Why medical interns are usually on strike

Medical interns hold placards as they demonstrate during their sit down strike over allowances last year. Photo by Alex Esagala

Last week, 205 medical interns at Mulago National Referral Hospital and its subordinate hospitals of Kiruddu and Kawempe lay down their tools over their three months allowance arrears, paralysing operations at the hospitals.

Such occurrences have become common during the mandatory one year of hands-on medical training among the interns including medical doctors, pharmacists, dentists and nursing students pursuing degrees countrywide.

This has always put the interns and the parent ministry of Health at loggerheads as the former demand for better working conditions while the latter decries the inadequate refunds available to address their needs.

During the one year of internship, newly qualified doctors work under direct supervision by specialists in hospitals to put their mainly theoretical knowledge into practice.

The training is also a pre-requisite for one to be registered by the Uganda Medical and Dental Practitioners’ Council (UMDPC) for medical practice in Uganda.

According to the government proposal that caused controversy recently, the freshly qualified doctors would be subjected to pre-entry exams before one is deployed for internship, scrap allowances for students who privately funded their university studies, while the government sponsored students would be bonded for two years of public service after internship.

This led to a bitter row between the two parties, putting the whole programme at halt.

The 2016/2017 batch of interns therefore started their internship in October 2016, two months late.

“Interns are not slaves, no bonding, pay all medical interns,” read the placards carried by the then in-coming interns across the country during one of the protests they staged to show their grievances.

Poor welfare
Dr Fauz Kavuma, the medical interns’ leader, decries the routine delayed remittance of their monthly allowances, which he says has made many o their colleagues to live under very harsh conditions.

“At times some of our colleagues are forced to share meals (usually posho and beans) prepared for patients when they are broke. Others end up staying in dingy places and slums,” Dr Kavuma says. He says some have been thrown out of the houses they rent.

Since their appointment letters are silent on the hours and number of days they are supposed to work in a week, Dr Kavuma says, it is almost a norm that all interns work 10 hours daily, often seven days a week. The other hospital staff take days off.

Although hospitals in rural areas are able to provide accommodation for a big number of the interns, none of those at Mulago hospital is accommodated ever since the over 100 interns who were occupying the Galloway Hostel at Mulago hospital were evicted to have the hostel renovated in 2014.

Mulago hospital executive director Dr Byarugaba Baterana says the structure is still under renovation, but it is currently occupied by police officers as a barracks.

Dr Diana Atwiine, the Ministry of Health permanent secretary, says there are always delays in remitting medical interns’ allowances because the ministry of Finance sends them money on quarterly and not monthly basis.

“We can only give them the money when we receive it from the Ministry of Finance,” Dr Atwine says.
Every interning medical student receives Shs 940,000 gross allowance a month, which they say is not enough to cater for all their needs.

This comprises Shs 250,000 for accommodation, Shs 90,000 for feeding and Shs 600,000 training allowance. The sum reduces to Shs756,000 after tax.

Unlike their colleagues who train in rural hospitals where government still gives free lunch to staff and sometimes accommodation, medica interns at Mulago hospital always have to find means of accommodation, food and transport to work, which they say worsens when the allowances delay.

Generally, interns who train in the private not-for-profit hospitals of Nsambya, Rubaga and Mengo have their utility bills, accommodation and meals footed by the hospitals as well as a monthly allowance on top of what the government offers, the reason why interns in those hospitals never strike.

On a daily basis, the interns, especially those in urban hospitals, say they need between Shs12, 000 and Shs15, 000 a day to spend on transport to work and meals.

But the Shs 90, 000 given by government to facilitate their meals means an intern has available Shs 3000 for breakfast, lunch and supper on a particular day.

More complaints
However, the problem of welfare is just a tip of the iceberg, the interns say in a various interviews with this reporter.

Ordinarily, a medical intern is supposed to be fully supervised and assessed by a senior consultant in a specific field of medicine, although they work more closely with medical officers who are trained in a wide range of medicine and medical procedures.

Despite the structuring norm, however, interns have on several occasions complained about the rampant absenteeism of the senior consultants, which leaves them at the mercy of the medical officers who are not as knowledgeable as the latter.

The senior consultants are said to either be away attending to patients in other private hospitals where they earn extra money, spending time in their clinics or busy doing donor-funded research.

Daily Monitor understands that a senior consultant in a government hospital is paid Shs 3,447,065 as their gross salary while a medical officer is paid Shs1, 107,600 gross salary and a monthly allowance of Shs144,000.

“The situation is even worse when it comes to pharmacists. I remember seeing my supervisor only once; on the day I reported and the next I saw him was the last day of my training,” a female pharmacist who did her internship training in 2015 at one of the upcountry hospitals says.

Other intern doctors and nurses in both urban and upcountry hospitals complained of the same, saying it makes it hard for them to take critical decision when their supervisor is away which puts at risk the life of the patient.

But in most cases, an intern doctor at Mulago hospital says, “We are able to do work on our own though no one will notice until you make a grave mistake.”

During the one year internship, the trainee directly in different medical procedures including diagnosis, examinations and surgeries, which requires him to rotate in the three major departments of medicine. The departments include Obstetrics and gynaecology; surgery, internal medicine; and pediatrics.

As the country continues to experience exponential growth in the number of medical schools from only two in the 1990s to nine by 2017, there have been concerns raised about the quality of the training and supervision of medical students.

Dr Jane Ruth Aceng the minister of Health, based on this to suggest that pre-entry exams aimed at improving the standards in the health sectors are introduced to gauge the competence of the interns and to put a cap on the number of interns deployed to enable government only take those that they are able to facilitate.

“I cannot tolerate to see society being treated by incompetent students,” Dr Aceng told the parliamentary committee on health last year when summoned to explain the intention of the guidelines.

Dr Ekwaro Obuku, the secretary general of the Uganda Medical Association under which the interns are also registered, disagrees with the minister, says by proposing to reduce the number of interns, the minister suggests that the country has too many doctors. He says this is not the case.

“There is a very big demand for health workers in this country and therefore the demand to train more health workers instead of reducing them,” Dr Ekwaro says.

On the quality of interns, he notes that pre-entry exams at the end of the five years of medical training would not solve the problem but that instead, standard continuous assessment would be more effective if it’s done when the students are still at University.

He adds: “This is wrong; there is no empirical evidence to show that it is the medical students who graduate from universities are of inferior quality.

How they are trained during internship is the problem because there are no specialists to train them.”

Despite the increased number of medical schools and interns over the years, Dr Ekwaro says the government has not increased the number of training centers in the country to prioritise training more health workers.

“The contradiction is that there is a demand (for health workers) in hospitals and the supplies are there from the medical school but because of the poor planning, they are not ready to receive them,” Dr Ekwaro adds.

There are currently 33 training centres, including government regional referral hospitals, general hospitals and private not-for-profit hospital.

For a hospital to be qualified as a training center, it must have at least two specialists in each of the four major departments of gynaecologists and obstetrics, pediatric, internal medicine and surgery.

However, information available to this newspaper is that majority of these training centres have got one specialist in each of the departments, while others do not have specialists in some of the departments and others have since stopped taking in interns.

For example, Mityana General Hospital only trains interns in their obstetrics and gynaecology departments, while Moroto Hospital has ceased taking in interns because the hospital has a 60 percent staffing gap and lacks specialists.

On the inadequate supply of senior consultants, the Ministry of Health says they cannot recruit unless the Ministry of Finance provides them with more money.

Records from the Uganda medical Dental and Practitioners Council (UMDC) indicate that there are 6000 registered practising medical doctors and dentists, 30 percent of whom are estimated to be abroad and 30 percent are absorbed in non-government organizations as administrators.

This leaves the country with an estimated 2500 practicing medical doctors to cater for 35 million people, which is far below the World Health Organisation (recommendation). The WHO recommends a 1:1000 and 1: 600 by 2020 doctor-to-patient ratio, but the ministry of Health estimates that in Uganda the ratio is at 1:24,000.

According to the 2015/2016 annual Health sector performance review, Uganda has a staffing gap of 73 percent anesthetic officers, 60 percent pharmacists, 51 percent, and 25 percent midwives.
The situation gets dire when interns strike.

Last week’s strike, for instance, paralysed operations and some of the pharmacies closed, forcing patients to buy prescribed drugs from private pharmacies.

Medical officers at the affected three hospitals who talked to Daily Monitor on condition of anonymity for fear of reprisal stated that they were forced to postpone most procedures and could only attend to emergencies like C-sections due to the gaps created by the absence of interns.

“In most cases you find that the number of maternal mortality is high in those days when the interns are not at the wards because of the delays due to the overwhelming numbers,” a medical officer at Kawempe Hospital, which largely handles deliveries, told this reporter.