With a population of about seven million people around independence (1962), Uganda had one of the best health service systems on the entire continent
By Chris Kiwawulo
With a population of about seven million people around independence (1962), Uganda had one of the best health service systems not only in Sub-Saharan Africa, but on the entire continent.
Health indicators were favourable, despite the few health facilities then. Ten years after independence, however, the political turmoil that hit the country through the early to late 1970s (ousting of President Milton Obote and President Idi Amin respectively), and the early 1980s (the NRA guerilla war) greatly affected the health sector.
But as peace started returning after 1986, the population also started growing, subsequently over-stretching the existing health facilities. This necessitated putting in place new facilities and improving the existing ones.
In the late 1980s, the NRM government pledged to improve the health sector in a number of areas. Construction of health centres in every part of the country to allow people access health services in a distance of 5km was one of the pledges, although it is yet to be achieved in some areas.
Founded in 1913, the first and biggest national referral hospital, Mulago, for instance, was constructed with a bed capacity of 1,500. But the political upheavals of the 1970s and 1980s affected its growth. But since NRM took over in 1986, Mulago, among other government hospitals, has undergone a series of rehabilitation works, developed human resource and procured equipment.
With the country’s population at 34 million today, Mulago has an annual in-patient turnover in excess of 140,000 and attends to over 600,000 out-patients — the existence of several health facilities (private and public) countrywide notwithstanding. The overflow is similarly experienced at most other public health centres countrywide.
Besides Mulago, Mbarara and Butabika (mental) hospitals have since been upgraded to national referral status. There are 12 regional referrals and at least 40 government hospitals.
In Kampala, plans to construct general hospitals in each of the five divisions are under way. Construction of the general hospital in Nakawa Division has been completed at Naguru, although the facility is not yet fully in use.
Other general hospitals are due in Kampala Central, Kawempe, Rubaga and Makindye divisions, although issues of land are yet to be finalised.
Besides, there are over 70 private hospitals countrywide. The military has Mbuya and Bombo hospitals, while the prisons service has Murchison Bay in Luzira.
According to Dr. Ian Clarke, one of the few people who have nurtured Uganda’s health sector from the time he started Kiwoko Hospital in Luweero in 1986, there is hope that with combined effort, Uganda’s health facilities can handle the growing population.
Clarke, the director of International Medical Group, is among the private investors who, over the last seven years, have put in place health facilities that have greatly complemented the existing ones.
His International Hospital Kampala (IHK) has a capacity of over 200 beds. Other private facilities include, Kampala Hospital, Nakasero Hospital, AAR, The Surgery, Case Clinic and Paragon, among others.
Clarke says the existing facilities are not enough for the growing population. “We don’t have enough facilities and sadly, many of the structures, which we have are only partially functional.”
Clarke is of the view that hospital development needs to progress from secondary care to tertiary care, which is what IHK is pursuing through a partnership with Fortis Hospitals, one of the Indian groups of private hospitals.
Drugs and supplies
Whereas the Government has laboured to procure drugs, a significant percentage of public drugs end up being swindled by health workers and sold to private clinics/drug shops, while some expire at the National Medical Stores without health centres collecting them.
Health advocates have time and again called for improved systems to handle drug supplies, and impromptu inspection to ensure that the drugs reach the intended beneficiaries.
To counter drug thefts, the Government decided to brand all medicines supplied to its facilities “NOT FOR SALE”. President Museveni also introduced the drug monitoring unit headed by Dr. Diana Atwine, to check the theft of drugs and equipment.
But these cannot solely eliminate the vice without community participation. It is in public interest that whenever drugs are released from the National Medical Stores, the public is informed by displaying the information in public places for easy accessibility, the Anti Corruption Coalition Uganda (ACCU) suggested in its annual report of 2007.
ACCU also called for the restriction of operations of private drug dealers at the pharmacies/drug shops and enforcement of policies to manage over-the-counter purchase of drugs.
Sunday Vision recently published a story in which investigations found that restricted drugs were being sold over the counter without prescriptions as required.
In the developed countries, it is not easy to buy certain types of drugs without prescription. But in Uganda, self-diagnosis has become a big problem leading to drug resistance. This, for instance, explains why several Ugandans have become resistant to malaria drugs.
With 9.8% of the budget allocation last year (2011/2012) going to health, the funding is still far below the 2001 Abuja Declaration and the 2003 Maputo Declaration, both of which recommended funding to the health sector by African countries of up to 15% of their respective national budgets.
Uganda needs $244,476,913 (over sh606b) to ensure that the country has all the reproductive health supplies it needs over the next five years, according to Reproductive Health Uganda.
Whereas the Government tries to allocate funds towards the health sector, challenges like absenteeism of medics and drug thefts continue to bog down the sector.
According to a 2009 World Bank study titled Fiscal Space for Health in Uganda: Contribution to the 2008 Uganda Public Expenditure Review, 37% of health workers skip work, costing the Government an equivalent of sh26b.
To improve health infrastructure, Clarke suggest that more money should be injected into the sector and more public-private partnerships and methods of payment sought for those who cannot afford high cost services.
Number of medical workers
Uganda has about 2,000 doctors, according to data from the health ministry. The doctor to patient ratio stands at 1:15,000, way below the recommended World Health Organisation ratio of 1:10,000 for Africa. According to the Government policy framework, the target is to have the ratio drop to 1:12,000 by 2015.
Brain drain impacting the sector
Although doctors are one of the most highly sought after professionals, there is a lot of brain drain due to poor pay. Medics argue that they prefer to work in foreign countries because of better pay. The same story is true with nurses and midwives.
Most of Ugandan doctors go to Rwanda and other southern African countries like Lesotho, Zimbabwe, Zambia and Botswana for better pay. Some also go to America and Western Europe.
In 2010, the health minister revealed that 13 senior surgeons left Uganda for Rwanda due to poor pay. South Africa employs 250 Ugandan doctors, Swaziland 10 and an unknown number was reportedly scattered in other southern African countries.
In Uganda, a doctor starting out earns about sh700,000 after taxes. A consultant surgeon in Rwanda is paid between sh5m and sh9m while in Uganda such a consultant is paid a paltry sh1.5m.
A medic who was offered a job in Botswana recently revealed that he was offered $2,800 (about sh7m) after taxes with a house and other benefits but he declined to take it because of family obligations. South Africa also pays in the same range.
According to findings by the Global Health at the University of Ottawa, Uganda spends $21,000 (sh52m) to train one doctor. The findings were published in the British Medical Journal last November.
To tackle this challenges, Dr. Clarke says there is need to develop appropriate facilities and put in place a firm policy to remunerate and motivate health workers. There is also a need to develop appropriate facilities as well as work closely with the private health sector if the country is to reduce brain drain.
High population, brain drain weigh down health sector