Tiriri Health Centre IV in Katine, Soroti, offers a distressing statement about the state of public healthcare in rural Uganda. With piercing sadness, Anna Grace Itoju sat speechless at the entrance to the outpatient section at Tiriri Health Centre, her red eyes fixed on the still little girl on her lap while her chin slumped in her right palm.
She looked lost in thought and in need of help. The last time I had been here, a woman had lost her baby to malaria, and Itoju’s sadness made me fear the worst.
On talking to her, I discovered that her daughter, Fiona, 5, had severe malaria and she could not eat or drink anything. A clinician had prescribed intravenous quinine but the health centre did not have any, neither did it have coartem, the official frontline drug for malaria.
Itoju was told to buy the medicines from the nearby Atirir trading centre. As she did not have the Shs 8,000 ($4), she returned with the cheaper injectable quinine.
“They sent you for iv quinine, why have you bought this one for injection?” asked a nursing assistant who I requested to assist Itoju. “I don’t have money,” Itoju mumbled, painfully looking up at the younger woman.
“But it is written here clearly, ‘IV quinine’,” the nurse snapped, inviting an uneasy silence.
As a health centre IV, Tiriri is a mini hospital, the major facility serving Katine and neighbouring sub-counties. That the centre often runs out of effective medicines for malaria – a leading killer in the country – is a distressing statement about the state of public health care in rural Uganda.
Yet it could be worse. While medicines for most common ailments can be bought from drug shops at Atirir trading centre, located just outside the health centre, if Itoju needed obstetric or other surgery, she would have to travel 30 kilometres to the referral hospital in Soroti town.
And this is not because Tiriri is a village clinic that can’t offer better services, as I found out from Charles Elepu, the man in charge of theatres.
“What is missing to make this theatre operational is very small compared to what is already in place,” Elepu said, as he guided me around the theatre full of cobwebs and dust and the only functional gadgets – a pair of wind-propelled fans.
Built about seven years ago, the theatre has all the equipment it needs and, in Elepu, someone who knows his stuff: four autoclaves of various sizes – for sterilisation of equipment, an operating table, two delivery suites, oxygen cylinders and concentrators, suction machine, ultrasound scanner…
Elepu says a few modifications are needed. The theatre needs water to be connected and the plumbing system redone. Water from the National Water and Sewerage Corporation was extended to the health centre compound last year but it has now been turned off over a Shs 600,000 ($300) bill.
SHS 11M BUDGET
The new clinical officer in charge of the centre, Samuel Malinga, says water was not budgeted for in the current financial year, but the bill should be paid soon. He is, however, worried about how future bills will be managed.
According to official figures, Tiriri has about Shs 11 million ($5,800) for operations for the whole financial year. This money is inadequate for such a large facility. Back to the theatre, the cemented floor would have to be replaced with tiles or terrazzo, Elepu tells me, and the wind-fans would have to be replaced because they let dust into the theatre.
And it needs power. A generator lies idle, barely 30 metres away but it needs fuel to run. No money for fuel. So, at night, the place is dark, save for a single kerosene lantern in each ward, a candle here, a wick lamp there.
Although Tiriri is fitted with a solar system, the bulbs and tubes have since blown out. Malinga says the men to fix the lights have yet to come from the district headquarters. The African Medical and Research Foundation (AMREF) plans to repair the theatre and blames any delays on lengthy consultations with the Ministry of Health.
Also, for the last two years, AMREF has been planning to install a solar-powered system to pump borehole water to the health centre. That is also still at the planning stage, with work involving AMREF, the Soroti District water office, and the Directorate for Water Development.
Yet, even if all these things were done, the theatre would remain closed. “The biggest challenge we have with the theatre at Tiriri is staffing,” says Dr. Charles Okadhi, the Soroti District Health Officer (DHO).
“Tiriri is supposed to have two doctors: a senior medical officer and a medical officer, and the lab needs anaesthetic staff and some additional nurses.”
Okadhi says last year the district advertised for doctors at Tiriri but did not get any applications. Now they hope to re-advertise the positions in March. But why don’t doctors want to work in Tiriri?
“I am not surprised, because many doctors prefer to work in urban areas and there are many NGO projects that pay much higher salaries than the district can afford,” Okadhi says.
The starting monthly net salary for doctors in government units is $340, while some NGOs can pay three times more. In a bid to attract and retain doctors, the district administration resolved to pay each doctor a top-up allowance of about $100 (Shs 200,000).
But Okadhi says this money is not promptly paid because it comes from locally generated revenue, which is very little compared to the district’s funding needs.
NO POWERFUL LOBBY
Although the government has just laid a power line through Katine to the neighbouring district of Kaberamaido, there is no power going to Tiriri Health Centre, which is barely six kilometres from the line.
The centre actually had power but the lines were vandalised during the LRA rebel insurgency seven years ago. Some of the poles and wires still survive; so, filling in the missing bits would not be overly expensive.
Okadhi is not aware of any plans to extend the power to the health centre. What, I ask, would it take to get the government to extend power to this major health facility? A very powerful lobby is the answer.
Every now and then an MP will tell the national press how he lobbied the authorities to take power to his constituency, so I place a phone call to Peter Omolo, the MP responsible for Katine just in case he is doing something.
He complains about the inadequate staffing at Tiriri and the lack of drugs. These, he says, are problems the central government must address. “It is not only Tiriri that does not have power, but several other health centres,” Omolo says.
“I intend to write to the Rural Electrification Agency to push for these facilities to get power.” Back at Tiriri, as I leave, I check on Anna Grace Itoju. She is seated on the lawn outside the female ward, her head still resting in her right palm.
Her daughter has received two injections of the quinine. The two now have to go back home, which is six kilometres away. “We are going to walk back home, but I am still resting; I am too tired,” she says.
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One story reflects one hundred written by Dev Das , March 10, 2010
Thanks Richard for this fine piece of on-the-ground reportage. As you rightly point out, Tiriri IV is the defining statement for many comparable rural health institutions in Uganda. And powerful lobbies are certainly part of the solution, because, the 'national interest' can no longer be relied on as an automatic reason to act. But what it would take for such lobbies to demand social services for the common good, rather than seek personal enrichment, I don't know.
Tellingly it saddens to the core. written by Russo , March 11, 2010
This is sad, very pathetic and inhuman for a government that claims to have the best GDP average of 6% for the last decade.A government that has collected billions of shillings from taxpayers, a government that is able to call its local political councillors countrywide to state house to dine and wine with the executive, a government that can spend billions of shillings to carryout its party voters' registration exercises(cleaning and re-registration), a government of bonna baggagawale since 90s: what I mean, it's the main political party that runs the programme of the government, yet it fails to address the plight of its voting rural masses.We should stop acting like punishing rural masses in Uganda irrespective of their voting opinions.If you let the 5 year olds die or get complications because of preventable and possibly curable ailments yet NRM plan to rule for the next 40 years, what is the science behind this strategy?Blind we are! Mr. Kavuma the only missing bit would have been atleast photograph-as it speaks volumes. For God And My Country.
Tiriri written by Kakayi , March 11, 2010
The people who embezzeled Global Fund $$ for malaria live in mansions because the rightful recepients suffer. All corrupt officials should be ashamed of themselves! This is terrible news; it should be a campaign issue!
We as Ugandans need to act. written by Bukenya , March 11, 2010
A nation that does not care for its citizens is doomed. Having been to the developed countries, where i currently stay, one common thing i have noticed is that most of these countries care for their people. This they do, because only healthy people can steer the country ahead.
People have to form Civil Organisations that are well organised and dedicated to seeing things being done in the right way. Such organisations would work as watch dogs, and make sure government is responsible and does what it is supposed to do.
With active policing from these organisations, even corruption would be reduced as the corrupt would be put to task to account for every single penny they use. I know of many cases where money is allocated to a district but some district officials chose to first put the money on an interest generating account before it could even be disbursed.
Its easier to target/frustrate one individual fighting corruption but its difficult to fight 1000 district based Civil organisations with hundreds of members per group.
Lets have the each district form numerous Action Groups or Task forces monitoring Public service provision and see if it wont make a slight change in the way our leaders do things.
People have to fight for what they deserve from government, and not just sit there hoping, wishing and praying that someday a miracle will happen.
People have to put in their time and effort with great dedication if anything is to be done, otherwise we will keep talking, and talking forgetting that this government if full or thieves who dont care whether someone in Nakapiripit is dying of Malaria.
We are not solving the root causes written by Sigye , March 11, 2010
I respect every ones opinion, but i i think its time for some of us who have had a chance to study and understand the countrys' health problems to advise aggressively on what needs to be done than talking politics like how many years a party wants to stay in power.
Before i left the country for further studies last year, i was part of team that carried out a health worker and health facility assessment in Eastern Uganda on behalf of IDI-Mulango.
I was there in Soroti and visited several health centers also in Mbale, Sironko, Iganga, Jinja... the situation is even worse in some rural areas. Tiriri is lucky that they have the structures and some facilities but the problem in man power and ofcourse stock outs which is a common phenomenon across the country.
But the other thing in Uganda, is the lack of monitoring and accountability, some of these doctors and lab technicians that are on the so called small government pay rolls do not report to work, the incharge of tiriri is rarely at the centre, you have to make an appointment for an interview, and we met him in the town.
ofcourse you will say they are looking for more money cos they are not paid enough. For me i beleive the doctors and health worker that decide to go on govt pay rolls should do there work, or go off to the private pracitise.
nursing assistants are doing everything, why not be paid this money than to a so qualified doctor who comes for duty at midday and leaves at 2pm, and thats like twice a month.
ofcourse the govt has to invest alot in training and retaining the health workers by paying them what they deserve and make sure they do their work, the govt has money, e.g the defence ministry is taking a big part of the budget yet this money can be allocated to health.
I have visited nearly 70% of health centres in the country,health is security, and i have to say, the govt has really tried to set up structures for HC IVs, but we need to tackle the issue inadequate health worker, remuneration, community senstization, drug stock outs and monitoring.
What you have done is really good, and needed, the media is very much needed in this struggle to pressure the govt to commit its self to invest and monitor the health services. We reserchers are contracted, we do studies and our reports with recommendations are shelved.
Its time that people who know and understand the nations problems like Russo, begin talking substance (what needs to be done)and not politics. The media, has a big role to play in pressuring the govt, by exposing such cases, continuously and aggressively with purpose.
Uganda has the resources, but the govt is not committed enough, Cuba has improved its health status yet its not among the most developed country. But cos the govt invested alot in the health sector by training health work especially doctors, funding scientific research and setting up facilities, and services are free and accessible.
Its not the president to study health issues, but experts, and i do not think there is anything to study, everything is there to be seen. We need to act now, or we shall continue blaming 'God for calling us' at 50 years or less, dying of preventable diseases, mothers and infants dying every day.
If we really believe in our motto, then our leaders, experts, public servants and every citzen, need to stop behaving like their generation is the last, eating and stealing everything that comes across their mouth, but think about a better nation tomorrow, where there is good health care for every one affordable and accessible
Good Job Sigye written by Bukenya , March 12, 2010
I do agree with Sigye, and i wish to give a highlight from a health practitioners point of view. I happen to be in the same field and have had chance to work both in Kampala (Mulago hospital) and Kabale, Kyenjojo and Hoima.
I dont think ALL doctors dont want to work in rural areas, i believe we have so many doctors with Uganda deeply engraved on their hearts. Problem is that in as much as they want to work in the rural areas, they do not get the resources they need to do their work.
Imagine you were a doctor, a surgeon, you wakeup early in the morning go to work 7:00am, start attending to patients, then you realise there are no equipments to do some of the basic surgery you need, so you say to your self i will send them to another Health centres where they can get the surgery done, but in the meantime you think they would benefit from an antibiotic to prevent or treat any opportunistic infections, and an anti inflammatory (NSAID) to help reduce the pain and any signs of inflammation so you check the dispensary to see what they have in stock, and the dispenser tells you they dont have any antibiotics or NSAIDS, all they have is Panadol. Well, you say to yourself, its better than nothing. So you write them a prescription to go and buy the antibiotic and NSAID and send them to the dispensary to get the available panadol.
This becomes you usual routine, monday to sunday, for months. As time goes on, you realise you are losing practice, you no longer do any operations, infact you turned into a referring surgeon, and the only medication you prescribe best is panadol.
As time goes on, you start losing motivation, and you get depressed sometimes, your salary doesn't come on time for reasons you don't know or comprehend, you have a family that you need to support and yet you often meet with your colleagues in Kampala who are enjoying their work place and have not much financial worries at the same time. After sometime you say enough is enough, and packup and go back to Kampala.
Now, how long one can stay in such conditions varies from person to person and a number of other reasons.
Government needs to make conditions favourable for health care worker to stay, work and feel proud of the work they are doing.
There is a lot of money being wasted by government, yet such money can be put to good use. Government doesnt have its priorities put straight, so Ugandans have to act.
Media can do a good job, but there is no greater power than the power of an apolitical Civil Society organisation teaming up with a vibrant media. Remember media can only do much, as they are a business and are always at a risk of being suffocated by government. I mean let one media group run back-to-back articles about the state of affair of health care in Uganda and see how fast its Branded an "Opposition Paper" and thereafter chocked.
The media can do more written by Mutebi John , March 13, 2010
The diversionary actions of the president from the core issues affecting the health sector needs to be urgently countered by the media and all ugandans of good will. The president needs to read daily about the Tirirs just like he has opted to talk about the non existing stolen drugs. You need to have visited another HC IV, Apapai still in soroti, its much worse. I do not condone theft of drugs in health centres but the president needs to be told enough is enough of his lies to the common man. We are the victims of a neglected health sector since we can not fly to get treatment abroad. Ugandans lets stand up and demand for what is rightly ours!
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