Why we have to seek specialised care abroad

Bbale Francis’s fundraiser to go to India for specialised treatment for cancer was yet to gather thrust, when his colleague in the trade Dan Kyazze breathed his last, also after a long battle with cancer. At the time Bbale died, hopes for former NTV news anchor Rosemary Nankabirwa had been literally lost after a three-months battle with cancer. No amount of medical attention present in Uganda would save her life. She passed on barely two days after she had been admitted to a hospital in Nairobi.

These are some of the few deaths that understandably made it to the media during the last four months. The common denominator remains the need to seek specialised treatment abroad, a thing more Ugandans are opting for besides medicare in private institutions within the country.
The numbers and details of government-sponsored patients are still elusive. The Health ministry’s permanent secretary, Dr Asuman Lukwago, in a recent interview revealed that Shs$2.2m (about Shs6.5 billion) is spent on public officials’ treatment abroad and $78 million (Shs230 billion) for the entire country, inclusive of “private patients.”

Is the hospital system sick?
Mr Enock Kusasira, Mulago hospital’s spokesperson, says Mulago does not refer patients to private hospitals in the country, instead it is the reverse. Additionally, there are other 13 Regional Referral Hospitals (RRH) serving the 112 districts in the country.
The 2015 Auditor General John Muwanga’s Value for Money audit report of the referrals issued last month states: “...the average inefficiency scores were 6, 13 and 9 per cent during the financial years 2011/12, 2012/13 and 2013/14, respectively.

“This implies that for instance in 2013/14, all the inefficient hospitals had the potential to reduce their inputs by 9 per cent in total, while continuing to produce the same level of output,” the report reads in part. “Approximately, 50 per cent of the RRHs exhibited this potential for improvement.
However, stories on a daily basis—shortage, absenteeism and negligence by medical staff, coupled with strikes, absence of drugs, the dilapidated structures, worn-out equipment, to mention but a few that spring from the referrals, could render the audit findings unfounded.
The state minister for Health - General Duties, Dr Chris Baryomunsi, admits it is true Uganda’s health system still has a long way to go in terms of efficiency and focus.

“We have a lot of potential, and this is exhibited by the fact patients come all the way from DR Congo, Rwanda, Burundi, South Sudan, among other countries,” Dr Baryomunsi says. “What we need to focus on now is strengthening, especially in specialised treatment.”
The major challenges, he points out, is the lack of equipment, inadequacy of resources, notably the shortage of personnel for specialised treatment. “But we have a plan to address these issues one at ago. We started with the ongoing rehabilitation of Mulago, which we are going to equip, stock and focus on specialised care,” Dr Baryomunsi adds.

Specialised treatment takes a number of forms, from primary to secondary care. Specialised services offered at Mulago range from medical services, pediatrics and child health, obstetrics and gynaecology, surgical services and diagnostics and therapeutics.
According to the head of the Department of Surgical Services at Mulago, Dr Cephas Mijumbi, Mulago as a national referral is essentially supposed to be a centre of specialised treatment.

“But because the patient influx is overwhelming, we handle the situation the way it comes,” Dr Mijumbi noted. “Majority of the cases we handle here are supposed to be handled at health center IIIs and Vs.”
The surgical department comprises of several units such as Neuro-surgery-diagnostics for the nervous system, Upper Gastrointestinal/Hepatobiliary (for the liver, pancreas), Breast and endocrines (glands), Cardiothoracics (heart issues), Burns and Plastics and the Emergency and Accident Unit.
Averagely, Dr Mijumbi noted his department handles about 300 patients per day.

“This facility (Mulago) originally was designed for 700 patients, with each ward taking 52 patients only, but we are now have hundreds in wards,” he says.
Can you imagine Uganda, with a population of 35 million people, has only four qualified and practicing neurosurgeons?
Majority of specialists, Dr Baryomunsi says, also moonlight into private practice, because of the limited resources allocated to health.
Information from the Ministry of Health indicates heart operations top the referral cases. Others include cancer, organ transplants, bone diseases, organ transplants, and aging related complications—forcing people to seek alternatives elsewhere in Europe, Asia and USA.

Improving step by step
Dr Lukwago says there are a number of areas in which Mulago has made strides. Case in point is the renal unit—which deals with the ailments related with urinary system—the kidneys, bladder, urethra, name it. The hospital, on average, receives 1,000 kidney patients annually. This is against a staff of six renal clinicians in the whole unit. Most patients at the unit require dialysis treatment—and support of hemodialysis machines—that filters harmful wastes, salt, and excess fluid from blood, as is the function of the kidney in the body. Mulago has only 28 dialysis machines, out the averagely 50 machines required.

Dr Baryomunsi, however reveals they have strengthened the system by “sending some renal specialists to India for further training. So by the time renovation is complete, Mulago will be a centre of excellence.”
To Justinian Kateera, the executive director of the Institute of Public Policy Research, a think tank which recently took on government in court over exporting specialised doctors to Trinidad and Tobago under the pretext of “accelerating bilateral relations”, the search for treatment abroad is a catch 2-2 and a losing proposition not just for Uganda but for a lot of African countries.

“It is a divestment out of our own health sector, which exacerbates the problem. But to retain the 280 billion, we must build local expertise and technology. So, what comes first?” he rhetorically asks.
Dr Baryomunsi says there is no magical bullet. The plan at hand is to invest in both—building capacity and technology. Mulago officials and a few heads of referrals say in Uganda, it is all about talking.
At Mulago and other RRHs, there is also a number of equipment often donated, but they lie unused or underutilised either because of lack of qualified staff to run them, have broken down or have little use at the moment.

Uganda is signatory to the 2001 Abuja Declaration, which requires African countries to contribute about 15 per cent of their annual budget on health, but this has remained on paper since.
On staff challenges, Dr Mijumbi says the grim situation is salvaged by the partnership with Makerere University’s College of Health Sciences, where medical student/ interns are absorbed into practice.
This implies in the absence of qualified doctors, mostly as a result of pay, the gap left filled by medical students. The other challenge that always goes unmentioned, he adds, is the leisurely supply of drugs and supplies from the National Medical Stores (NMS).
Coining the term “medical tourism”, Dr Baryomunsi says Uganda’s middle class at the same time has evolved and there is a growing tendency of people seeking even basic treatment abroad.

RRHs have reported an increasing number of diabetes and chronic obstructive pulmonary disease patients either admitted in their medical wards or seen at their out-patients clinics. According to Mr Muwanga’s report, although there was an improvement in efficiency between 2012/13 and 2013/2014, there was still a considerable variation in the inefficiency levels of individual hospitals, ranging from 1 to 33 per cent.
The RRHs of Mbale, Moroto, Mubende, Masaka and Hoima were relatively efficient over the three years, while Arua, Jinja, Kabale, Lira and Mbarara RRHs were relatively inefficient and hence had room for improvements over all the three years under review.

The government in 2012 embarked on a programme to repair and bring up to standards all the RRHs and improve on the services offered. In Kampala, works are underway on Kiruddu General Hospital , which officials say will also offer specialised services and lessen on the influx at Mulago. However, Naguru hospital, which was conceived and constructed to serve a similar purpose, is now in dire straits. Can there be any change?

An equipment crisis

Both Dr Chris Baryomunsi, the state minister for Health - General Duties, and Dr Cephas Mijumbi, the head of the Department of Surgical Services at Mulago, however, agree the lack of diagnostic equipment is primarily what keeps patients away. Non-communicable diseases (NCDs) particularly; cardiovascular (heart) diseases, diabetes, cancers and chronic obstructive pulmonary diseases, according to the ministry, are becoming increasingly important as causes of morbidity (illness) and mortality (death) in the Ugandan population. It is for these that most equipment are either broken or unavailable.

Mulago hospital for instance, requires a new Magnetic Resonance Imaging (MRI) scan that costs an average $700,000 (Shs2.1 billion). The MRI scan uses powerful magnetic waves to screen soft tissues of the body such as the brain and the heart, to detect any anomalies before operation can be recommended. It is also used in scanning cancers and brain tumours'.
The existing MRI scan is of low resolution and stories of its constant breakdown are well known. Additionally, the hospital has on numerous occasions got stranded with the machine after failing to secure funds to either repair it or buy its spare parts.
Some private hospitals also have MRI scans but the nearest with a high resolution scan is said to be in Nairobi. One examination session can cost between Shs500,000—Shs700,000 per session. Add to this other consumables like drug specifications, specific tissue tests, name it.

The head of Clinical diagnostics at Mulago, Dr Rosemary Byanyima, says the shortage of specialists is a well-known story but the situation can be salvaged if diagnostics equipment were in place.
“The truth of matter is that we try our best. It is every doctors wish to see their patients making it through,” she says. “However, sometimes as you handle certain cases, you realise you are going nowhere without A, B, C and you have to refer the patient elsewhere.”
The clinical diagnostics department also comprises of several units, including Radiology, Laboratory, Pathology and nuclear medicine - the latter being the worst equipped. Radiology comprises of x-rays, ultra scans, CT scans and interventional radiology—a technique that guides a needle into a body organ to take a tissue sample other than having to split one’s body to pick a sample.

The hospital has 40 CT scans, about 100 ultra sound scans, which on average are used on between 100-200 patients. This is against the staff of about 40 radiographers (some trainees) and only six radiologists (qualified).
The radiologists make the final assessment reports, Dr Byanyima, says “each day is assigned to two radiologists, who are supposed to write reports of up to 40 people.”
With the ever growing incidence of cancer in the country, the nuclear medicine unit, officials say, is in dire straits. Uganda Cancer Institute 2013 data shows that for the last three years, the number of cancer patients shot up from 1,200 to 2,800, with more than 60 per cent of the patients showing advanced cases of the ailments.

The unit, however, is grossly underequipped with both staff and equipment. Officials also say the unit mostly uses radioactive materials poor.
Dr Byanyima, however, exuded optimism that with the ongoing face-lifting of Mulago, the first major since the hospital commenced operations in the 1960s, a lot could change for the better. There are plans to buy specialised equipment and put emphasis on training and boosting specialists numbers. Where machines are available, she explained, there is a challenge of consumables like specific drugs, spare parts, technicians, etc.

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