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Sunday, May 8, 2011

Caring for the sick in Uganda

One of the most insulting protests you can make in Uganda is to strip naked in public.  This is what happened the other day when a ‘Good Samaritan’, as he was called by the media, arrived at a health centre in Buyendo with an injured three year old boy with septic wounds and a ripe boil.  Medical staff refused to treat the child until the man provided them with surgical gloves.  The man proceeded to walk down the street to the police post stark naked, surrounded by a growing crowd and supported by the Local Council (LC3) chairman.  The child remained untreated until local people ‘mobilised’ 10 pairs of gloves, at which point the man put his clothes back on.  The doctor in charge said that they had not received any supplies for over eight months.

Public health care in Uganda is generally perceived to be a disgrace.   The well-off middle classes have medical insurance and pay their way through the hospital and dental systems.  We ourselves are provided for by a private general practice and know that if we have serious ailments or injuries we will be attended to in a private hospital or transported home.  Ordinary Ugandan people, however, die from common and entirely treatable conditions.

The maternal death rate is particularly shocking.  For example, 6000 mothers die in childbirth or from pregnancy-related causes each year, that is 435 per 100,000 compared to seven in the UK (data from WHO, UNICEF, UNFPA and the World Bank).  Every day, 16 Ugandan women die this way.  A Ugandan woman’s lifetime risk of dying in childbirth is one in 35, whereas the risk for her British counterpart is one in 4,700.  This is 3-4 times higher than the Millennium Development Goal (MDG) target.  Most deaths are from severe bleeding, infections and obstructed labour.  Thousands of women also suffer permanent damage, such as ruptured uterus or bladder.
  • Only 42% Ugandan expectant mothers receive skilled medical help in childbirth.
  • Only 30% deliver in a health facility overseen by a midwife.
  • Only 24% have access to emergency obstetric care.   
  •  67% turn to traditional birth attendants or deliver alone. 
  • 75 infants die for every 1,000 births. 
  • 137 children out of every 1000 die before they reach the age of five. 
Uganda needs at least another 2,000 midwives.  Lack of skilled birth attendants mean that many children are born with HIV through mother-child transmission.  About 27% of births to HIV positive mothers result in babies being born with HIV.  In Lira (north) 60% of HIV positive women deliver at home without the oversight of trained medical workers.

A reduction in unwanted births, often to young teenagers or exhausted older mothers would dramatically reduce maternal deaths.
  • 56% of pregnancies are unintended
  • The unmet need for family planning services is 41%.
  • Only 24% of women use contraception. 

However, the crisis in healthcare is general and affects all services.  Why this crisis?  One reason is that there are too few healthcare facilities and those that exist are too far from people’s homes.  The Ugandan National Household Survey 2010 survey found that 75% of the sick had to walk to get treatment, 14% went by bicycle and 7% by boda boda (motorbike “taxi”).   

Another reason is that the health centres are often described as filthy, un- or under-staffed and empty of drugs.  Staff receive inadequate pay, buildings are crumbling, medical supplies and equipment are in short supply and staff are poorly supervised.  It is difficult for us in the west to imagine hospitals without piped water supplies, latrines or proper facilities for washing contaminated bedding (or people).  Health services are said to be characterised by lack of commitment and low morale among health care staff, endemic corruption, high absenteeism, and, sometimes, a lack of care and compassion which borders on callousness. 

Here are a few recent stories from the newspapers.  We cannot verify these accounts directly and our own experience of private healthcare has been fine; however, this is a selection of the stories which we read every day in the Ugandan press.
  • ‘There are no gloves or even forceps to use during delivering.  Gloves have been out of stock for a month and expectant mothers have to buy their own.  Even sterilisation of equipment is not possible because my charcoal stove that I usually use is worn out.’ (midwife from Pingere Health Centre in northern Uganda, quoted by Isis-Women’s International Cross-Cultural Exchange August 2010).
  • A woman in Mubende died as she could not afford Shs2,000 (60p) for surgical gloves and the nurses refused to attend to her.
  • A patient in Kagadi Hospital died because he was unable to afford Shs150,000 (£40) for a hernia operation.
  • Nakaseke hospital has no ambulance and patients – including expectant mothers and the critically ill - are stretchered in on bicycles.
  • The children’s ward at Kiryandongo Hospital stinks.  The adult toilets are shared by men and women, are not cleaned and are located outside the hospital fence.  Last year it operated with only one toilet for three months.  The National Medical Stores have failed to deliver drugs and patients have to pay at least Shs5,000 (£1.50) daily for medicine.  The hospital hasn’t been renovated since 1970.  Child Fund International provided Shs100 million in January but, for some reason, it has not yet been put to use.
  • Former Internally Displaced Persons (IDPs) in Nwoya District, northern Uganda, trek more than three hours to reach their nearest health centre.
  • The nurse in charge of Kyeibare Health Centre in Mitooma District allegedly stole government drugs from the centre and sold them at his private clinic.  He paid someone else to do his work so that he could concentrate on his private practice.  A nursing officer in Kyabasengya has also been arrested for similar offences.
  • A doctor at Masindi Hospital refused to attend to an expectant mother claiming he was off duty.  She died on arrival at Hoima Hospital, 56 km away along a rough murram road. This doctor also owned a private clinic.
  • When accident victims were recently brought to Fort Portal Referral Hospital, no nurses were on duty as they don’t work at the weekend.  It is also not uncommon for the money and possessions of accident victims to be stolen from them at the scene of an accident, leaving victims with nothing with which to pay for an ambulance or treatment.
  • Nine expectant mothers died in Bundibugyo (west) last year because they couldn’t get to health facilities.  There is one doctor for more than 300,000 people in the area.  When he is away, patients cannot afford to travel to Fort Portal and die without medical attention.  The area does not know how many children under five have died as it doesn’t keep records.  The Rwenzori Anti-Corruption Coalition said that ‘some health workers steal drugs and sell them or put them in their clinics.’  They also allege ‘late reporting of health workers to work, congestion, lack of hospital equipment and lack of hospital latrines and kitchen.’
  • Some IDPs in northern Uganda, where HIV prevalence is 8.2%, higher than the rest of Uganda, are choosing to stay in camps as village health centres do not have Anti-Retroviral drugs (ARVs) and even the camps run out of drugs.
  • In Serere Health Centre (east), a fully equipped theatre has not been in operation for a year because the hospital has no surgeon.  There is one Theatre Assistant who earns Shs200,000 per month (£50).
  • Less than a quarter of children with cancer complete their treatment at the Uganda Cancer Institute (300 out of 1,200) because their parents cannot afford the cost of treatment.
  • Kyatiri Health Centre has no drugs, not even anti-malarials or mild pain killers.
  • The toilets at Itojo Hospital are covered in faeces.  Women lie on the floor in the labour ward.  It has no surgeon, paediatrician or gynaecologist and, it is claimed, the few other doctors spend most of their time running their private health clinics (International HIV/AIDS Alliance in Uganda).
  •  Kilyandongo Hospital has no latrine at all as all the pit latrines are full up and covered in maggots.
  • At Kiyunga Health Centre, toilets and showers at the theatre have been destroyed by termites and the autoclave for sterilisation no longer works.  The maternity wing cannot carry out emergency operations as there is no doctor.  The entire area, classified as hard-to reach, has a population of 200,000 but no doctor.  
  • In Moyo, there are three doctors for 360,000 weekly patients attending the main hospital, not including referrals from Southern Sudan.  
  • In Kamion (Karamoja), one trained nursing assistant handles 400 patients daily, referring serious cases to Kaabong Hospital 34 kms away.When he has other commitments, the health centre is locked.  The district health officer said that there was no money to recruit more staff.

One of the main problems across the country is reported to be that National Medical Stores which are responsible for providing drugs do so irregularly and in too small quantities.  Last month babies in several parts of the country remained unvaccinated due to problems with distribution.  Quite apart from this issue, 64% of infants do not receive the full course of three injections, only 59% receive immunisation against polio and 68% against measles.

According to a recent article, the principal government hospital in Uganda, Mulago National Referral Hospital in Kampala, is ‘plagued by…corruption, lack of drugs, mismanagement, patient demonstrations, congestion, fraud, power failure and faulty equipment.’  Again, we have no direct knowledge of this situation, but the poor reputation of even national facilities has a very negative effect on the perceptions of the general population.  Recent newspaper reports have included the following.
  • Last month 15 patients are alleged to have died because of a power cut. 
  • The hospital has run out of drugs for inducing birth.
  • A mother gave birth to her stillborn baby on her own, the nurse just arriving to clean up.
  • In February, patients in the Spinal Unit and their attendants (in Uganda a member of your family goes to hospital with you to provide nursing care, change bed clothes and buy and cook food.) paraded outside with their bedding demanding to be discharged as they had each paid at least Shs500,000 for a doctor to attend them but had received no care.  (This is unofficial personal payment over and above doctors’ salaries.)  The doctors had refused to share their takings with the nurses who in turn also refused to care for the patients.
  • A one-year old CT scanner purchased at hundreds of thousands more than its worth (providing a nice windfall for someone) is now dysfunctional. 
  • The hospital receives less than half of the budget it requires for drugs and other materials.
  • Many women being treated for cervical cancer lie on mats in the hallways due to a lack of beds.
  • It is said that patients pay for their own bandages.
  • In August, 300 ghost workers were found on the pay roll.
  • Pipes from oxygen equipment for heart operations have been stolen from the Intensive Care Unit and theatre at the Uganda Heart Institute, allegedly with inside help, and operations have been discontinued.  Some people are alleged to have died as a result.

However, the problems with healthcare in Uganda do not just reside within individual healthcare units.  Newspapers claim that the issues go right to the top.  In March this year, the health ministry returned Shs350 million to the Treasury unspent because of ‘management problems’.  This month the Ministry of Health cut its budget by Shs2 billion to refund the Global Alliance for Vaccine and Immunisation (GAVI) money  allegedly stolen by three former ministers.   The money was for use in combating HIV/AIDS, TB and malaria, major killers in Uganda.  Ordinary Ugandan taxpayers are being expected to contribute their hard-earned money to cover up corruption.  It also means that the same thing is likely to happen again because people know the government will always cover up.  The loss of health service funding from the rest of the budget will affect the treatment of thousands of patients.  The Action Group for Health, Human Rights and HIV/AIDS (AGHA) and other civil society activists yesterday called on donors to halt funding to the government until the State gives accountability for grant money already spent.  The Acting Permanent Secretary, Mr Asuman Lukwago, told the Daily Monitor yesterday that’ the move may cause a little crisis at the ministry but it could be dealt with’.

What can be done to sort out the mess?  One approach is to sue.  The Centre for Health Human Rights and Development and some individuals have sued the government for not providing ‘basic indispensable maternal commodities’ in government health services on behalf of the public.

Before the election, donors including the World Health Organisation, the German Foundation for World Population, Marie Stopes Uganda and Communication for Development Foundation Uganda said that politicians should sign a Memorandum of Understanding with the electorate to improve funding in the health sector, particularly reproductive health.

The UK’s Department for International Development, the Mellinda Gates Foundation and John Hopkins University are funding a project in rural Busoga which provides transport to health facilities for ante-natal and post-natal services, saving the lives of mothers and newborn children many of whom risked dying in banana plantations or at the roadside on the way to distant health centres.

In Kaabong (Karamoja), expectant mothers who used to have to walk for 40 kms or more, are now brought to a maternity facility three weeks before their due dates through an initiative started by a local organisation, Action for Women and Awakening in Rural Environment (AWARE).  Also in Karamoja, one of the worst-served regions, Medecins sans Frontieres (MSF) have set up a mobile clinic to treat a range of conditions.  MSF's Head of Mission in Uganda said 'Our aim is to strengthen government services but it is hard if there is no greater investment in the services.'  The main issue is a huge human resource gap.

Life is cheap in Uganda.  The gap between the rich and the poor is enormous.  You can see it in the weekend supplements which describe a complacent middle-class world which bears no relation to the world described in the rest of the newspaper or the one out on the streets.  A key priority lies within education.   The young, educated and privileged, the people to change things in the future, need to learn more about their own country.  They appear to whiz past in their parents' four-by-fours oblivious to what is around them.  The youth pages in newspapers shock us with their depiction of a spoilt and privileged elite.  These young people are the medical staff and politicians of the future.  They should be encouraged to recognise motivations beyond those of money and material goods.  They also need to learn about the responsibilities of government in providing resources for services, and monitoring their use and impact.  Schools need to put much more effort into developing a shared sense of social responsibility and directly tackling issues like corruption.

Uganda appears to be the sort of country which Mrs Thatcher was applauding when she said ‘there is no such thing as society’.  It seems to us that people care for their own family and within their own village, but few appear to care for the poor, or indeed the general population, hence the proliferation of NGOs, many of which do the government's work for them.   Churchgoers pray for personal salvation but barely mention the poor, the weak and the sick.  The rottenness in the healthcare system reported in the press is symptomatic of an ethical issue which runs right through the entire social and political structure.

Postscript 9 May 2011, from today's Daily Monitor. In Kabale Regional Referral Hospital (south-west) only 200 out of 325 posts have been filled. It serves the areas of Kabale, Kisoro, Kanungu, Ntungamo, Rukungiri and parts of Rwanda and DR Congo, from which it receives 500 out-patients every day.  There is currently just one doctor instead of the 37 required.  The majority of patients and their attendants at the maternity, paediatric and other wards sleep on the floor.  The maternity ward has a 30-bed capacity but each month accommodates about 300 patients.  The hospitals' budget for electricity only covers a third of the electricity costs.  One patient said that he had spent 4 days at the hospital without being attended to by a doctor.


If you found this post interesting, you may also like to read What do we mean by 'motivation'?.

1 comment:

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