Mulago Hospital limps in agony

Mulago Hospital has been through the ringer of late. Patient demonstrations and faulty machinery have been met by accusations of fraud, mismanagement, and a power failure last month that allegedly led to the deaths of 15 people.

A Spokesperson for the national referral hospital, Mr Dan Atwijukire Kimosho, takes particular offense to this last charge. Although he concedes that backup generators did not go on automatically that day, he says in places where power is absolutely essential – such as intensive care and incubators – reserves are always available that can last for hours.

“In 30 minutes (the length of the power outage), those people could not have died,” Mr Kimosho maintains. He says the backlash the hospital received was not warranted, especially in the context of the larger challenges the facility continues to face.

Challenges at hand
Mulago has a 1:40 doctor to patient ratio – the same ratio applies for nurses. In the first two months of 2011, they saw 92,496 outpatients alone. The 2,300 government staff are overwhelmed and under resourced, and the burden shows no sign of slowing, with patient demand steadily inclining with each passing year. “The space does not increase, but the number of patients increases every day,” says Sarah Mulongo, another Mulago spokesperson.

Not only does the referral hospital also act as Kampala’s district hospital, it also performs the duties of some neighbouring districts. “Many patients travel distances to access care at the referral hospital, namely for blood transfusions when other clinics run low,” she says.

The hospital’s assessment centre takes the bulk of outpatients. In February, it saw 39,980 patients in total. One patient, Gladys Narika, waited more than four hours for treatment last week. But she acknowledges the number of patients waiting alongside her, and says at least today, as compared to her previous visits, there were tablets available. “It’s tiresome, but I have no other way,” she says wearily.

While Ms Mulongo says the construction of health centres in Kawempe, Kiruddu and Naguru should alleviate the burden, many patients will still come to Mulago because it is simply what they know. “The patients are many, the doctors are few – but we cannot chase them away,” she said.

A report from the referral hospital to the ministry from 2008-2009 shows this conflict is nothing new. It says it is “not possible to turn away patients for primary healthcare procedures despite the fact that Mulago is not funded under PAF (the Poverty Action Fund)". PAF is a mechanism that was put in place by government more than a decade ago to target priority needs in the country, including primary healthcare.

Mr Godber Tumushabe, the executive director of think tank Advocates Coalition for Development and Environment (ACODE), has just wrapped up a research project that tracked public expenditure in the health sector.

The project aims to give “a more qualitative analysis” of why these problems tend to arise in the first place. Due out by the end of March, the report confirms a number of trends most already know: conspicuous drug stockouts, money failing to trickle down to where it’s needed most and chronically under-staffed health centres.

Its main goal, however, is to expose inefficiencies in the higher echelons of the system. “We are seeing that there is a problem with the entire public service delivery system in this country mainly because there is an assumption the delivery of public services is to be achieved through local government,” Mr Tumushabe says. “I always refer to local government in this country as poorly-funded NGOs. Because if you don’t have control over your budget, there isn’t much that you can do to change the situation yet they are blamed as the ones failing to deliver services.”

While district case studies were the focus of the ACODE study, the case of local governments “absolutely applies” to the case of Mulago, says Mr Tumushabe.

Despite being described as fully autonomous in the Ministry of Health’s five-year strategic plan (2010-2015), Mr Kimosho says the hospital is constricted by a perennial lack of budget support. “What Mulago does is in line with government policies, with the Ministry of Health,” he says. The hospital’s report to the ministry for 2008-2009 in fact showed the hospital was “seeking autonomy”.

It said less than half of the requested budget for drugs and sundries was met that year. From a requested Shs24.3 billion, only Shs10 billion was provided. The same trend applied across the board, from equipment and maintenance to staff training and food costs.

Mr Tumushabe says the lack of autonomy is a key problem to be addressed, and one that can be remedied with an increase in discretionary funding – that way, longer-term strategic development plans can be put in place that will ultimately deliver better services.

Unspent millions
The Deputy Permanent Secretary for the health ministry, Dr Asuman Lukwago, confirmed last week that his ministry returned Shs350 million to the treasury in the last financial year. He says it is a result of a “manifestation of managerial problems that occurs when people are not engaged in real front-line activities”.

Mr Tumushabe says the inability of the system to absorb that much money so direly in need is a travesty and one that cannot be excused any longer. “For me that is like the highest level of incompetence on our part as a country. That we don’t know what to do with the money and people are dying? It’s difficult to understand,” he says.

“What you are seeing is really a systemic problem which is related to inefficiency in the system. But also corruption because it looks apparent that when public officials are not able to get a cut on some of the expenditures, they would rather actually keep the money and send it back to Ministry of Finance.” The Ministry of Health responded to the string of negative events that have recently plagued Mulago by transferring executive director Dr Edward Ddumba out of his position recently.

Dr Lukwago said the decision was partly due to the recommendations of the government-appointed, Medicines and Health Services Delivery Monitoring Unit (MHSDMU). He says investigations there are ongoing. “The ministry will work on the recommendations of an internal auditor who will soon be in place, and outside of Mulago,” Dr Lukwago says, adding an overhaul is already underway. An organisation is looking into an apparent misuse of ministry vehicles across the system, and regional hospital staffs have been upgraded to ensure they are technically trained.

Treating symptoms
But critics say the formation of MHSDMU – like so many anti-corruption task forces instilled by the Museveni government – is merely a bandage solution that will not address the deeper-rooted problems continuing to affect the system.

Mr Tumushabe says another anti-graft body was the last thing Uganda needed when it was put in place in September 2009. “Whenever there is a problem – instead of resorting to the existing institutions to address that problem, we create a new institution,” he says. “In the process we’ve created multiple institutions that actually continue to blur the lines of responsibility and accountability… You are almost putting a vote of no-confidence in your own institution, which is not helpful at all.”

Clinical officer James Mugeni agrees that the unit has only made health service delivery worse off than it already is. He calls MHSDMU head Dr Diana Atwine a “decoy” planted in place to distract from tackling the real issues at hand. “She can’t be the best person to monitor service delivery in the country,” says Mr Mugeni, a former public health worker in Tororo District. “She is given money – I call it oiling – she has all the money that anybody would want, but out of it she has to deliver to the boss, to the master. That kills the whole state of health workers.”

By delivering Dr Ddumba alone without looking more closely at the procurement and management processes that are still in place, the same mistakes are doomed to repeat themselves, says Mr Mugeni. Though he does not shy away from admitting all too common malpractices, such as drug theft and worker absenteeism, he says the bigger risk is in shifting blame to the wrong places.

Mr Mugeni says an ethical health worker is incompatible with the country’s current system. “You have health workers who are living like paupers and you entrust them with drugs… they look at something they can sell to support themselves,” he says.

While he absolutely does not condone the malpractice, he says health workers are painted as villains stealing from the sick, while they themselves are forced to endure poor pay and a complete lack of government support. “I am not proud to be called a health professional,” says Mr Mugeni. He cites squalid living conditions for health workers in rural areas. Collapsing structures, open sewers and food and water shortages are the norm, he says.

Combined with the lack of a unified protest from health workers against the ongoing trend, Mr Mugeni became disenfranchised and left a system he describes as “like being in a garden without a hoe”. “What are you digging? What are you treating when you prescribe drugs and patients can't get them?” he asks. “Money is being wasted on so many things – if we ingest it into the health service, it could be vibrant, and it could be an admirable profession.” The next and final installment of this series will look at potential ways forward for Uganda’s healthcare system

Potential for Uganda to stop wasting health dollars

The Ministry of Health (MoH) knows it is wasting money. From the Shs26 billion it estimates is lost each year to health worker absenteeism, to the Shs350 million the ministry returned to the treasury in the last financial year – the problem is rooted at every level. “When you analyse the ministry generally, and the health sector, you find wastage plays a big role – the little funds which are available are not put to appropriate use,” says the Deputy Permanent Secretary for the Ministry of Health, Dr Asuman Lukwago.

Mr Godber Tumushabe, the executive director of think tank Advocates Coalition for Development and Environment, suggests more autonomy for service providers – by giving more room to make longer-term plans, which respond direct needs of patients, he says both delivery and accountability would improve. At the July 2010 session of the State of the Nation Platform, ministers gathered to discuss the budget and how to better spend it. Two emerging options arose that would keep government financing the health sector but lessen its involvement in service delivery itself.

Minister of State for Finance Fred Jachan Omach said, “We are revising PPDA (Public Procurement and Disposal of Public Assets) Authority law to enhance procurement and allow departments to spend all money given them.”

In a recap from her budget speech, Finance Minister Syda Bbumba said a Public-Private Partnership in Health (PPPH) Bill would be presented to Parliament in the 2010-2011 financial year. It would aim to harness private sector financial and human resource skills while sharing construction and operational risks between the two sectors.

Dr Lukwago said of the PPPH Bill: “When it becomes a real act of parliament… it will affect all levels of our operations, including the national referral hospital.”

Testimonies

* Helen Ajiko, 54, and Helen Amoding, 49, are both in-patient cervical cancer patients at Mulago. Since their respective surgeries, the two are now under the care of the hospital’s radiotherapy department undergoing treatment. But due to a shortage of beds, they lie day after day on mats spread across an enclave in the hospital’s open hallways. They are two of dozens in this area alone. “The floor, it’s hard on my wounds,” says Ms Amoding.

During treatments, Ms Ajiko says sometimes the machines fail. “We might miss a treatment, but then, they will repair it in the morning,” she said. The women say they often end up paying for food and medicine, borrowing from friends and family, as their doctors have advised them they are not well enough to work.

* Twenty-two-year-old Sebaduka Mawejje suffers from epilepsy. After a recent fit, his jaw was badly broken, unhinged from its sockets. His mother, Christine Namilimu, says three days after his surgery, they have come back for his pain treatment and injection of fluids – the only thing he has been able to consume since. On this day, the two have been waiting seven hours and counting. “He has wounds inside his mouth, can’t open it, can’t talk, and he is in pain,” she says.

Yet Ms Namilimu does not blame the doctors. She knows they are working through an overcrowded room of people all waiting to be seen. This visit will likely cost her Shs50,000, she says. Although the tablets are free, the bandages her son will require are at least that much.