Uganda-Trinidad doctors export deal renews debate on broken health system but is gov’t doing?

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.