Uganda-Trinidad doctors export deal
renews debate on broken health system but is gov’t doing?
On
a good day at a rural government health facility when doctors are present and
nurses are not barking, drugs will be out of the stock. On a bad one when drugs have been stocked,
health attendants will be out of sight.
It
was to such undoing that is typical of majority health centers around the
country that Joyce Ategeka, a resident of Nyawaiga village deep down West on
the shores of Lake Albert in Buliisa district was left widowed at 35. Her
husband succumbed to acute malaria and diarrhea about a month leaving behind the
burden of 10 children.
A
nurse at a health center III in the neighboring village, Sebagoro, where the
deceased had been admitted four days before says chances of saving him stood at
70 percent. Problem is-- there were neither drugs nor qualified doctor-so he
could not be helped further. The best the nursing assistant could do was giving
him painkillers-panadol.
The
doctor had been transferred some three months earlier.
“We
don’t have enough staff here; we sometime even take up to 6 months without
getting drugs supply, so there is nothing much we can do for patients. The best
is, we give out panadol most of the time since it is what we get in plenty,”
says the nurse.
Buliisa
is one of the five oil rich districts of the Albertine Graben. Almost a decade
since oil exploration commenced in their backward, locals live in total
disbelief of the status quo—punctuated by the visible chronic poverty and
worsened by lack of meaningful social service infrastructures.
The
health center in Sebagoro is a -20 by 40- feet container that moonlights for
patient examination, emergencies, labour ward, antenatal and clerking, name
it. The unit is shared by seven
villages, with a daily patient influx of between 30 t0 40 and a staff of seven.
Four
hundred kilometers down South West in Nyakashaka, Burere Sub County in Buhweju
district the situation is perhaps slightly but not any better.
Early
last month, residents of Burere village were motivated to break into the
village health center III, and cleaned the unit of drugs and other medical
supplies. For about three days before the unit had been closed, and when they
were told it would reopen, by 11am there was not attendant in sight.
At
the 14 regional referral hospitals, the status quo is only marginally better.
The major problems--limited work force, poor working conditions, excessive
workloads, low salaries and poor remuneration---are the same plaguing health
center IIs, IIIs, IVs across the country.
Add
to the mix—the wrecked state of the health facilities, obsolete diagnostic
equipment,, medical workers stealing drugs, and drug shortages yet stockpiles
are rotting away in stores.
Same
cries--year in/year out
Dr.
Asuman Lukwago, the Permanent Secretary in the Health ministry, says the
challenge plaguing the sector are bigger than the ministry, and a solution, if
any requires multi-pronged approaches.
“There
is a lot progress but the problems keep growing every day,” he said in an
interview last month. “And where we are now, we just need to think through
again some of our policies and approaches. Otherwise that is why sometimes even
when money is allocated challenges remain the same.”
One
policy discord that has led to the near collapse of the health system, Dr
Lukwago, points out decentralization which he said is exceedingly offside for
example when it comes to maintaining health facilities, staffing them,
remunerating these staff, and equipping facilities with drugs.
“Health
centers bring basic serves to the majority of Ugandans but as a ministry we
have little input on how they are run or organised. [The ministry of] Local
government has the bigger say on them but on their inefficiencies it is us that
have to explain.”
Critics
of the government point to the limited budgetary allocation to the sector
coupled with deafening mismanagement and misuse of public resources.
Ingrid
Turinawe, the chairperson of the FDC Women’s league says health is the first
priority of any human being but what government gives is not enough. “Who
doesn’t know that 19 women die every day while giving birth out of negligence
of attendants who are paid poorly?”
The
party recently launched a health campaign dubbed “Shs6200” of taking mama kits
to upcountry health units where mothers die in droves in maternity, but she
says, whilst it is a an ongoing success project it is not the solution to the
problem.
But
budgetary allocation to the health docket has been improving steadily during
the last three financial years. In FY 2013/14, health received a boost of 7.2
percent--sh940b up from sh852b in 2012/13.
In
this FY ending Shs1 trillion was allocated to the sector, notably to address
issues of health workers’ remuneration, capacity building, and renovate health
facility infrastructures at both local government and referral levels—the
latter which is ongoing- from monies allocated in previous budgets--but as the
budgetary cycle winds up health facilities remain understaffed, salaries flat, the usual stories.
Understaffing---the
biggest challenge—poor working environment
According
to the ministry’s Annual Health Sector Performance Report for the FY2013/14
issued in October last year, seven out of the 14 regional referral hospitals
have a staffing level below the average. These include Moroto (41%), Mubende
(55%), Naguru (67%), Kabale (70 %), Soroti (74%) and Hoima (74 %).
At
Moroto regional referral hospital, even with the laughable staff numbers,
getting patients to treat is a miracle. While facilities elsewhere are fatigued
by patient influx, in Moroto patients choose to stay away, except for the maternity
ward where expectant mothers wobble in occasionally.
The
first impression, one might assume it is deliberate, but the reasons are
essentially reasonable—ranging from the bad roads, drought, famine, absence of
specialised facilities and medical attendants, electricity.
The
hospital was constructed in the 1970s with a bed capacity of about 115, and
serves five neighbouring districts of Nakapiripirit, Abim, Kaabong, Moroto and
Kotido. In between the 100 beds
management fitted in another 70 beds. With limited access to clean water, the
hospital is forced to rely on the hard water available which frequently breaks
down the equipment.
The
hospital’s chief medical supretendant, Dr Filbert Nyeko, says they have to
refer patients to as far as Soroti to access specialised services. The famine
has also forced patients start using alcohol to take drugs.
Yet
in the face of all such challenges, government is in plans of sending at least
263 specialised medical personnel to the Caribbean island of Trinidad and Tobago,
a deal which officials from both Health and Foreign Affairs, defend is intended
at “accelerating diplomatic relations” between the two countries.
Uganda
is number 149th in rankings of healthcare around the world. Trinidad on the
other hand is in the 67th position and in third position in the Americas after
United States and Canada. With a population of 1.3 million people, Trinidad has
12 times as many doctors per capita than Uganda.
According
to the shortlist , the personnel set to go include , 15 of 28 orthopedics
Uganda has, 4 of 6 urologists, 15 of 91 Internal medicine specialists, 15 of 92
pediatrics, 4 of 25 ophthalmologists, 4 of 11 registered psychiatrists and 20
of 28 radiologists.
Others
include, 20 Radiologists, 15 of 126 gynecologists in Uganda, 4 of the 15
pathologists, 15 Pediatrics, 4 Ophthalmologists, 15 general surgeons, among
others.
But
Dr Lukwago says the decision to offer Trinidad a helping hand has nothing to do
with Uganda’s health sector being afflicted because when they remain the
challenges will remain hardened.
“The
sector has some human resource challenges but this is not because of
availability on the front line; there are some frontiers where we even have
excess and the question that begs is what should we do for such people without
work?.”
World
Health Organisation (WHO) recommends a ratio of one doctor per 1,000 people.
But the UN body’s recent research findings indicate Uganda’s ratio of doctors
is 1: 24,725 in urban areas and 1:100,000 in rural areas.
Malaria
remains the leading cause of mortality in hospitals with 12.8 percent, followed
by Tuberculosis. The ministry’s report indicate that in the FY 2013/14, Mulago
hospital had 1,999 staff; a number of which 8 were expatriates, 159 are locally
hired private service staff, and a large number medical interns who are not on
payroll .
Mulago’s
approved staff capacity for effective service delivery is 2,426 staff. The
national referral year in-and-out witnesses strikes by medical interns over pay
and cruel working conditions, unpaid utility bills, breakdown in equipment,
list is endless. The hospital’s alternative, relatively high-class private wing
accounted for only 2 percent of the 603, 876 outpatient and 105, 593 in patient
numbers, registered respectively.
“The
hospitals major problems are, overwhelming patient numbers, old
infrastructures, understaffing and low pay for staff,” the report observed.
“42% of all Health Center IIs have a staffing below 40% compared to 9% of all
HC IIIs, 9% of all HC IVs. On the other hand 91% of all HC IVs have at least 50
percent of the established key positions filled by workers. The staffing levels
are closely linked to the observed service gaps at different levels of care.”
So
where are the doctors—about 300 graduate from medical schools every year?
A
2011 research conducted by Canadian scientists led by Dr Edward Mills,
indicated that the cost of educating a doctor in Uganda from primary to
tertiary is about Shs60.9 million ($21,000).
Majority
however end up in private practice or pursue happiness elsewhere beyond
borders. Ministry of Public Service
figures indicate medical officers in Uganda are paid a gross of Shs846,000,
consultants Shs1.3m while senior consultants earn a gross pay of Shs2.3m.
In
neighbouring Rwanda, for instance, the starting salary for a medical officer is
Shs3.8 million. For that matter South Africa, Rwanda, South Sudan, Europe and
Australia are among the top destinations for medical workers from Uganda.
Dr
Mill’s research documented further that medical brain drain costs Africa a
whopping Shs5.8 trillion ($2 billion) and Uganda alone Shs36 billion ($
13million). The most perhaps depressing detail of the research is countries—Zimbabwe,
Ethiopia, Kenya, Malawi, Nigeria, South Africa, Tanzania, Uganda and Zambia
that have the highest HIV/AIDS prevalence in Sub-Saharan African suffer the
worst economic losses due to doctors emigrating.
The
Institute of Public Policy Research Uganda (IPPR), a local think-tank last year
dragged government to court in the landmark medical brain drain case of
exporting medics to Trinidad, calling the decision “ illegal, irrational,
unethical and contrary to government health policy.” Judgment on the case is
pending.
IPPR’s
executive director, Justinian Katera, says the recent Ebola outbreak in West
Africa revealed the vulnerability of African health systems and the risk that
medical brain-drain poses to national and global public health.
“Uganda does not graduate sufficient medical
workers to meet the health needs of 37 million people, with a growth rate of
1.5 million annually,” he argues. “Of a graduating medical class, 70% leave the
country, 20% opt for research and administrative roles and only 10% remain to
perform clinical services. Consequently,
we lose over 100,000 children to malaria and 7,000 women to labour
complications.”
Way
forward?
Mr
Kateera says there is no magical bullet because the challenges existed even
before decentralisation came into force. “But even in the current environment
it is easier for a district Chief Administrative Officer (CAO) supervise a
rural health center than an officer seated at the [health] ministry’s
headquarters.”
“We
would be persuaded if the challenges at Mulago, which is across the road (from
health ministry offices), were resolved before imposing the burden of far-flung
health centres. To me I think what is lacking is coordination; It is not a
binary choice but an integrated approach; I don’t think recentralisation will
resolve the problem.”
Recently
appointed junior minister in charge of general duties, Dr. Chris Baryomunsi,
says whatever the approaches to the problem are, the focus now should be on
creating a condusive environment to retain health workers in the country which
requires more funding to the sector.
Currently
government is a nationwide drive of renovating all the 14 regional hospitals
but who will work in them?
Dr
Lukwago is of the same thought but avers that the solution should start with
fixing gaps in both the old and new policies.
But
as the saying goes that money makes the world go around, any solution would
require government to revise upwards the health budget. Uganda is signatory to
the 2001 Abuja Declaration which requires African countries to contribute about
15 per cent of their annual on health. Unfortunately, according to the next FY
2015/2016 draft budget paper, government is instead proposing budget cut for
health.
