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Who will heal Uganda’s ailing health system?

Building hospitals without ensuring that they are staffed by qualified, well-paid staff and stocked with essential drugs, will be futile, writes Edward Ssekika.

After three days of illness at home, Evelyn Adyero decided to go to Kaladima health centre III, Lamogi sub-county, Amuru district, walking three kilometres to the facility. After waiting for more than six hours, Adyero was diagnosed with typhoid – caused by drinking dirty and contaminated water – but there was no medicine.

“A nurse gave me two options: either to pick drugs after two days  because typhoid drugs were out of stock, or buy them from private clinics,” says Adyero, 27, a mother of five.

The drugs, she was told, would cost her at least Shs 20,000, money that sounded so much she took the first option. Two days later, Adyero skipped her breakfast of sugarless black tea and some of the previous night’s leftover food - just to be among the first patients at the health centre’s drug dispensary.

But after queuing for four hours, she was told there were no drugs.

I found Adyero, hungry and tired, slumped at the verandah and lost in deep thought.

“I am gathering same energy to take me home,” she said, carrying a tattered Picfare exercise book — her medical prescription form.

Adyero says she will try some local herbal medicine. If that fails, she will sell two of her three cocks to raise money for drugs. The drug stock-outs aside, Kaladima health centre is enveloped by a knee-high bush and a sickening odour from the latrines.

Patients complain that some health workers here first ‘tend their gardens’ before reporting for work. Like many other health centres in the district and across the country, Kaladima offers less hope than despair to her patients. Health workers here referred us to the ministry of Health, saying they were not ‘authorised to speak to the media’.

The unit has neither electricity nor a generator. At night health workers use phone torches or a paraffin lamp that often runs out of paraffin, a nurse said. The in-charge, a nursing officer, was out of office though according to ministry of health policy, such a health unit is supposed to be headed by a clinical officer.

Amuru has no district hospital. Atiak health centre IV, the biggest Health facility in the district, is in an equally in a sorry state.

Dr Odongo Olwedo, the Amuru district health officer, was hesitant to discuss the health challenges in the district arguing that they are simply beyond him.  Last year, 11 health units in the district were temporarily closed for some weeks, due to drug stock-outs.

‘Sick sector’

Dr Michael Lulume Bayiga, the shadow Health minister, one of the MPs who recently toured public health units across the country, describes the healthcare situation in the country as “pathetic and says the facilities are “sick and also need help”.

He cites the example of Moroto regional referral hospital, which has only two doctors who alternate duties (when one is on duty, there other is off) and tired-looking nurses and midwives.’

“We [MPs] found the hospital has no running water, the theatre is dysfunctional while electricity only visits,” Bayiga told The Observer recently.

Despite being a regional referral, the hospital refers its patients to a privately-run facility, St Kizito hospital Matany, run by Moroto Catholic diocese. Dr Bayiga further reveals when MPs on the Health Services committee visited south-western Uganda, they found Kabale regional referral hospital with only one doctor, a gynaecologist. This means the entire referral hospital cannot conduct other, general surgeries.

Bayiga, himself a physician, explains that once a doctor specialises, he or she can’t conduct a surgery outside his or her area of specialty. One of the biggest challenges the country faces is an acute shortage of health workers, to match with the increasing number of patients. As a result, the work that would be done by a doctor is often done by either a clinical officer or even a nursing assistant, Bayiga says.

The Uganda Medical and Dental Practitioners’ council, (UMDPC), puts the number of doctors in the country at 3,894 as of June 2012. With a population of about 34 million people, this means that there is only one doctor for every 10,000 Ugandans.

Even then, eight out of 10 doctors are located in urban areas, leaving only two doctors to rural areas where more than 80 per cent of Ugandans live.

“When we went to Kitagata hospital, we almost closed it. The hospital was very congested with no running water for the last two years, no electricity, few health nurses; the medical superintendent was contemplating resigning. The functionality of the hospital is up to now in trouble,” Dr Bayiga says.

Daunting task

Studies on the sector in Uganda, point to one thing – that offering public health services remains a daunting task. Dr Sandra Kiapi, the executive director Action Group for Health, Human Right and HIV/Aids (AGHA), in a paper titled, Health Worker Shortfall: Impact in Uganda, notes that due to critical shortage of health workers in the country, night watchmen sometimes come in to prescribe drugs for needy patients.

Another, 2011 report by the Voluntary Service Overseas and HEPS-Uganda, lists, gross under-staffing, inadequate pay, crumbling infrastructure, limited and poor-quality staff accommodation and shortages of medical supplies and equipment, as Uganda’s major healthcare challenges.

This report quotes health workers speaking heatedly about their struggles to survive on low pay – support their dependants, educate their children, pay rent and other bills, and afford transport to work, among others. If paid better, the report notes, a nurse would work on patients with love, care and happiness.

The health workers wondered how a doctor could afford university fees, which can go up to 2.5 million a semester, while taking home Shs 700,000 a month.

No health kits

In the report, rural midwives in the government sector also spoke of how they struggle to provide a service with no delivery kit; cord clamp, sucker, gauze or cotton wool and just one pair of scissors.

“Working without protective wear – gloves, aprons, gumboots, shoes, masks – is a huge risk, especially for midwives working in the dark: sometimes you find yourself bathed in blood,” one midwife is quoted as saying.

Glass half-full

However, Dr Ruhakana Rugunda, the minister of Health, downplays these challenges. He says the country has registered tremendous success in the sector. For instance, he cites the construction of many health units in rural areas, meaning that patients no longer walk long distance to access services.

“We are aware of the challenges, and there are already plans to address those challenges,” Dr Rugunda said.

For Dr Bayiga, the issue is not putting up infrastructure, but being able to offer a service.

What next

Dr Sam Okuonzi Agatre, Vurra MP and a health planning specialist, believes the sector needs reorganisation. The starting point, he stresses, should be increasing on the funding to the health sector, recruitment of more health workers and increasing their pay – so as to keep them from running abroad and to rich NGOs.

“Doctors can’t settle here for Shs 700,000 monthly salary, when our neighbours are paying them more than Shs 2m,” he notes.

He explains that government left the health sector to donors. Though it is good for donors to fund the health sector, he says, they often implement what they want and not what is supposed to be done. Dr Bayiga says government views health as a consumptive sector that doesn’t produce profits that is why its budgetary allocation remains meagre.

“We need to invest more in the health budget. Government needs to increase the budget to at least 15 per cent of the national budget in line with Abuja declaration,” he notes.

Currently, the health centres account for only eight per cent of the national budget. Bayiga says the government also needs to put more emphasis on preventive, as opposed to curative, approach to healthcare. This means putting more money into preventing diseases like malaria through provision of mosquito nets and indoor residual spraying.

Until now, most attention has gone to curing common diseases. But as Evelyn Adyero’s plight shows, health centres often have no drugs.


This Observer feature is published in partnership with Panos Eastern Africa, with funding from the European Union’s Media for Democratic Governance and Accountability Project.

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