Day 8: Thoughts About Uganda’s Health Care System
The Baganda have a saying when loosely translated says: It’s good to have a heavy downpour ; you differentiate a solid house from a simple hut. This is exactly what the COVID-19 pandemic has done to health care systems worldwide. It has brought to the surface what has been simmering below for many years.
The pandemic has shown the strengths of the health care system like professionals that can lead in the control of a pandemic and weaknesses like overstretched , underpaid workers with little Personal Protective Equipment(PPE) working in an underfunded health care system.
I thank them from the bottom of my heart for their unwavering commitment and dedication to the noble profession and the people of Uganda.
I feel that I am well positioned to comment about our health care system than many other people for I worked in it for twenty years and by then it was delivering free, effective services to all. Those who felt that they needed to pay a little to be seen by the consultants would attend the Private wing of the New Mulago hospital and be admitted in the private wards on the top floor. President Amin Dada’s son, Moses , had his tonsils removed on the 6th floor when I was the internee on duty. His many wives delivered their babies in the 6th Floor maternity Ward.
I left for greener pastures in Botswana, southern Africa in 1994 then came back almost four years ago.
After the National Resistance Army bush war of 1981 to January 1986, I had great hope that the our health would be given the priority it deserved. A country’s greatest asset is its people because people have to be healthy to participate fully in their own development and that of their country.
I left because I could not get a decent pay as a health worker and the tools I needed to perform my work were inadequate. There was no way I could realize my full potential and at the same give my children a better education and more opportunities than myself. I practiced the best clinical medicine in Botswana, a middle income country, an oasis of good governance and prudent management of the natural resources for the good of every citizen.
All along I followed what was going on in my country more so in the Health sector. Whenever I visited home, I would cry silently because of the deteriorating state of the health care system.
Do not get me wrong; some remarkable achievements were made in areas like the control of HIV/AIDS epidemic and the control and management of Ebola epidemics.
I thank all those workers who stayed on to sustain the thin thread that held the health care system together . I salute them for their commitment and dedication and acknowledge their relentless struggle to support their families under tough conditions.
On my return home, I was shocked to the core when I recognised that there were two tiers of the health care system: one for the rich and another for the poor. 70% of Ugandans live in the rural areas depending on subsistence agriculture. Falling sick in such an environment is close to committing suicide. They sell whatever they have to have the sick treated in dilapidated facilities lacking even the simplest drug like Paracetamol. They are seen by the health workers then prescribed the necessary drugs . Most times they cannot afford to buy the drugs thus compromising their health.
It is strikingly different for the privileged few who can be flown out with attendants to be treated in India, South Africa, UK and Kenya.The irony of things is that in some of those places, they are treated by Ugandans born and trained in Ugandan Medical schools!
In this day and age, what nags my conscience fiercely every day as a health worker , is the fact that 16 women continue to die every day in Uganda from complications from pregnancy or childbirth. Indeed the rate has reduced in the 22 years I was away but 16 is still high. Considering that most of those mothers die from preventable or treatable complications like excessive bleeding, severe infection and unsafe abortions and that each mother who dies leaves behind 5-7 children, it is one of the biggest tragedies of our time.
The number of women who die from complications of pregnancy or child birth per 100, 000 live births per year is known as MMR- Maternal Mortality Ratio.
According to data.worldbank.org
Uganda has a Maternal Mortality Ratio of 438 per 100.000 live births (2014). It is unacceptably high.
Kenya has a MMR of 362 per 100,000 live births per a year.
Rwanda’s has a MMR of 216 (2016)
Botswana 144 deaths per 100,000 live births( 2017)
High MMR are a combination of:
- limited access to quality maternal health services,
- distance to facilities,
- lack of information
- Cultural beliefs and practices.
All citizens have a right to quality health care from the womb to the tomb.
Similarly, we are all part of the solution.
According to the ubos.org , in the years I was away , Uganda’s population increased from 19.79 in 1994 to 36.91 million in 2014. However, the increase in functional health facilities did not catch up and the government expenditure on health in 1995/1996 was 9.8% of the total budget and a mere 7.4% in the 2018/2019 budget.
The Abuja Declaration of 2001 requires each country which is a member of the African Union ,to spend a minimum of 15% of its total yearly budget on Health. At the peak of the HIV/AIDS epidemic in Botsawana, 2002-2006, Botswana spent 40% of its total budget on health to avail universal Antiretroviral Treatment to its people and care and support the orphans of the epidemic.
As a health work who took the Hippocratic Oath to save all lives these are my simple ideas on how to improve our health care system so that it delivers quality, effective , affordable services to all citizens wherever they are:
- Prioritise Health- Like any other government of a developing country, our government has many demands made on it but the planners should take health as a priority by increasing the expenditure on health closer to the Abuja requirement- minimum 15% then put in place transparent mechanisms of accountability.
Health structures can be revamped, well stocked with medicines and the health workers can be retrained regularly and paid more so that that they can be retained. A satisfied worker would strive to deliver of her/his best.
2.Empower Communities to be in charge their health- The 1995 Constitution mandates the Ministry of Health to focus on Policy and Regulation while the Ministry of Local Government runs the health care system below the regional Referral hospitals as it is done in Botswana. Emphasis on Primary Health Care will focus on Prevention other than the treatment of diseases. Communities will be healthier and will require less of treatment of diseases. Uganda is known to have excellent policies on paper which are never implement or take over ten years to implement.
3.In this 21st century, governments cannot shoulder and finance the running of a functioning health care systems alone. It will require the government, the citizens themselves and business partners to set up a locally appropriate Health Care Scheme that covers all. Botswana has had a Medical Aid scheme since 1991. I greatly benefited from it though I could still get free treatment from my local clinic.
Consultations should start at the grass roots and move up so that the groups involved agree amicably on an arrangement that satisfies all. The scheme has to be inclusive, effective, of good quality , affordable and sustainable.
4. Education- the role of education in changing people’s behavior about important issues in society like accepting immunisation or use of health facilities is well known so the Ministry of Education should continue to educate the young about the strong relationship between health and development. By the time they are adults, they will be able take informed decisions about their own health and the health of the population in general. They will be empowered enough to demand more from the governments of their day.
COVID- 19 pandemic has forced us into lockdown and affected the economy negatively but at the same time it has done us a great service by showing us the biggest gaps in our health care system. I only hope that the numbers of new cases will not rise above a hundred otherwise the fragile heath care system may collapse.
The Great Depression of the 1930s taught the Americans many things and forced them to design policies and programmes to help them stand strong if a depression of such magnitude were to recur.
This is the right time for all Ugandans to focus on our health care system, to change it into the type of system we want for ourselves : the one that can effectively deliver services to the population whenever they are and survive another pandemic in future.