL.
Ghana, most of the amputees were male (67.0%), between the
ages of 19 and 65. A significant part of this distribution can be
attributed to the fact that relatively young men of working age
are more prone to engaging in activities like motorcycling (locally
referred to as “boda-boda”) and operating heavy industrial machin-
ery, which increases their risk of sustaining traumatic injuries that
may result in amputations [38,39]. Also consistent with other
reports, the majority of amputations performed at these hospitals
were for the lower limb [1,3,15,40–43]. The ratio of LLA:ULA found
in this study is similar to that reported by Chalya et al. [14] in
Tanzania. The relatively low known prevalence of ULA likely con-
tributes to the limited advancements in upper limb prosthetics
compared to lower limb prosthetics globally, especially in
resource-constrained settings [44]. The bias in caseloads favouring
LLA may also suggest that orthopaedic personnel become more
competent in practising lower limb prosthetics [45]. The most
common level of upper limb loss was above-elbow amputations
(AEA) (59.4%), followed by below-elbow amputations (BEA) (40.6%),
and a similar trend was seen in studies done in Malawi, Nigeria,
Ethiopia, and Rwanda [1,10,38,46].
The distance patients travel to hospitals is relevant to health-
care planning, particularly for access to services. Understanding
how far patients are willing to travel to access orthopaedic ser-
vices may be indicative of the availability of adequate access to
these services. In this study, patients lived a mean distance of
65.4 km from the hospital where they accessed orthopaedic ser-
vices. Six patients travelled over 300 km to access services at an
RRH outside their home region. Travelling longer distances to
receive orthopaedic services would be expected for MNRH, as it
is the convergence point of all referrals. However, for the RRHs,
this phenomenon may be driven by the limited availability of
specialised rehabilitation services at nearby hospitals. Interestingly,
some studies showed that mothers in rural Tanzania and Eastern
Uganda seeking obstetric service delivery would bypass nearer
facilities due to inadequate human or supporting resources,
including infrastructure, medical equipment, or medicine [47,48].
This finding has an important implication for the healthcare sys-
tem and clearly shows the need to improve orthopaedic service
delivery at even the higher hospital levels to overcome barriers
to rehabilitation, such as high transportation costs and geographic
distance.
Although the indication for amputations varied between
hospitals, gangrene was the leading indication, accounting for
30.3% of cases where the cause was documented. This finding
that gangrene was the most common cause of limb loss was
also reported by Onwuasoigwe etal. [2], Salawu et al. [49], and
Agu and Ojiaku [50] in Nigeria, Grudziak et al. [10] in Malawi,
and Murwanashyaka et al. [46] in Rwanda. It should be noted
that gangrene is a secondary condition that results from necro-
sis in a limb due to lack of blood circulation, injury, or infection
and can result from diabetes or infection of trauma injuries
[51,52]. As the global burden of diabetes has increased signifi-
cantly in recent decades [53], it indicates that the number of
diabetic patients who develop gangrene may also increase. The
present situation suggests a serious threat to the healthcare
system and calls for governments and other stakeholders to
take immediate action. Although there is a lack of information
on the prevalence of diabetes in Uganda, with a 2016 study
[54] estimating the overall prevalence to be low (1.4%), rapid
changes in lifestyle and economy could increase the risk and
prevalence of diabetes [55].
Key information (such as residential area, indication for ampu-
tation) necessary for patient follow-up, and monitoring was either
partially registered or not registered at all in the patient records.
For example, only rarely was any information registered in the
records for the cause of gangrene. The unsatisfactory quality of
clinical record-keeping uncovered in this study highlights the
need for improved documentation and record-keeping practices
to enhance the provision of comprehensive patient care.
Well-controlled prospective studies are needed to fully under-
stand the major causes of limb loss in Uganda. The study also
indicates considerable scope for improvement in wound man-
agement practices.
The majority (n = 14) of respondents were orthopaedic tech-
nologists. In many LMICs, orthopaedic technologists are at the
centre of P&O service delivery for patients, especially
post-amputation. Integration of comprehensive multidisciplinary
rehabilitation services, including the availability of a sufficient
number of trained rehabilitation physicians or physio/occupational
therapists to facilitate the transition of patients back to their
communities, is lacking in P&O healthcare systems, especially in
LMICs. Consequently, technologists are left responsible for pro-
viding comprehensive services to patients following amputation,
including occupational, physical, and psychological aspects of
rehabilitation [56]. Given the potentially huge patient load and
minimal resources available, this may in turn adversely affect the
quality of care and outcomes of rehabilitation for patients.
All participants in this study were practising P&O personnel in
major rehabilitation workshops in Uganda, and it can be reported
that they have all received some form of training in orthopaedic
technology. Just under half of the participants had been trained
at the School of Orthopaedic Technology, the only specialised
Table 3. Orthopaedic services and resources available for P&O service
provision.
Frequency (%)a
Decentralisation models adopted by
facility
Orthopaedic services and outreaches 13 (68.4)
Tele-rehabilitation 8 (42.1)
Mobile orthopaedic clinics 5 (26.3)
Satellite services 2 (10.5)
None of the above 4 (21.1)
Services oered by individuals
Prosthetic and assistive devices
fabrication and assembly
19 (100)
Bracing, casting and splinting 19 (100)
Maintenance, repair and follow-up 17 (89.5)
Counselling 16 (84.2)
Orthopaedic shoe making 11 (57.9)
Education 10 (52.6)
Reskilling 5 (26.3)
Others 3 (15.8)
Commonly used materials
Plaster of Paris 18 (94.7)
Plastics and other polymers 17 (89.5)
Leathers 17 (89.5)
Metal and metal alloys 15 (79.0)
Wood 9 (47.4)
Fabric 8 (42.1)
Others 7 (36.8)
Access to materials
Mostly imported 16 (84.2)
Locally available 3 (15.8)
Major funders
Government (MoH) 12 (63.2)
NGOs 10 (52.6)
Private sector 4 (21.1)
Donors 5 (26.3)
Clients 5 (26.3)
None of the above 2 (10.5)
Others 4 (21.1)
aAll percentages have been calculated based on 19 responses.
PROSTHETICS SERVICES PROVIDED BY UGANDAN REFERRAL HOSPITALS 7
training centre in Uganda that offers a Diploma in Orthopaedic
Technology. Even though the MoH and the Uganda National
Council for Higher Education recognise the school, it is not an
ISPO-certified training institute. Only eight participants had
received training from the Tanzania Training Centre for Orthopaedic
Technologists (TATCOT), a certified ISPO Category-II training insti-
tute established to provide regional training. However, the diploma
course in orthopaedic technology at TATCOT can admit only 15
students each year, which is insufficient to meet the demands for
skilled personnel in East Africa [57]. Although there is very little
evidence on the direct effect of education of P&O personnel on
their service provision [58], it can be argued that the level of
training and skills imparted during that training may greatly
impact the quality of services personnel can provide. Many of the
participants said they had been working in the field of orthopae-
dic technology for over ten years, with thirteen participants spe-
cialising in the lower limb and only three in upper limb prosthetics.
There is a significant gap in provision of services for upper limb
amputees, even though upper limb amputations are more chal-
lenging to manage.
Decentralisation of P&O services through outreaches, mobile
clinics, and telerehabilitation and integrating them into lower
levels of healthcare systems could be the answer to bringing
these services closer to users. However, these decentralisation
models are not without challenges in scaling, quality control and
cost-effectiveness [4]. From this study, it was clear that
respondents were well conversant with service outreaches, while
the other decentralisation models were less famous. Participants
were confident in providing services aimed at reskilling patients
to return to work or addressing quality of life issues. However,
factors like resource constraints mean these services cannot be
brought closer to patients, and those living in rural areas have
to incur high transport costs to be seen [59]. This situation was
made much worse during the COVID-19 pandemic when patients
could not have face-to-face interactions with the technologists,
and as a result, service provision was constrained [60].
To fabricate high-quality prostheses most efficiently, P&O ser-
vice units require a consistent supply of high-quality components,
materials, and consumables [61]. In Uganda, and many other
LMICs, access to these components is often limited [56], and it
is difficult to manufacture durable, serviceable prostheses due
to the high production costs. One of the respondents noted that
a patient would have to be referred if the materials required
were unavailable at the facility. Numerous studies in South Africa,
Tanzania, Malawi, Sierra Leone, and Ghana have highlighted the
difficulties associated with the provision of amputee rehabilitation
services due to the limited resources available [59,62–64]. This
study showed that international material suppliers outperform
the local capacity, availability, and reliability in supplying quality
P&O supplies. Additionally, as each user is likely to purchase
these materials independently from a supplier outside the coun-
try, excessive costs and lengthy delays hamper service provision.
Figure 3. A graph illustrating participants’ self-rating of their ability to perform tasks required for optimum P&O service provision.
8 B. MULINDWA ETAL.
This suggests great scope for improvements to be made via a
more integrated supply chain system for P&O supplies.
Participants reported that most of the orthopaedic workshop
funding came from the government and non-governmental organ-
isations. However, data on the Uganda National Health Expenditure
[65] showed that rehabilitation care had no budget allocation in
the financial year 2018/2019. This means orthopaedic workshops
depend heavily on NGOs [56] to provide financial support, materials,
and assistance. Even in public sector hospitals, it is common for
patients to be asked to pay for components, which is often a barrier
to accessing services [59,66]. Of equal concern, we found that some
of the essential equipment needed to deliver adequate prosthetic
services were either missing or in a poor state of repair at the
workshops. Based on their self-evaluation, participants were com-
petent in applying many of the skills recommended in the ISPO
training curriculum for Category I and II professionals. However,
because there is a lack of emphasis on research-oriented practice,
orthopaedic personnel are not geared toward research and the
design of fit-for-purpose cutting-edge technologies for patients [67,
68]. Without maintained and serviced equipment and a reliable
supply system of necessary P&O materials, the skillset of orthopaedic
personnel cannot be fully utilised, and patients receive poor service.
Limitations
It was observed that key patient information was missing from
record files. For instance, patient residential villages were missing
for 58.0% of the records reviewed. The problem was particularly
acute at MNRH, where healthcare personnel only recorded obser-
vations or information they regarded as important. Also, data on
whether patients had received prostheses from orthopaedic work-
shops was not correctly registered and could not be included.
Similar poor levels of record-keeping have been reported in stud-
ies of nurses in Ugandan hospitals [69,70]. Reasons for this con-
sistently observed problem may comprise organisational issues,
high patient numbers resulting in fatigue on the job, the high
volume of often difficult issues that need to be solved to deliver
services, and a lack of continuous monitoring and incentive sys-
tems. Omission of patient information could result in communi-
cation pathways breaking down amongst health professionals, a
lack of follow-up mechanisms to track care decisions and goals,
a lack of clear planning and budgeting, and excessive amounts
of time wasted during care provision. Additionally, the subjectivity
of the responses from participants was a limitation, particularly
when it came to reporting their experiences and skillsets.
Conclusion
The Ugandan public healthcare system lacks adequate P&O ser-
vices both in terms of personnel and professional training and
supporting infrastructure and resources, including equipment, and
supplies including materials and components. The provision of
prosthetics and general orthopaedic rehabilitation services is lim-
ited, especially in rural regions, contributing to increased poor
outcomes of amputation. Decentralising orthopaedic workshops
and strengthening supply chains could improve access to these
services and encourage collaboration between healthcare workers
and the community, which is vital to improving the long-term
outcomes following major limb loss. Additionally, providing com-
prehensive multidisciplinary rehabilitation services for both lower
and upper limb amputees can improve patient outcomes and the
chances of achieving acceptable levels of functionality following
amputation. There is an urgent need for clinical personnel to
improve the quality of patient record keeping. This will provide
a solid foundation for adequate research in the future and ensure
that complete and accurate data is available for analysis.
Notes
1. A recognised professional association for orthopaedic tech-
nologists and technicians in Uganda.
2. A regulatory body that was established to regulate, super-
vise, and control the training and practice of Allied Health
Professionals in Uganda.
3. Clinical personnel, whose training involved completion of
an approved 3- or 4-years course of education and who are
authorised by the AHPC to evaluate, design, fabricate and
t orthopaedic appliances to restore the quality of life (QoL)
for clients.
4. Technical personnel that have either completed at least a
4-year apprenticeship or two years of formal training with
a focus on P&O device fabrication.
Disclosure statement
No potential conict of interest was reported by the author(s).
Funding
This work was supported by the UK Government Global Challenges
Research Fund through the Engineering and Physical Sciences
Research Council and the National Institute for Health Research
under Grant (EP/R013985/1).
ORCID
Erisa S. Mwaka http://orcid.org/0000-0003-1672-9608
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