Covid-19 offers govt chance to focus on sick health sector

The Uganda Virus Research Institute (UVRI) stands as the fortress erected to guard against the coronavirus pandemic, which has brought life to a shuddering halt in the country.

Today, it is a symbol of resilience as it shoulders the country’s lofty research dreams.

But as the research institute trails the blaze on viral hemorrhagic fever, and arboviral diagnostic services in the Great Lakes, it operates on a shoestring budget, as chronic underfunding has become a metaphor for the country’s misplaced priorities.

In the current financial year, the research institute was only allocated Shs9 billion up from Shs6 billion in the last FY 2018/2019. However, by last September, documents reveal that only 961 million was released to the facility.

According to the latest Auditor General’s report, UVRI had an approved structure of 237 positions. Of the 237, only 88 or 37 per cent were filled at the time the audit was conducted.

Yet, government in its policy documents says it plans to reposition UVRI into a dynamic, internationally competitive research institution, contributing to the global challenges of addressing communicable diseases in order to achieve the SDGS and contribute to economic growth and development knowledge.

Chronic underfunding bears parallels with job drain precipitated by low wages.

In 2015, Uganda was placed under the spotlight after a decision was midwifed by a section of technocrats in the Health and Foreign Affairs ministries to “export” 263 specialised medical personnel to the Caribbean island of Trinidad and Tobago to “accelerate diplomatic relations” between the two countries.

According to the shortlist, the personnel included 15 of 28 Orthopaedics Uganda had at the time, four of six Urologists, 15 of 91 Internal medicine specialists, 15 of 92 Paediatrics, four of 25 Ophthalmologists, four of 11 Registered Psychiatrists, and 20 of the 28 radiologists.

Others included 15 of the 126 Gynaecologists the country had at the time, four of the 15 pathologists, 15 Paediatrics, 4 Ophthalmologists, and 15 general surgeons, among others.

At that time, Uganda’s healthcare ranked dismally at 149th position in the world, according to World Health Organisation (WHO). Trinidad, with a population of 1.3 million people, on the other hand, ranked in the 67th position and among the best in the Americas.

In fact, Trinidad has 12 times many doctors per capita than Uganda. However, Ugandan technocrats argued that the move was in Uganda’s best interest; that if government did not have money to absorb or remunerate them well, it was better to find them employment elsewhere, and furthermore, it would increase remittances from abroad.

A polarising debate over the matter ensued for months until development partners, led by the United States, which funds a sizeable chunk of the health sector budget, threatened severe action.

The Trinidadian government entirely distanced itself from the move, which it said was crafted by its diplomats accredited to Uganda at the time. As a result, Trinidad closed its diplomatic mission in Kampala.

The irony, though, was that even with the never-ending tales of Uganda’s health system being understaffed; almost all the medical personnel shortlisted for “export” were from government health facilities including Mulago National Referral Hospital (before it was split) and regional referral hospitals around the country.

Yet, a 2015 Human Resource for Health audit by the Health ministry, showed that the vacant posts for consultants and senior consultants in both national and regional referrals stood at 61 per cent while the gap for specialised cadres was at 83 per cent— to date.

Last month, after Uganda confirmed its first cases of coronavirus, the Health ministry embarked on the recruitment of 200 health workers on a temporal basis in a bid to build a rapid response team to the crisis.

However, amid the recruitment exercise, government hastily moved in, first with a partial and later a near-to-full lockdown of the country to contain the spread of the virus.

Broken system
“These are things we have been speaking about for a very long time,” says Mr Moses Mulumba, the executive director of Centre for Health Human Rights and Development, a non-governmental organisation, which advocates for justifiability of the right to health.

“They put a cap on health worker recruitment over the years now when you have a crisis like the covid-19 pandemic, you come out saying you are recruiting for six months, where is the motivation?” Mr Mulumba says, adding: “Unless we begin to prioritise the health sector in terms of funding, we cannot build a health system.”

Since the shutdown, stories are abound of health facilities operating short of health workers as many cannot travel to work; some of course deliberately staying away out of fear of the virus, health facilities being overwhelmed, patients suffering from other ailments, expectant mothers stranded or delivering in the worst circumstances, the shortage of and dysfunction of the ambulance system, as well as a shortage or lack of personal proactive equipment like gloves and masks.

The Finance ministry has availed the resources necessary to deal with the emergency. President Museveni in his several addresses has also rallied investors and well-wishers to donate four-wheel drive vehicles to pool a fleet of ambulances that can be used across the 125 districts to transport mothers and other patients.

While Uganda has been praised for its response system to Covid-19, better than several developed countries, it has also since emerged that the response system is largely bankrolled by the US government.

On March 27, the US Department of State issued a statement on its government’s Covid-19 health assistance to several developing countries, with Uganda missing on the list, something that alarmed officials in Kampala.

As technocrats consulted Ugandan diplomats in Washington, the State Department in Washington and US embassy officials in Kampala later clarified that Uganda had already benefited substantially, and the earlier country list was “based on several factors, including caseload and existence of community transmission; vulnerability; ranked as having particularly weak or fragile health systems; and others.”

For example, the US embassy spokesperson, Mr Phil Dimon, told this newspaper that the Centres for Disease Control and Prevention (CDC) was in daily contact with the Health ministry officials.

Other US government agencies, including The United States Agency for International Development (USAID), are participating in the Covid-19 response National Task Force strategy sessions; CDC personnel are supporting local laboratories in building their sample transport network and training lab staff to collect specimens, test, and report results.

CDC is also supporting Covid-19 disease surveillance, building capacity of Ugandan health workers and laboratory staff, and strengthening incident management and emergency operations.

Through the US President’s Emergency Plan for AIDS Relief (PEPFAR), the US had also procured urgently-needed Information Technology hardware to improve communication among hospitals and district officials, facilitated dissemination and implementation of Covid-19 guidance, and established virtual platforms for the Health ministry meetings and communications.

USAID is supporting the Health ministry to develop and scale-up risk management communications for Covid-19 and is working to expand virtual learning and telemedicine platforms to regional hospitals.

In his televised address to the country on the coronavirus pandemic last Wednesday, President Museveni waxed lyrical about Uganda’s efforts of dealing with the pandemic, especially with the speedy testing of suspected cases by the UVRI.

He says previously, the country had to fly all viral samples to either South Africa or Centres for Disease Control and Prevention, commonly known as CDC in Atlanta, Georgia in US.

However, the US government is also bankrolling UVRI through CDC since 2010 after years of neglect.

Generally, the US pools a sizeable chunk of Uganda’s health sector budget. Of the $896 million (Shs3.4 trillion) in assistance to the Uganda in 2018, $511m (Shs1.9 trillion) went to the health sector, specifically interventions in HIV/Aids, Malaria, Tuberculosis and other Communicable Diseases, Maternal and Child health, nutrition, and health systems strengthening.

The problem with this, Mr Mulumba argues is “the people who finance the sector determine what the priorities are; funding is disease specific but not the systems.”

Some health development partners, sources said, are also ambivalent about the US government’s approach to the health sector.

Black Swan or the New Normal?
In an interview with Daily Monitor, Health Minister Jane Ruth Aceng argues that these are “unusual times but to the contrary, I want to believe that government has done well with the pandemic.”

“Not one sector can respond alone; it requires multisector response, which is why we have recorded successes in whatever we do,” Dr Aceng says, adding: “When you look at other countries like the US you see it is only their health systems responding so for our case when you have an outside partner coming to help, you say thank you.”

Dr Aceng acknowledged that development partners have been integral in helping Uganda build a robust viral hemorrhagic fever response system saying we learn through working together.

The current Covid-19 response system, she says, was being used to deal with Crimean Congo fever outbreak in January in parts of western Uganda and also prepare for Ebola outbreak in Eastern DR Congo, as there was little anticipation the coronavirus would migrate nearer home.

As regards other pressing challenges afflicting the health system, the minister says they could be addressed progressively.

“It is true the health budget is inadequate but you also have to understand that health is huge,” she says.

“If we are to give the health sector the 15 per cent budget that we generally talk about, others will be deprived; we have also come a long way in terms of mobilising our own resources now at 24 trillion shillings, and I want to believe that once we are done with the roads and energy, government has prioritised to deal with health in an equal measure.”

Uganda is a signatory to the 2001 Abuja Declaration, which requires African countries to contribute about 15 per cent of their annual budgets towards health.

The Covid-19 pandemic has overwhelmed health systems everywhere but the WHO and UN are specifically concerned it could hit a much heavier blow to African countries whose health systems are already ailing.

According to Dr Olive Kobusingye, the author of the book, The Patient: Sacrifice, genius, and greed in Uganda’s healthcare system, most of the problems downstream that have rendered Uganda’s health system near-to-dysfunctional “are as a result of upstream factors; for example governance is lacking or highly inadequate”

“The most glaring challenge is the insufficient workforce; many are poorly trained, do not know what to do when services are needed or which equipment to use,” Dr Kobusigye, whose book details the emergency health services crisis in Uganda, says.

She adds: “There have been many recommendations of how much needs to go in health; in Uganda right now we have a 6.7 per cent of the budget going to health as opposed to a reasonable 15 per cent recommended by the African Union. The main reason being that the people who have the power, do not ever use this health system so they do not have the motivation to improve it.”

Government efforts
Analysis of the health sector budgets for the last five years shows that government’s percentage contribution to the sector has been growing considerably currently above 50 per cent. In the last financial year, government’s share of the Shs2.3 trillion allocation to health was 58 per cent and 42 per cent by external financers up from 52 per cent and 48 per cent previously.

In the next financial year budget, the health sector financing was augmented slightly from Shs2.5 trillion to Shs2.8 trillion, placing it in fifth position by allocation behind Works and Transport, Security, Interest Repayment, and Education.

During deliberations for the budget, which Finance technocrats admitted was authored before the Covid-19 outbreak, MPs quizzed junior Finance minister David Bahati noting that the executive was not scaling up the health sector budget.

Bukuya County MP Michael Bukenya who chairs the health committee indicated that there is a tendency by the executive to increase the health sector budget yet in the long run the money is not availed, which for the most part renders various functions including recruitment of workers untenable.

But even with this modest staffing capacity and cumulative budgets—including several donor interventions—the thought of functional health systems remains a distant dream in Uganda.
On a good day at most health facilities when doctors and nurses are present, drugs will be out of stock.

Often when drugs have been stocked, health attendants will be out of sight.
This awakening has been following the newly junior Health minister in charge of general duties Robinah Nabbanja on her countrywide tour to become accustomed to herself with the new assignment.

Last Tuesday, Ms Nabbanja visited Mityana general hospital, which was among a dozen health facilities recently renovated and refurbished by government using a $130m (about Shs493.6b) credit facility from World Bank, but was startled not to find health workers present.

During a visit to Fort Portal regional referral hospital last month, she found casual workers providing essential services in the absence of medical personnel.

According to the Health ministry, at least 39 districts do not have a hospital at all; 29 constituencies do not have a health centre IV at all; 331 sub-counties have no health center IIIs but have health center IIs, which can be upgraded; and 139 sub-counties do not have a health facility at all.

There have been commendable government efforts, of course some supported by donors, such as revamping the 13 regional referral hospitals, which provide a wide range of services like imaging, diagnostic, intensive care, and dialysis, and reinforcing six national referrals such as Mulago National Referral Hospital and Mulago Specialised Women & Neonatal Hospital, and specialised facilities like Uganda Cancer Institute and Uganda Heart Institute.

For years, government has spent considerably on treatment of senior government officials and other VIPs abroad as a result of the failure to invest adequately in the healthcare system at home.

But with the coronavirus pandemic, it means they can no longer travel to first-class hospitals. If there is one lesson the Covid-19 crisis has taught the world, it is that countries must place investment in the health sector as the first-priority and not giving it a lesser priority.

Health work ratio
Handling patients. Uganda’s health worker to population ratio, according to the Health ministry’s 2018/2019 sector performance report, improved from 1.85 per 1,000 in 2018 to 1.87 per 1,000 in June 2019.
But it was still below the WHO ratio of 2.5 per cent per 1,000 people.

According to WHO, the ratio is based on the number of health workers required to attain the objectives of the health system. This looks at the threshold of minimum availability of health workers to address priority population health issues.

Health sector report
The 2018/2019 Health ministry’s sector performance report shows that the stock of qualified health profession available for employment in the health sector stood at 107,284 in 2019 on the account of increase in production from pre-service training of nurses, midwives, laboratory staff, and clinical officers.
The ministry, however, says even if the current positions are filled, the human resources available will still be inadequate to serve the ever-increasing population amid the routine need for training, absorption, retention plan, and better remuneration.