This financial year, the Government has allocated an additional sh49.5b to the health ministry. Of this, sh6.5b has been availed immediately to kick-start the recruitment of over 6,000 health workers in health centres III, IV and V
This financial year, the Government has allocated an additional sh49.5b to the health ministry. Of this, sh6.5b has been availed immediately to kick-start the recruitment of over 6,000 health workers in health centres III, IV and V. Vicky Wandawa explores the likely impact of this
The health ministry has been given an additional sh49.5b, bringing an end to a week-long debate on the issue regarding the health budget. Out of the sh49.5b, sh6.5b will cater for recruitment of 6,172 health workers.
These include senior medical officers, medical officers, senior clinical officers, enrolled nurses and midwives, anaesthetic assistants, laboratory technicians, nursing officers and midwives.
In the last financial year, the Government allocated sh799b to the health ministry, reducing its expenditure on health from 8.9% in 2010/2011, to 8.3% in 2011/2012. This year, the Government instituted a ban on recruitment in all government ministries, agencies and departments, due to lack of funds.
Poor staffing levels
Judging by the statistics, additional health workers are not being recruited at the rate at which they are needed. In the 2011/2012 annual sector performance review report, the health ministry said it filled only 58% (31,951) of the available vacancies.
Currently, the staffing levels are as low as 19% in some areas like Namayingo district. About 37.7% of the districts have staffing levels of between 40% and 50%.
According to statistics from the Coalition for Health Promotion and Social Development (HEPS-Uganda), a health rights organisation, in Pallisa Hospital, the number of medical officers should be 11, but only five vacancies were filled.
The gap grows even wider when it comes to the number of enrolled nurses, who should be 46, but only 26 were recruited, leaving 20 vacancies.
A health centre III in Pallisa district should have 24 clinical officers, but only 14 vacancies were filled, leaving a gap of 10.
The statistics also show that only 36% of the vacancies were filled in Mbarara health centres, leaving a 64% gap.
A 2009 World Bank study, Fiscal Space for Health in Uganda: Contribution to the 2008 Uganda Public Expenditure Review noted that on any given day, 37% of health workers skip work, costing the Government the equivalent of sh26b.
Medical personnel speak out
Dr. Anthony Konde, the Mukono Municipality health officer, says: “The Government should recruit more health workers to fill the gaps and also improve their working conditions.”
Every month, a total of 400 mothers give birth at Kawolo Hospital, while at Mukono health centre IV, the number is 320 per month.
“There is no moment when we have an empty bed in the ward. Sometimes we are forced to call upon volunteers to help,” Konde said.
Dr. Betty Nalumansi, a nursing officer in charge of the maternity ward at Kawolo Hospital, said they were overwhelmed by emergency cases, which usually occur at night, yet they are a small number of staff. Unfortunately, neither Kawolo Hospital, nor Mukono health centre, have a standby ambulance to rush patients to better-equipped hospitals.
Civil society explains
Dorcas Amoding, the advocacy and communications manager of Community Health and Information Network, says Maluku health centre III in Mbale has an enormous gap in human resources.
“When I visited the health centre, only three medical staff were on duty, one of whom was an intern. Life in this area is hard because beyond 5:00pm, residents cannot access medical care. Medics stay away from the facility, yet the huge number of patients at the regional referral hospital delays access to a doctor,” Amoding says.
She adds that health workers are critical to saving lives. “Without them, no vaccine can be administered, no life-saving drugs prescribed, no family planning advice provided and no woman can be given expert care during childbirth.
Without skilled health workers, preventable diseases can easily become deadly,” says Amoding.
High mortality rate
Maternal mortality has remained high since 2006. According to the 2011 Uganda Demographic Health Survey Report, about 438 mothers, out of 100,000 live births, die from pregnancy-related complications or during labour.
Amoding adds that health workers are vital to the improvement of maternal and child survival. Ensuring that a health worker is within reach and is trained, equipped, motivated and supported, is crucial to the achievement of Millennium Development Goals 4, 5 and 6.
“Uganda will not achieve zero transmission of HIV from mother-to-child, if there are no health workers to provide the necessary care needed by HIV-positive mothers,” says Amoding.
Similarly, Lillian Mworeko, the regional coordinator of the International Community of Women Living with HIV and AIDS, Eastern Africa, says the shortage of health workers is one of the biggest drivers of mother-to-child transmission of HIV.
She explains that due to the insufficient number of health workers, priority is given to emergency cases. A woman with HIV will end up with an unplanned pregnancy because the midwife has no time to advise her on the right measures because she is overwhelmed by patients.
“When an HIV-positive woman gets pregnant, she will end up giving birth at home or at a traditional attendant’s place, where her baby will not be given neverapim, yet prevention of mother-to-child transmission requires that a woman gives birth from a health centre,” says Mworeko.
She adds that women who seek family planning services are not attended to because they are not emergency cases. “The workload is excessive. This does not give health workers enough time to make full diagnosis of conditions.
For example, if one is suffering from malaria, one’s immunity should be checked, but health workers do not have that time,”she says.
According to Mworeko, midwives see more patients a day than they are supposed to. They should also work in shifts and not deliver more than two women a day.
Similarly, Rosette Mutambi, the executive director of HEPS-Uganda, says it is inexcusable to expect one or two health workers to work day and night in order to offer services to a whole parish. “Some health centres are being manned by nursing aides, while in others, patients can even be attended to by security guards,” Mutambi says.
Mworeko says besides working long hours, the poor remuneration of health workers worsens the situation. “There is no way they will be committed. They do not even know where their next meal will come from or whether they will get back home and find their property outside due to non-payment of rent,” Mworeko adds.
Janet Obuni, the president of the Uganda Nurses and Midwives Union, acknowledged that the overload due to the limited number of health workers has led to burnout among medical staff.
According to the Ministry of Health Strategic Plan II 2011, only 32% out of the targeted 50% women, were giving birth in government hospitals, with only 26% accessing emergency obstetric care (EmOC), yet 15% of pregnancies need EmOC services.
“Every day, Uganda loses over 16 women in child birth. This, too, has promoted the use of traditional birth attendants to handle deliveries, causing more harm than good,” says Obuni.
She notes that the stress and burnout is the reason patients complain that nurses and midwives are rude to them.
Dr. Margaret Mungherera, the president of the Uganda Medical Association, says health workers have continued to shun employment in regional referral hospitals and health centres due to poor pay, yet there is an influx of patients to these facilities.
Mungherera explains that the Annual Health Sector Performance report 2011/2012 shows that the amount of health investments (human resources and finances) by the Government are below the health sector strategic investment plan targets, which are already below the globally recommended targets.
Financial investment in health shows a decline over the years from 9.6% in 2009/10, to 8.3% in 2011/2012.
“The President pledged to increase the pay of scientists, especially health workers, in 2005. To date, the pay has remained the same, despite the increase in the cost of living and inflation,” she said.
She also noted that the Ugandan health workers’ salary is the lowest in East Africa. “Medical workers are demanding a 50% increment in salaries across the board,” said Mungherera.
Health Ministry Explains
According to the health sector policy statement, inadequate and poorly-motivated human resource is a big challenge to health service delivery in Uganda. Furthermore, health service delivery is affected by a shortage of qualified health workers, especially in hard-to-reach areas.
The proportion of approved positions filled by qualified health workers is 56%. This figure, however, masks the gross mal-distribution of health workers, with some districts having less than 30% of positions filled. There are also significant shortages of specialists like dentists, anaesthetists, anesthesiologists, psychiatrists and pathologists.
Staff shortage is further compounded by absenteeism and inability to retain critical cadres, even when health workers have been recruited.
Civil society slams govt’s offer
Civil society organisations are not happy with sh49.5b additional funding to the health ministry.
Speaking at a press conference in Kamwokya on Wednesday, Leonard Okello, the country director of Alliance, an HIV/AIDS NGO, said the decision to use sh3.5b, out of the sh49.5b to increase allowances of a few medical officers at health centre IVs so that their consolidated bill would be sh2.5m a month, ignored the importance of the frontline cadres.
“Midwives and nurses who take home a pittance, but are the daily donkeys treating women, children and people living with HIV, expected to benefit from this decision,” he said.
Okello added that there was a likelihood of the decision angering the nurses and midwives, leading to serious demotivation.
However, Asuman Lukwago, the health ministry’s permanent secretary, said although nurses and midwives had not been considered in the payrise, they would be catered for in the next budget. “It is a process that will see us eventually catering for all of them.
“With the pay raise, we hope doctors will now be able to pay their rent and send their children to good schools. We are also certain that the new remuneration will attract and keep the health centre IV workers at their bases,” Lukwago said.
On the other hand, Amoding says the allocation of only sh6.5b, as opposed to the required sh260b, is a mockery to the taxpayers, in a country that loses sh900b annually on corruption and spends sh365b on treating government VIPs abroad.”
“It is a shame that this is happening even after 50 years of independence. This clearly shows that health is not a fundamental human right for Ugandans,” she says.
Premier Amama Mbabazi, while delivering the speech on the additional funding for the health sector, said: “We all agreed on the urgent need to improve health care in the country. We shall, therefore, address the human resource challenges so as to have a properly-functioning system at the local government level throughout the country.”
Will sh49b additional funding boost health services?