Budget and health: Staffing challenges are far from over

Ms Mindra Palma’s commitment is incontestable.
The amount of time and passion the enrolled midwife, also referred to as Sister, invests in her work—attending to patience, supersedes almost everything.
Sister Palma was found by the Daily Monitor attending to about 40 expectant mothers all alone at Kiryandogo Hospital, Bunyoro sub-region.
In an interview, she said the amount of work she is dealing with is beyond what she would handle by herself. If it was not for her passion, it is most likely that Sister Palma could have thrown in the towel redirected her energy, time and skill where she would be handsomely rewarded.
For all her work, she does not expect any overtime allowance or payment of appreciation.

“I have to attend to mothers in the labour suit, antenatal and post natal wards at the same time since I am the only midwife on the ward,” Sister Mindra says, as she walks to the labour suite where a mother is impatiently waiting to have a baby delivered.
Ms Mindra’s story is not a fairy tale but a narrative that has since become part of “everyday-life” here. Importantly perhaps, this is a story that defines the condition of the entire health sector in the country and how detached. Better still, it tells a tale of how the national Budget seems to have failed to deal with staffing issues in the health sector.

Disturbing sector statistics
Health sector statistics indicate the doctor-patient ratio is one doctor to 24,725, with other reports showing the ratio has since scaled to nearly one doctor to 35,000 of the population. World Health Organisation recommends one doctor/physician for every 1,000 patients.
Disturbingly, also, is the nurse (including the mid wife) ratio to the patients, which annoyingly, is way above the normal recommendation.
According to the Health Sector Strategic and Investment Plan, by end of last year, the total staffing levels should have reached at least 84 per cent, up from 52 per cent, a feat that is yet to be achieved.
Over the five years which ended in 2015, it would have required between Shs471b and Shs918b with an estimated annual increment of 8 per cent.

Government technocrat weighs in
The ministry of Health Permanent Secretary, Dr Asman Lukwago, in an interview said as a result of a tight budget, human resource issues end up being relegated down the pecking order.
He said: “Lack of enough money in our budget directly affects the staffing levels. Because of that, we are not in position to pay as we would because all that is being influenced by the budget.”
He continued: “For the same reason, we cannot attract international medical personnel or our people working internationally, especially those who can provide specialised services because our budget cannot take care of that.”
Dr Lukwago says that coupled with other challenges, among them upgrading of the dilapidated hospitals and other medical facilities, let alone negotiating the delicate balancing act required of a budget, implies that staffing issues are not among the immediate priorities.

He said: “For now, this is something that is not going to end. I cannot see it (funding issues) being solved now.”
However, according to the health sector ministerial policy statement for financial year 2016/17, Shs36 billion is needed as the wage for 3,542 health workers for general hospitals to meet 72 per cent target by end of 2016/17. This, the document presented to Parliament, says will enable the general hospitals deliver improved services.
The policy statement further discloses that in an attempt to solve the human resource challenge, the Ministry of Health is working with development partners to offers scholarships to persons pursuing courses in selected medical fields and thereafter bond them.
The sector requires Shs13.5 billion to recruit and bond 300 doctors and pharmacists to enhance better service delivery, says the report.

Interviewed for this article, Dr David Basangwa, a senior consultant psychiatrist, said budget is normally tagged to priority areas. Dr Basangwa also the executive director of Butabika hospital, said without a budget for increasing the level of human resource to an acceptable levels, quality of service delivery is bound to be impacted.
He said: “Butabika hospital also has an outpatient wing and that is where the budget issues come in. We have a shortage of nearly 130 workers. And if we can have all the position filled up then the quality of service will certainly increase.”

Overseer makes a point
Dr Bitekyerezo Kab Medard, the chairperson of the health committee, in an interviewed last week, said much as inadequate funding of the health sector is an issue that is impacting proper delivery of services, it is risky to believe that that is the sole reason responsible for poor service delivery in the health sector.
He said: “The funding gap is not the only problem. The bigger problem is management of the sector. There is a lot of wastage in the sector and lack of proper management.”

“What explains the fact that x-ray machines that were procured for hospitals in Masindi, Nakaseke, Mubende, Entebbe, Mbale and Kamuli are all being wasted? You cannot blame the government for that although I think there is laxity in supervision.”
Regarding, the funding gap, the Mbarara Municipality Member of Parliament, said some money has been allocated for that in the coming budget, although he didn’t indicate the amount.
Dr Bitekyerezo’s committee allows Parliament to provide oversight to the health sector, and enhance the quality and quantity of health service delivery to the citizens of Uganda.
Speaking on NTV last week about the country’s health sector, the head of Medicines and Health Service Delivery Monitoring Unit at State House, Dr Diana Atwine, said despite all the challenges the sector is grappling with, there have been some rosy developments.

However, her approach is to streamline developments in the sector and for that she will apply both the carrot and the stick as and when need arises.
Importantly though, she would like to see a well-motivated work force in the sector that is well paid. And part of seeing that vision come to fruition will be in her recommendation that the power that be waives taxes on health workers’ wages.

Analyst’s view
Weighing in on the matter, Stephen Lwanga, a statistician and health information specialist, said the problem of the health sector is beyond funding.
He said: “Motivation issues and elements of accountability are some of the problems and not money per se. Diverting resources from their intended plans is a thing that should be dealt with because even if money is available and all these things are present, of what use will the money be?”

CSO take

Presenting a five-year Journey to transforming Uganda’s Economy; Prospects of the FY 2016/17 budget in addressing today’s social economic challenges, the coordinator for Civil Society Budget Advocacy Group (CSBAG), Julius Mukunda, cautioned about over reliance on foreign funding in the sector, saying that should be reversed.
Donor support makes up nearly 50 per cent of the total budget of the health sector.
Despite the increase in the sector budget, there is a wage short fall of Shs36b, something the CSOs, spearheaded by CSBAG, are concerned about.

“The sector still remains highly funded by external financing, it contributing 49.6 per cent of the sector budget in the FY 2016/17 up from 35.6 per cent in the FY 2015/16,” Mukunda said.
He continued: “Whereas this seems desirable, this puts the sustainability of the sector budget in question. What happens if we fall out with the current darlings who are offering over Shs879b in the FY 2016/17?”