How to revive the health care system in Uganda? My 10 cents

By Dr Richard Idro 

In August 2016, Uganda Medical Association will hold a major conference for all doctors in the country focusing on the sustainable development goals and health system in the country.

This conference will make proposals on what as doctors we think should be done to improve healthcare in the country. But even before this comes, here I share some of my own thoughts. 

A lot is actually being done especially with the health infrastructure. Mulago hospital is being refurbished, new hospitals have been built in Kawempe, Kiruddu, and Naguru and several hospitals along the highways are being rehabilitated.

However, a major overhaul of the system is needed for these investments to bear the expected fruits. I suggest 10 areas for the Ministries of Health and Finance to invest the tax revenue in. 

1. Preventive healthcare

The major determinants of health includes the environment in which we are born, grow, work and age and the level of poverty. Many diseases we suffer in Uganda are preventable.Evidence for this is clear from the effects of the vaccination programs.

Since the introduction of the pentavalent vaccine for infants in 2002 and more recently, the Pneumococcal vaccine, the burden of pneumonia and meningitis in children has fallen dramatically.

Similar reduction should be expected with diarrhoeal diseases when we introduce the Rota virus vaccine. Let us continue to invest in preventive services including vaccines, hygiene and environmental sanitation and safer roads but also bring back the health inspectorate.

The health inspectorate system which used to work so well in the past ensuring community hygiene and sanitation has been relegated. 

 2. Primary Health Care

Many Health Centre II in the country are not staffed and non-functional and so, the higher health units are unnecessarily overloaded. Although those who can afford private care go to the private clinics, these too are poorly supervised and operated by almost any cadre.

The quality of care is therefore often times questionable. We should make primary healthcare services work. If not already available, standards including for health workers in this service are urgently needed and these should be implemented.   

3. Referral system

Many deaths in Uganda occur after patients have had contact with the health service either before referral, on the way, or after reaching the referral unit. The country's referral system is so weak; there are so many delays in making the decision to refer, patients taking up the referral, arranging and sourcing the transport (e.g. no fuel in the hospital ambulance) and on arrival, initiating emergency treatments to preserve life.

The severe lack of resources to support emergency services mean that many patients receive below optimal services resulting in preventable deaths: e.g. many of the deaths following road traffic crash injuries should really not occur.  

 4. Medicines supply and management

A few years ago, the Ministry of Health took a policy decision to have the National Medical Stores manage all the sourcing, procurement, ware housing, supply, transportation and delivery of medicines, sundries, equipment and stationery for all public health units in the country.

Although the decision had good intentions, it has had some disastrous consequences. On many occasions and in too many health units, life-saving medicines often run out.

Either health unit managers delayed to place orders for the medicines, made the orders but NMS delayed delivery, no delivery was made, incorrect specifications were delivered or the health unit was told they had exhausted their funding for the year and so their orders could not be honored.

Between April and August 2015, we hardly had any medicines to control convulsions, treat acute asthma, or severe malaria in the Acute Care Unit of Mulago because we understand the hospital had exhausted its allocated funds. We continue to limp to date.

Something has to change in this system: a proper logistics management system and human resources is urgently needed together with significantly increased funding for medicines and supplies.

5. Health financing

This is the elephant in the room. The current financing mechanism is not only inadequate but also untenable. A complete rethink is urgently needed including sourcing from universal health insurance, re-introduction of the user fees, and a special fund such as the road fund. 

6. Quality standards and guidelines.

There are some guidelines for the management of basic health problems but these are inadequate and many times, not adhered to. Most disorders of increasing complexity do not have nationally agreed management guidelines and standards.

Moreover, in many cases, therapies listed in the available guidelines are often those that have been relegated in other countries but are used in Uganda because they cost less.

Clear and updated guidelines and standards are needed and the costs for implementing this provided for. In addition, a mechanism should be put in place to ensure the practice of medicine according to the agreed guidelines.

7. Human resources for health; attitudes of personnel, supervision, and quality training

Healthcare is a labour intensive industry. Current staffing levels are grossly inadequate and this is made worse by chronic absenteeism.

For example, in an intensive care unit, each bed requires four nurses for a 24 hour period; three to work 8 hour shifts and the fourth resting. So, a hospital that has a six intensive care beds will require 24 nurses employed in this unit alone. Secondly, the current public service structure is obsolete.

We now have nurses with Bachelor's degrees and although this is the trend around the world, there are no positions and tracks for promotion for these nurses. We have several other healthcare specialists with unique skills and trainings such as speech and language therapists for who there are no positions.

An urgent review of the human resources is needed. 

As health workers, many of us also have a problem. Whether because of poor pay, inadequate supervision, and bad examples by seniors or a decadence of morals and values overtime, the attitudes to work and provision of care to patients is often poor.

In recent years, there has been a proliferation of training institutions. The quality and skills of the products of some of these institutions is questionable. A review of competences, staffing levels, continuing education and professional standards is urgently required.

This should be supported by meaningful remuneration of this skilled personnel.     

8. E-health, records and IT

Today, the majority of patients attending outpatients' services in public health units leave no records behind. Most buy exercise books and their clinical notes are written in this books which they travel with because the health units have nothing to write on.

The health system therefore has no records of these activities and other than the registers; there is no systematic collection of data to document trends.

Both the General and Referral hospitals however have the basic infrastructure to host an electronic e-health system and it is time this resource is utilized and the system implemented. 

9. Emergency preparedness

The ministry of health has distinguished itself in responding to epidemics. We have heroes here who went to West Africa and ensured the Ebola catastrophe that was visiting the world was brought to an end.

Our responses to emergencies and disasters is however still poor. There are rudimentary signs of a developing ambulance system but even when these reach the health units, the receiving centres have very poor preparedness.

Many health workers are neither well trained nor prepared to manage the severely injured when these are brought to their units or have the sense of urgency required. The current rehabilitation program for hospitals along the highways should be comprehensive enough to cater for these deficiencies. 

10. Specialist high quality care, high tech medicine and research

Non communicable diseases will be the main health problem tomorrow. Many of these require a system for specialized and high tech medicine which we have not invested in enough.

This is the time to do it - infrastructure, human resources and equipment. As for human resources, we have the basics and Ugandans in the diaspora can be called to join us but they will need equipment and of course a good pay. We need to sit down and determine what we need to achieve and then train to have these established.

It is possible and if we start today, in the next five years, we will be somewhere. Just as we have started with the Cancer Institute and the Heart Institute, let's identify the next and do it - buying one piece of equipment at a time. Let us invest in health research too. Research is critical as it informs tomorrow. 

The writer is a senior lecturer of Makerere University and consultant Paediatrician, Mulago Hospital