By Caroline Ariba
Betty Nakiboneka had just had her ninth baby at a private clinic in Busunju, in central Uganda when she started bleeding profusely.
The placenta was stuck. The nurse did all she could to remove it, but it was obvious she needed a doctor’s intervention. Fortunately her clinic was near the police station.
She asked a Police officer for a patrol truck and Nakiboneka was rushed to Mulago hospital, an hour’s drive away.
“Because a truck does not have the amenities of an ambulance, and we were driving fast, the patient would be flung up and down every time we hit a pothole. I was also holding the drip line,” the nurse narrated.
They got to Mulago but Nakiboneka could not be taken into theatre immediately. She had bled too much and needed a blood transfusion.
“She was given two pints of blood but she kept bleeding. She died before she could be wheeled into the theatre.”
This incident brings alive the findings of the New Vision poll conducted in June. Some 44% of respondents cited health-related issues as the most pressing needs they want their leaders to address.
According to the poll, the voters’ five top concerns were about shortages of health facilities, drugs and ambulances in health centres, long distance to health centres, few and unfriendly health workers as well as poor maternity services.
In the poll, the voters want their leaders to address the high cost of health services; corruption, malaria, unlicensed health workers, poor pay for medical workers, expired drugs, family planning services and the high rate of abortion.
Health service improvement has been a consistent plea from voters. Health issues have topped all others in a New Vision poll prior to the 2011 election and also in an Afrobarometer poll in 2012.
WHY HEALTH IS KEY
Agatha Talemwa, a health activist and researcher at Makerere University, says the Ugandan voters are right to care about healthcare. “A healthy nation is a prosperous one,” she said.
“But how can you be a healthy population if you do not have a proper or rather a result-oriented healthcare system?”
She says for every time there is a failed healthcare service, there is a less productive population. Dr. Dan Kaye, obstetrician and gynaecologist and also a senior lecturer at the Makerere University College of health sciences, says we must take the views of the people as paramount.
“If the people are saying something is not right with the health services, we must agree that something is not right. The starting point is the patient. Do they know that they are sick?”
“Once this is answered, the next question is whether the hospitals have health workers and the services are being offered. At the very least, qualified health workers, drugs and equipment should be at every health centre,” he says.
Dr. Kaye says beyond patients and health workers, there should be a health system that works. “Is the ministry organised?” He regrets that all these three levels in the health sector are wanting.
In 2011, the Government promised, in its manifesto, to improve staffing of health units, provide ambulances and medical equipment to all hospitals and health centre IVs.
It promised to build more hospitals to decongest referral hospitals. It pledged to tackle preventable diseases through immunisation, hygiene and nutrition and to provide medicine to the sick.
At the April 2015 launch of the report, Fast tracking Progress in addressing gaps in service delivery in the Health sector, the state minister for health in charge of general duties, Dr. Elioda Tumwesigye, gave a breakdown of the government achievements.
Among those listed included the staffi ng level in the public health facilities had reached 70% and that there were 28,874 health workers in service. “General hospitals are 68% staffed, health centre IVs are 79% staffed, health centre IIIs are 75% staffed while Mulago and Butabika stand at 81% and 85% respectively,” he recounted.
He cited vaccination against measles and training of health workers in 37 districts to handle the main killer diseases among the major successes. A total of 8,000 health trainers trained on Integrated Community Case Management.
Severe malaria cases had reduced by 21%,” the minister’s report said. In 2014/15 the health sector budget allocation was sh1,197b almost double the 2010/11 budget allocation to health of sh660b. Despite the increase in funding, the state of the health services remains a major concern for the population.
Shortage of ambulances
Many Ugandans that could have been saved, die due to delays in receiving health care. Though ambulances are important to quick access to emergency medical care and are crucial to saving life, there are few.
Most Ugandans during emergencies will be rushed to a health facility using ordinary transport means. It is pitiful in remote areas. Here all manner of rudimentary methods including carrying patients in slings are used to get them help.
The problem of access to ambulances is so severe that in some rural areas, innovative social workers have improvised and designed bicycle and motorcycle ambulances to transport patients in hospitals .
The bodaboda ambulance, as it is called, is a small cart that can carry a patient and is drawn by a motorcycle or bicycle.
“I cannot vouch for their effectiveness,” says a consultant obstetrician and gynaecologist who preferred anonymity. “I don’t know in what state you will receive a bleeding woman who has ridden on a rough road for several kilometres. But it is still better than nothing,” she says.
Rukia Nakamatte, the spokesperson of the health ministry, says they do not have an inventory with the number of ambulances in the country. She, however, said 19 ambulances were recently procured with funding from a World Bank loan under the Uganda Health Systems Strengthening Project.
They were distributed to the hospitals of Anaka, Moyo, Nebbi, Kiryandongo, Masindi, Apac, Nakasero, Mityana, Itojo, Entebbe, Iganga, Buwenge, Bukwo, Moroto, Kitgum, Mubende, Lyantonde, Bugiri and Pallisa. Dr. Godfrey Mulekwa, the district health offi cer of Pallisa, was indeed glad that the district hospital had been given an ambulance.
However, with a budget of sh32m per quarter for all hospital operations, fuel for the ambulance becomes a concern.
“Sometimes, the patients have to buy the fuel,” he said. Sadly, many rural poor patients can barely raise the money needed,” he says.
Denis Ddamulira, a programme offi cer with St. Johns Ambulances, a charity that has been running ambulance services in Kampala since 1930, said it roughly costs about sh5,000 per kilometre, to hire an ambulance. The fees go toward fuel and maintenance of the ambulance mostly.
Tom Kyobe of City Ambulances, a private service, says it costs about sh120,000 for a 20km distance within Uganda to run the service profi tably, (about sh6,000 per km). He says this is too expensive for an ordinary Ugandan.
SHORTAGE OF DRUGS
Evelyn Cheptoris, a single mother of two and petty trader, on Mutungo hill, a Kampala suburb, rushed her sick daughter to Kiswa Health centre, about 3km from her home but did not stay long. Instead she took a boda boda to Mulago hospital, another 4km away.
“There were too many patients and few health workers. The queue was long yet the baby was getting hotter,” she said. Cheptoris had to wait another two hours before seeing a doctor at Mulago.
“They only gave me malaria medicine and told me to buy the antibiotics but I didn’t have money. I came to Mulago thinking I would get all the medicine free. Now I have to buy a few tablets and buy more when I get money,” she said.
Dr. Tumwesigye would be disappointed to learn that Cheptoris had to buy medicines yet government has increased funding for essential drugs.
Essential Medicines and Health Supplies funding to National Medical Stores increased from sh201.7b in 2010/2011 to sh219.4b in 2013/2014 including antiretrovirals, vaccines and malaria drugs. The 2015-2020 Health Sector Development Plan also reports improvement in pharmaceutical supplies and access to essential medicines from 43% in 2010 to 63.8% in 2015.
But the money does not seem to translate into what people expect — medicine when they need it. In fact, though it is allocated, it does not seem to be released in full.
For example, according to a June 2015 Ministry of Finance Policy Brief, the 2014/15 budgetary allocation for HCIIs basic kit of medicine and health supplies was sh11.16b. However, only sh3.44b (30%) was released and all of it had been spent by December 31, 2014.
The brief states that in 2014, 43% of health facilities reported a stock-out of tracer medicines in the six months ahead of the survey. This though was an improvement from 79% of facilities that had reported stock-outs in 2010.
Mulago Hospital, for example, ordered items worth sh531m on February 26, 2014, but items worth only sh380m were received in March 2014. The brief states: “Phenytoin Sodium (an anticonvulsant) required by the Neuro unit to treat emergency or traffic accidents cases and convulsions among others had not been received since February 2014 yet the unit receives over 47 medical cases daily.”
“Failure to access medical supplies in time translates to loss of life,” the brief’s authors state.
Dr. Patrick Tumusiime, the District Health Offi cer, Kabale district says that the problem is beyond NMS. “The two main factors affecting availability of drugs is that the budget is inadequate,” he said.
He says the drugs are indeed delivered every two months, but sadly by the time the two months elapse, many health centres have no drugs left. “And that is where the problem begins, because then, the health centres have to wait until their stock arrives.”
When asked how much money would be sufficient to ensure effective medical supplies, NMS public relations officer, Dan Kimosho, referred to management challenges instead. “If there were no thefts, wastages, the budget would be sufficient,” he said.
“But because of the shortages people have to dig deep into their pockets to fund their health needs,” said Patrick Ojilong, the programme offi cer of Action Group for Health Rights, an advocacy organisation. Ugandan households’ out-of-pocket spending on health accounted for 33% of healthcare financing in 2013/14.
“This is far above the maximum of 20% out-of-pocket expenditure recommended by WHO if households are not to be pushed into impoverishment,” the Health Sector Development Plan 2015-2020 states.
Robinah Kaitiritimba, the executive director of Uganda National Health Consumers’ Organisation says efficiency in the district systems can lessen the shortage.
“If you have one health centre with no drugs, another that has piles of drugs, with some possibly expiring, why not share?” she asks.
Nakamate, the health ministry’s spokesperson says health centres within the same district can share drugs. “Sharing is only restricted when the health centres are in different districts.”
Kaitiritimba insists that one of the biggest reasons for drug expiry in the hospital is the lack of qualifi ed staff to do proper prescriptions.
“You have maybe two midwives in health centre, they are the nurse, the doctor, the lab technician, but how spot on are they in drug prescription?”
FEW HEALTH WORKERS
Thirty-five-year-old Atim (full name withheld for fear of stigma) is a fistula survivor who underwent repair surgery a year ago. Unlike many women who get the disease due to delay in getting to hospital, Atim had left home the moment her labour pains started.
“But I found the midwife at the maternity ward busy. She was alone and there were four of us in active labour,” she opens up.
“There was nothing the midwife could have done. She had just delivered one mother and another one was pushing. She urged me not to push but keep breathing through my mouth and cross my legs to give her time to deliver the other mother.
“I tried to hold but I could not. The baby tore through me. He was a big boy, almost five kilogrammes. The midwife was angry at my failure to hold on. The following day I noticed that I was leaking.
“Fortunately I was still in hospital. She counselled me and referred me for treatment until I got surgery. I am now fine,” says.
She is relieved that she has her life back after surgery but is worried that she could face another emergency under similar circumstances. Atim is not alone.
Shortage of health workers was the second most important health concern of the voters polled in the Vision poll. Up to 15.3% of the respondents who were concerned about health raised the issue. Despite an increase to 28,900 staff in public health service, the total staffing gap at national level is 30%, which is 12,400 vacant staff positions.
The staffing gaps are bigger at the peoples’ first contact with the healthcare system — at Health Centre II. The Health Sector Development Plan 2015-2020 states that only 45% of positions at health center IIs are filled as compared to the 70% at health center III and 71% at Health center IV.
In the regional referral hospitals 81% of positions are filled.
Dr. Asuman Lukwago, the permanent secretary in the health ministry, says the government recruited more health workers and increased the health budget from sh800b to sh1.2 trillion. He noted, though, that the population has also increased, meaning there are more people in need of health services.
Patrick Ojilong believes the shortage is exacerbated by the health workers’ work schedules. He said that it is a policy that once a health worker works for eight hours a day, six days a week; they must get a day off.
“So on any given day, you will find that a health worker somewhere is off duty,” he said.
Also part of the problem appears to be that even if a facility has staff, those staff members will not necessarily always be there because of normal activities.
“We once visited a health centre in Lira and found that two key health workers of the hospital’s eight health workers; the senior midwife and clinician were on study leave.”
He caught himself in a dilemma as he discussed the scenario. “But then again, this is health,” he said. “It is crucial that health workers get training, refresher courses in order to learn more,” he stated. He then said that it was up to the Government to put all this into consideration when recruiting. But also, Ojilong believes that the health ministry is stuck to an old health worker structure.
“We are still working on the 1990 health workers’ structure, which allowed for a smaller number of health workers per facility,” he said.
“But that worked for a population of 24 million, not today’s 35 million.” He says the leaders, at the local government level, should ensure that the workload is dealt with,” he said.
“But also, the politicians should work towards pushing ministry and government to accord the health sector 100% staffing.”
Salome Karungi, a health rights activist and social worker with Child Health Uganda, is pessimistic about change anytime soon. “Most health workers and young people today do not want to work in rural areas, anything less of that will cause a problem.”
To solve the issue of shortage of health workers, the country needs to equip the healthcare centres, said Dr. Fred Kirya, a senior consultant surgeon and urologist at Soroti Regional Referral Hospital during Fistula surgical camp in Soroti last year.
“In doing this, these different health centers become self-sufficient and minimize the frequent referrals,” he said.
He said that some of these health centres already have space; they just need equipping, so the health workers at the lower units reduce the loads at the referral hospitals.
Isaiah Mbuga, a population health advocate, formerly with the Population Secretariat speaks about what he observed when he worked in public service. “Uganda’s health sector is driven by aid. Government is not free to think on its own, but rather bounces to the donor decision.”
He speculates that the reason this has gone on for long is because donors fund a huge part of the health budget. He, however, points out that the bigger elephant in the room is the medical brain drain.
“It is not even those leaving the country that worry me, we have a bigger disease; health sector NGOs,” he exclaims.
Mbuga argues that instead of being in the hospital treating patients, medical workers are working in programming and advocacy or management. “You go into the Ministry of Health; many doctors are occupying the offices. Then who is in hospital?”
“We need to pass a rule, that every trained medical worker working in public health, should do some work in a hospital, for at least half a day,” he says.
In ministry’s defence though, state minister for health general duties, Dr. Chris Baryomunsi, argues that like all sectors, the health ministry needs managers. “These doctors, on top of their qualifications are specialists that help design many of Government health projects.”
FEW HEALTH CENTRES
Nearly 10 million Ugandans still walk more than 5km to a health centre, and those distances are greater in remote areas. That’s 28% of the population — a figure that has not changed much since 2011.
According to the 2015 District Health Information System2 there are 5,418 health facilities in the country. Two are national referral hospitals (Mulago and Butabika), 14 are regional referral hospitals and 144 general hospitals, 197 health centre IVs, 1,294 health centre IIIs, 2,941 health center IIs and 831 clinics.
The Director General of Health Services, Dr. Jane Ruth Aceng, said the number of health centers around the country has grown.
She noted that each of the 112 districts has a hospital, a health center IV or both. Dr. Lukwago, the permanent secretary in the health ministry, says the Government has done a lot to address the problem although new districts are yet to get health centre IIIs.
“We have not yet implemented the policy because of underfunding,” says Lukwago. In the New Vision poll, 15.8% of the issues raised by respondents was concerning the few health centres and long distance to get to them.
For example, the health ministry reports that in Yumbe district in north western Uganda, there are 0.4 facilities per 10,000 population while in Kampala it is 8.4 facilities per 10,000.
Health researcher Anthony Kwagala, of Uganda Health Initiatives says it begins and ends with distances. “There are more hospitals and health workers, but what is the distance between one health facility and the next? No one will walk many kilometres to a hospital or be happy they did so,” Kwagala says.
There are consequences. Constance Akullo, a midwife at Alebtong district’s Abia Health Centre II, said because of long distances and the long waiting hours, many mothers turn to traditional birth attendants in their communities, many of whom are not registered and who endanger their lives.
Kwagala says Government should go back to the drawing board, ensure that at least every 5 kilometers that one walks; they will find a health center however small.
“You know what, even if it is just a place where they can get pain killers, first aid anything, just ensure that a trained and qualified health worker is found every after 5km.”
Dr. Tumwesigye, the Minister of State for Health General Duties, explained in his speech at the launch of the Fast tracking Progress in addressing gaps in service delivery in the Health sector report that the issues with the health sector can be traced to the recurrent low public health cost allocations.
A lot of the money goes to health workers remuneration and expansion of health facility infrastructure at both local government and referral levels.
Only sh41.2b, for example was allocated as recurrent budget for health service delivery.
The state minister for health general duties, Dr. Chris Baryomunsi says that the health ministry would do with a budget increment. Asked how much would suffice, he said: “That would mean Uganda’s health budget would have to grow to about 2.4 trillion shillings for the health issues to get better.”
However, Dr. Dithan Kiragga, a health expert, and chief of party of the USAID/Uganda Private Health program, said, government needs to overhaul the health ministry, what it did with the Uganda National Roads Authority.
He however, said that in-spite of its many shortfalls, the last five years, have seen some islands of improvement, but these are smothered by the population growth rate. “Take a look at the heart institute, there is an improvement,” he said.
“Our issue is no matter the small improvements, the population numbers will make it hard to notice.”
TO THE CANDIDATES AND POLITICAL PARTIES
We, the voting-age citizens of the Republic of Uganda, have expressed in a Vision Group poll the most pressing issues affecting our country and our communities. We will be evaluating candidates based on these proposals.
1. Dramatically improve our health care system. Health care is one of the most basic needs of our citizens, but many of us do not have access to medications and adequately staffed and health facilities.
2. Upgrade and repair our roads. Despite some improvements, many of our roads, especially in rural areas, are riddled with potholes and floods during the rainy season.
3. Expand access to clean and safe water. Many of us rely on unhealthy water sources, have no regular source of water. This is a public health concern.
4. Poverty remains an overwhelming concern for the majority. We want to hear from the candidates about, contributors to poverty and lack of income-generating opportunities.
5. Personal security. Robbery, theft and overall crime rates are high. The Police are reluctant to act, or corruption interferes with the enforcement of the laws.
6. Education system needs to improve. The teaching staff are inadequate, school fees are very high, the curriculum is often weak, and both teachers’ salaries and school facilities are under-financed.
7. Jobs! Unemployment, corruption in the workplace, bribery and low pay are some of our major challenges in earning the income to support ourselves and our families.
8 There are many barriers to agricultural enterprise. They include high taxes and license fees, fake commodities and price fluctuations.
9. Corruption. It affects many aspects of our lives, from voting, to dealing with the Police to getting the simplest document from government agencies, and it seems to be everywhere.
10. Access to energy. Fuel costs are high, and rising. There is still not enough electricity, and where it does exist, the supply is unstable.
EXPERT AND COMMUNITY VIEW
Dr. Margaret Mungerera, Psychiatrist: What we need in Uganda's health sector is leadership. Good leaderships breeds accountability, and accountability will end wastage of resources. Before we even ask for more money, how are we using what we have. The health sector gets a lot of money, but unless it develops proper leadership, the management will always lack.
Dr. Patrick Kibirango, registrar Allied Health Professionals: Regulation of the services and professionals will make the health sector much better. We need to strengthen the inspectorate to be able to capture issues as they come and not wait for them to become a burden. If there is consistent inspection, in a sector as sensitive as health, all the issues especially regarding human resource will be no more.
John Okabale, a crafts man (weaves ropes): I am a blind old man. I earn between sh250 and sh1,000 a day, yet when I go to the nearest health centre, which is the health centre II at the Kacumbala sub-county, I sometimes find the medicine over and I am told to go to Bukedea, which means taking a taxi. In the end, I spend about sh10,000 to and fro, money that sometimes takes me a month to save. Please stock all of these health centres so that old blind men like us do not have to move long distances for drugs.
Claire Marunga, a social worker: Have you ever gone to government health centres and seen how people scramble for their turn to get treatment or medicine? I have dealt with mothers that have really had it rough when it comes to getting medicines, and many times, just go back home without treatment, yet they can barely afford it. I would want our leaders to improve the issues of shortage of health workers which leads to crowding in hospitals.