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Saturday, September 29, 2012

The health budget is passed but women and children will carry on dying

If one didn’t know better, one would have called it a ‘presidential tantrum’. Except, of course, we know that the father of the nation would only have the best interests of its people at heart.

And it was a difficult decision. In a country where 45,000 newborn babies die annually (76 out of every 1,000 born), 137 out of 1,000 die before their fifth birthday, 16 women die in childbirth every day, and 6,000 die of childbirth-related conditions every year, the Health Minister’s request for Shs260 billion to ‘recruit and motivate health workers’ in this vastly under-resourced and demoralised sector was - apparently - incendiary stuff. The health sector receives only 8% of the national budget, far less than the 15% agreed under the 2001 Abuja Declaration. The President was not impressed by being informed that staffing in the health service stood at 58%. He was unmoved when told that 320 Ugandans die of malaria every day. Indeed, all attempts at appeal fell on stony ground.
  • The MP for the Bukooli Islands pointed out that in his constituency, health facilities were manned by secondary school students and midwives.
  • The MP for Abim stated that in his area there is only one doctor for 98,000 patients.
  • The MP for Moroto noted that his patch only had two doctors in total.
The Health Ministry wasn’t even trying to recruit up to 100% capacity: a modest 66% would do. However, raising a sum like that would have required cuts elsewhere. Where specifically? In the defence budget. Shs15 billion had been suggested.

The President's own NRM supporters argued vociferously against him, not for the first time. They had even agreed on Shs5 billion to recruit two midwives for each health centre III. They threatened to block the budget.

The Prime Minister (NRM) made a statement, brave man: ‘This government is very conscious of the plight of the health of Ugandans and the health workers and the need for additional funding’.

The Speaker of Parliament (ex-NRM) wondered out loud why all ministries were cut by 23% to finance the war in northern Uganda but something similar wasn’t possible to fix Uganda’s abysmal healthcare system. (The military has retained the higher budget allocation assigned at that time, despite the fact that the insurgency has been over for six years.)

The MPs heckled the President.

What was the ambushed President to do? Answer: storm out of the NRM caucus meeting having (allegedly) sworn ‘never to sacrifice the defence budget for anything’. It is rumoured that he added that if the defence budget was cut, the soldiers would go out on the streets to rape and loot. Ugandans have some experience of such murderous mayhem by the UPDF, particularly up in the north. The Chief Whip explained his sudden departure by saying the president had only gone to ‘ease himself’ (a Ugandan euphemism for taking a crap). Well, there was certainly a lot of crap around.

However, don’t get too worried. It has now all been resolved in the way that everything is resolved here in Uganda. A couple of days ago, 40 recalcitrant MPs were summoned to a meeting with the President and, so it is said, offered ‘incentives’ to rethink their position on the issue. Magic! They all switched sides and this time heckled the defenders of the health budget. Defence was protected and Health was to receive a more modest allocation of Shs 39.2 billion, not the dizzy extravagance of Shs260 billion. Word was that there might be Shs49 billion of additional funding, but it was all very vague. Fortunately the defence budget escaped any cuts, so we can all sleep well in our beds tonight.

And let us make it absolutely clear, we are certain that the President had the best of reasons for his desire to protect defence. Who knows, at any moment Uganda might be attacked by DR Congo, once the various groups have lifted their heads from fighting each other. Uganda might want to declare war against Sudan. What about war against Kenya, against Tanzania? Perhaps not just now. Replacements for the four helicopters which flew into Mount Kenya one after another a couple of months ago? (You know the story, the rumour that communications were carried out by means of a personal mobile phone in the second plane.) The war against Kony is being funded generously by the USA and the Somali engagement by the African Union, so that can't be the reason. However, an unofficial Russian fairy has just whispered to The Daily Monitor that Uganda is planning to buy six more fighter jets, nine months after it bought its original six. 

Well, who knows? We don't anyway. Thank goodness the President is there to make sense of it all for us.

But if we don't know anything about defence, what do we know about health?

A new report has just been published, Maternal mortality reviews in three referral hospitals in Uganda 2009-2011, by the Association of Gynaecologists and Obstetrics in Uganda. The report reviewed 300 deaths in Fort Portal, Masaka and Mulago National Referral Hospital (Kampala). Apparently only 57% of Ugandan women give birth in hospital. Many claim they don't go to hospital because they have no transport and there are no qualified staff and certainly no doctors. Most of the complications women died of were treatable but many of them came to hospital too late. Health centres did not have facilities to deal with emergencies. A number of deaths were caused by illegal abortions: 300,000 of them every year in Uganda, evidence of lack of access to family planning. Evidence also of the male obsession with fertility and the lack of a woman's right to choose whether or not to conceive. Only one woman in four has access to contraceptives and 50% of all pregnancies are unintended.

Another report, this time by the Medicines and Health Service Delivery Monitoring Unit [hereafter Monitoring Unit], states that medical workers spend most of their time in their private clinics, leaving unqualified support staff like porters and askaris (security guards) to treat patients. The examples given included Burere Health Centre III where the askari did the clinical work and Nankandulo Health Centre IV in Kamuli District and Bagezza Health Centre III in Mubende District where porters and askaris were found dispensing drugs.

The absence rate among staff is 52% across the country: that is, 52% of the 57% who are in post. The more highly skilled you are, the more likely you are to be absent. However, the Ministry of Health Permanent Secretary said the situation wasn't that serious as the doctors would 'still be treating Ugandans' in their private clinics.

The Unit found 900 illegal clinics and drug shops across the country, with Kamuli District alone accounting for over 412. The clinics are said to have been in operation for eight years.

Many nursing schools, it reported, are illegal and run by directors with forged certificates. They simply paid bribes to district official to stay open. In one case, an ex-porter at St. Francis Buluba Hospital forged a certificate as a nursing assistant and set up a cancer clinic and nurses' training school in Mayuge. He was fined Shs500,000 (£125), not a particularly prohibitive fine given the enormous profits already made.
  • The Executive Director at Mulago National Referral Hospital (Kampala) says that his institution is in 'dire need' of 4,000 health workers. 
  • Pallisa local council (east) has stated that it has 17 nurses instead of the required 47, nine midwives out of the required 25 and two doctors out of the required seven. It is trying to find money to fund more doctors. 
  • The Ssese Islands has only two doctors, one of whom is the district health officer who does not do clinical work. The health service offers ante-natal care but does not do deliveries. The islands have an HIV prevalence rate of about 30%, compared with the country-wide rate of 7.3%. Maternal transmission of the virus during childbirth is a major risk.
  • The White Ribbon Alliance for Safe Motherhood has conducted a survey in six districts of Uganda. Among their findings is the fact that health facilities in Kabale have only 2% of required midwives and only one doctor. None of the health centre IVs could provide blood transfusions for caesarians. They lacked transport for obstetric emergencies.
The National Drugs Authority (NDA) has withdrawn some drugs which are substandard and have proved ineffective. Although the NDA has the expertise, it has no machines to test the quality of drugs when they enter the country.

And, of course, there are the stories which appear in the papers every week. The Monitor is currently running a series in which people are encouraged to send in photos of derelict ambulances. There are so many of these, I am not going to bore you with them. Let us just say that most hospitals have no functional ambulances at all, and that those districts which do have them had one for their whole area at most. I have given you just one taste of the situation below.

Transport to hospital
  • The whole of Nebbi, which also takes patients from DR Congo, only has one ambulance. Women have to pay Shs40,000 (£10) for fuel. Some women sell property to raise the money. However, most travel by bicycle or wheelbarrow. The trouble with using motorcycle taxis, apparently, apart from the cost is that they are often impounded by the Uganda Revenue Authority, leaving women stranded by the side of the road and in pain.
Bribery and corruption
  • A doctor at Jinja Referral Hospital was accused of asking an expectant mother for a Shs1 million bribe before he would carry out surgery. The family could only find Shs 500,000. They negotiated the bribe down to Shs 700,000 (£175, about three times a primary teacher's monthly salary) which they eventually found. It was too late. Both mother and baby died. Hospital staff went on strike in support of the doctor. The chairperson of the National Medical Workers Union said 'medical workers lacked basic equipment such as syringes and gloves', adding that workers were viewed as corrupt when they demand equipment from patients.
  • Five officials from Nakaseke District Health Authority, including the District Health Officer, have been interdicted on charges of mismanagement of health service delivery, failure to provide accountability, drug theft, absenteeism and forgeries. The report by the Monitoring Unit said the result of this mismanagement was a proliferation of illegal drug shops and clinics in the local area, some of which sell pilfered government drugs, while many operate without qualified staff or licences. The Monitoring Unit recovered medical equipment and drugs at the homes of the accused, while a scanning machine had managed to transport itself all the way to South Sudan. Funds provided to buy an air-conditioner for the non-functional CD4 count machine at Nakaseke District Hospital (CD4 tests for HIV/AIDs) had not been used for that purpose.
  • According to a report produced by the Apac Anti-Corruption Coalition, in Aduku Health Centre IV, a woman was asked to pay Shs5,000 (£1.25, about three days' wages for the majority of Ugandans) for delivery of her baby. The husband of another woman said, 'I had to run around and borrow Shs7,000 to pay for the midwife's allowance.' The report said the demand for bribes cut right across all levels of health units and district referral hospitals where maternity services should be free. At Aduku there was drug theft, with inadequate recording of medicines and medical supplies. At Apac Main Hospital, gloves were being sold for Shs4,500 and expectant mothers had to pay Shs5,000 for maternity services. The authorities are not aware of any complaints about bribery and refute the report that anti-malarial drugs are being stolen.
Poor and inadequate facilities in hospitals and health centres
  • Itojo Hospital at Ntungamo has no incinerator. Waste such as gloves, syringes, bloody clothes, theatre waste, bandages are left in a heap in the grounds and periodically burnt on a bonfire.

  • Kirema Health Centre III in Nakaseke, built by the Church Missionary Society in 1947, serves 20,000 people. It has dilapidated buildings, no electricity, a shortage of drugs and too few health workers. It has had no malaria drugs since January, a situation unknown apparently to the Luweero Diocese Health Coordinator, yet malaria is the most common disease it deals with. The hospital has absolutely no access to water as the borehole hasn't worked for three years and the water tanks no longer work. The government part funds the centre, providing some drugs and funds one member of staff. The other six are paid from patients' fees.
  • At Kiyunga Health Centre IV in Luuka, premature babies are kept warm with charcoal stoves as there is no electricity. Male and female, child and adult patients all share the one general ward. The hospital has no mortuary (or rather  the mortuary has no roof or windows) so corpses are kept in situ in the wards until collected by relatives. There are no post-mortems.
  • On their tour of health facilities in Luweero, the Uganda Women Parliamentary Association found totally inadequate resources in all the health centres they visited. The maternity wing at Kasana Health Centre IV had only 15 beds while 180 women gave birth each month there, and 5,000 attended outpatient clinics. The women slept on the ground. Unsurprisingly the parliamentarians found that large numbers of women use traditional birth attendants (TBAs) instead of attending hospital. The number of child mothers (at particularly high risk during childbirth) is growing.
  • In a separate report, the Acting Assistant District Health Officer, said only 46% of women in Luweero give birth at health centres. The authorities have no way of tracking the women who do not attend ante-natal clinics. Maternal mortality is difficult to assess for the same reason: people just don't register deaths. Many deaths are among young girls who have no money and no information about the experience they will be going through. Transport is difficult because there are no ambulances and poor roads.
  • Abim Hospital has as good as no beds. The whole hospital only has 20, with worn out mattresses bought in 1998. The maternity ward has two beds - one for delivery, one for examination. Patients sleep on the floor, are examined on the floor and undergo some surgical procedures on the floor. A doctor is quoted as saying, 'This situation has forced the majority of mother to go back to the old system of delivering under the care of traditional birth attendants.'
  • Today's Monitor reports that two babies have died because Gulu Regional Referral Hospital (north) ran out of blood five days ago. It had no testing kits for screening new sources of blood. The problem was compounded by Umeme (the national electricity company) causing the failure of the hospital's power inverter through load-shedding. Recently a mother and her newborn baby died after the oxygen machine to which the former was connected during delivery was removed to save another patient. The hospital has four doctors instead of 40, and they each treat 100 patients per day.
  • Moroto Regional Referral Hospital (Karamoja) also ran out of blood last week. Patients could not be transferred to other hospitals as it had also run out of fuel. Doctors are 'unavailable' and the hospital is being run by clinical officers (between a nurse and a doctor).
  • At least 85 patients in Adjumani Hospital are unable to receive the full course of treatment for Hepatitis B as the hospital has run out of drugs.
  • After a terrible traffic accident a couple of weeks ago, the victims being treated in Lyantonde Hospital were forced to share beds. Some had multiple burns and open flesh wounds. The mattresses were torn and there was danger of infections such as HIV being transmitted between patients. Some patients chose to sleep on mats on the floor without any blankets.
  • A ward in Kinuuka Health Cetnre III in Lyantonde has only three beds but is crowded with men, women and children. There is no incinerator and placentas are buried in a shallow hole frequented by dogs. It has four health workers instead of 18.
Unprofessional staff
  • A 20-year old woman in labour was taken to Lodonga Health Centre in Yumbe District (West Nile) and was examined by the nurse, who took no action. The woman's condition deteriorated so the family took her to Yumbe Hospital where the corpse of the baby had to be removed. The woman had a ruptured uterus and is now unable to have children.  The sister-in-charge at Lodonga said, 'By the time the woman was brought in, I was also busy attending to another woman delivering. The following morning, I left for Karuma. I had left notice to the next nurse to work on her. It is unfortunate that nothing was done.' The family have complained to the Uganda Human Rights Commission.
  • Gulu District leaders are concerned by the rising rates of maternal mortality at Gulu Regional Referral Hospital: they claim 18 deaths between January and August. Last year 400 patients died, in total, a quarter from the maternity ward. After the recent death of Sunday Achiro, an eyewitness said, 'All the nurses were not around when she died while struggling on her own after complaining against the midwives'continuous absence for hours.' The district vice-chairman said, 'We found her body uncovered for many hours.There have been recorded cases of harassment and absenteeism from duty of some health staff.' A member of the district executive health committee said, 'They report for a few hours and disappear.' He added that 'some even ask for money in order to render services'. The hospital has denied these allegations.
  • Kabale District is working on a by-law to force women to give birth at health facilities and penalise those who deliver by TBAs. However, one woman said that they prefer TBAs because they give them 'motherly care unlike in the health centre where we are attended to by young and abusive nurses.' They also extort money.
What are the implications of all these issues?
  • Civil society activists under the Uganda Health Consumers Organisation (UNHCO) have expressed their disappointment at the low level of budget eventually agreed for health. They say that 80% of posts in health centre IIIs are vacant and more qualified staff are needed to deliver babies. 'This means that mothers will continue dying in labour and children will continue being born with AIDS as a result of lack of a comprehensive package for mothers'. 2,000 midwives are needed for 2,500 government health centres across the country.
  • Lack of health staff results in poor education in healthy practices. Currently annually in Uganda, malaria kills between 70,000 and 150,000, 5,000 die of TB, 600 die of cholera and dysentery and typhoid kill 500 children and adults.  Only 40% of the population have access to latrines.
  • However, the most serous implication of the lack of sufficient government funding is the fact that Uganda may fail to meet the Millennium Development Goal (MDG) on maternal health in 2015. Instead of ante-natal visits going up to 60% by 2010 and 75% by 2015, such visits are in fact declining from 38.9% in 2008/09 to 34.1% in 2010/11. TBAs deliver 60% of babies largely because of the vacancy rate in districts of 44%, coupled by an absence rate of 35% for all health workers. The MDG is for 75% deliveries under skilled care attendance. The target for maternal deaths is a reduction to 131 per 1000 live births. Although there has been a reduction from 435, per 1,000, to 310, this is nowhere near the target. Maternal health conditions constitute the highest total disease burden in Uganda - 20.4%.
  • Uganda ranks 141 out of 172 countries in maternal deaths. 
Any good news at all?
  • The day after the health budget was finally agreed, the government announced it is to double the salary of doctors working in health centres IV, from Shs1.2 million to Shs2.5 million per month. Nurses and midwives, however, are aggrieved. Nurses currently receive Shs300,000 per month (£75). There is not enough money to increase their pay.
  • The World Bank is providing $130 million to boost safe motherhood. Mothers delivering in government hospitals will receive a free 'mama' kit - the essentials used in delivery (like a razor blade). Well, about half of them will (700,000). 1.5 million babies are born each year. Oh, and the government has decided to tax mama kits, contraceptives and condoms, just to make the fight against maternal death and AIDs even more difficult.
  • The USA as provided $400 million to improve health services across the country and specifically, with the largest share of the money, to target MDG 5, reducing maternal and neonatal deaths. The money will be used to reduce maternal mortality, build blood banks in five regional hospitals and set up a data based on health services across the country. The USA aims to halve maternal mortality in four areas of western Uganda under the project Saving Mothers, Giving Life. The US Global Health Director says the project will begin in Kyenjojo and Kabarole which accounts for 31% of maternal deaths in Uganda. She said, 'Some mothers do not get to the hospital due to poor transport coupled with long distances. Others who manage to get there have no one to attend to them.' Complications in pregnancy may result from malaria, anaemia and sexually transmitted diseases. As well, of course, complications from the huge number of raped children giving birth when barely into their teens and  with immature skeletal frames, resulting in fistulas (2,000 per year), mental and physical trauma,  and, often, death for either mother or baby or - most commonly - both.
  • Since 2009, Strides for Family Health, a USAID-funded project has been providing Mpigi district health department with ultrasound machines.  As a result, ante-natal visits have gone up from 10 per month to 58. The project has also trained midwives. The number of deaths has gone down.
  • Mildmay Uganda (a faith-based NGO) has demonstrated that mentoring of less skilled service providers is very successful. The number of clients enrolled in HIV care has increased from 13,000 to 21,00 in six months.
  • The Epilepsy Support Association of Uganda, an NGO, has launched a campaign to register all expectant mothers to reduce reliance on TBAs and, hence, maternal deaths. They have trained 60 support workers.
  • Senior members of the armed forces, members of the President's family and politicians within his close circle are sent abroad for medical treatment at public expense. For example, the President's two daughters gave birth in German hospitals. The lives of many important people have been saved in this way.
Conclusion?

Three cheers for donor organisations and NGOs across the world who are working hard to save the lives of Ugandan women and children. One cheer for the government whose responsibility it is to do this.


All information in this post was previously published in The Daily Monitor.


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Caring for the sick in Uganda
What price compassion in Uganda?
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