Govt hospitals have 96% deficit of health specialists — report

A new report commissioned by the Equal Opportunities Commission (EOC) shows that government hospitals have only four percent of the required  health specialists  to improve the quality of care, curb deaths, and reduce financial haemorrhage through medical tourism. 

“Out of the 8,272 specialists that are required in the country for the 2023/2024 financial year, the country has only 307 specialists posted in the different government hospitals, which are mainly located in the centre (Kampala),” reads the EOC Annual Report on the State of Equal Opportunities In Uganda for 2022/2023 financial year. The report was released last week. 

“The number of specialised medical consultants in the country is so limited and even those currently posted are overwhelmed given the increasing demand for specialised treatment from the local population, especially the vulnerable and marginalised groups of people,” the report reads further.

The report details 33 different specialties that the government should have in facilities to reduce medical tourism and preventable deaths in the country, many of which have few specialists recruited or none. 
This comes weeks after the release of the Annual Health Sector Performance report, which showed that 53,222 deaths were registered in health facilities in the country in 2022/2023 financial year, representing  a six percent decline compared to 56,878 facility deaths registered in 2021/2022 financial year. 

However, the death figures, which are also coming amid increasing population size and salary enhancement for health workers and scientists, are still too high, compared to the 2019/2020 and 2018/2019 financial years where 45,042 and 34,491 deaths were reported, respectively. 
Still in the 2022/2023 health performance report, it was observed that 22,125 deaths, close to half of the total 53,222 deaths, were actually children under five years.
This points to serious gaps in the care for children that the government should urgently think through and address. In the EOC report, the government has recruited only 60 out of the required 738 paediatricians (child health specialists). 

Back to the EOC report, some categories of Ugandans cannot access certain specialised services in government facilities except the well-to-do who can pay in private facilities or travel abroad for care. 
“Older persons make up 5.4 percent of the country’s population. However, there are no geriatric medicine specialists in the country to handle issues that are peculiar to such category of people,”  the report reads.

“This means that if an older person got an ailment that needs a specialist’s attention, he or she would have to go to a private hospital or fly out of the country to seek medical care. This is an expensive venture which majority of the older persons who are vulnerable in the country cannot afford,”  the Commission warned.
This report also comes amid the government’s plan to reduce medical tourism –the tourism which some citizens say costs the country a lot of money that could build or equip facilities to provide quality and specialised care in the country.
President Museveni, in his speech during the US-Africa Summit last December, said the country was “now working on eliminating medical referrals abroad.”

He said the focus on medical tourism was mainly on heart, kidney diseases and cancers that sometimes involve organ transplants that “have been taking $70 million per year”.
“We are going to have reverse medical tourism by providing this super-specialisation service to patients from abroad, also taking advantage of the good high-altitude climate of Uganda for the recovery of these patients,” he added. 

However, establishment of facilities and equipping the existing ones to effectively address financial haemorrhage through medical tourism has been slow, according to some legislators and doctors. 
The long-awaited Lubowa-based International Specialised Hospital of Uganda has not been completed years later and the incomplete renovation works at Mulago hospital have also affected provision of specialised services, according to facility management.

The EOC report, which has raised questions about government’s priorities, also indicates that the country has only 10 psychiatrists. 
“Yet, according to a report by Ministry of Health Uganda Counselling Association published in 2022, 40 percent (14 million) of the people in the country were mentally ill or had mental disorders,”  the report reads.

“The number of specialists posted in government hospitals is too limited to cater for the rising mental cases in the country, which in the end retards economic development since majority of the population that would be engaging in productive work are mentally ill with inadequate or no specialists to handle their cases,”  the report reads.
“It should be noted that specialist health professionals improve health outcomes in the country which in the end results into economic development if the population is healthy. Therefore, the government should consider investing more money in training and recruiting medical specialists in the country,” the EOC recommended. 

Dr Jane Ruth Aceng, the Health minister, while commenting on the state of human resources for health, said last Friday that the ministry has revised the employment structure to accommodate all specialists. 
“Recently we had a restructuring exercise. In the restructuring exercise, we have opened up to all specialties, existing and non-existing so that when you come [with your qualification as medical profession becomes more diverse] we can accommodate you,” she said.

“This will help us to avoid losing potential specialists who train outside on their own and come into the country when there is no existing structure [to absorb them]. The structure doesn’t have a salary limit, we left it open through negotiation with Public Service because we cannot fill it in all at once,” she added.

Dr Aceng, however, said their focus has changed as the Health ministry.  
“Our focus is on disease prevention and health promotion, it is not clinical services because it is a bottomless pit. If we prevent, we will get more results from it,” she noted. 
However, during the release of the health sector performance report about two weeks ago, the minister also said they are currently not recruiting more health workers. 

“Our role now is to advocate for increased wage [bill] to fill the vacant posts and also ensure health worker performance. Many have talked about limited numbers of human resources,” she said, adding: “But as we all know, currently, there is a ban on recruitment, except on a replacement basis. There is no wage and the country doesn’t have adequate money to pay salaries which is recurrent. So, our appeal is that the people on the ground should do their best as we wait for the ban to be lifted.”

According to the health sector performance report, however, there was an increase in the available health workers per population evidenced by an increase from 8,000 to 9,121 doctors and from 97,326 to 108,208 nurses and midwives registered with the respective health professional councils.

“The annual target of the number of health workers (doctors, midwives, nurses) per 10,000 population was met. However, we are not able to determine the population access. Staffing level in the public health facilities was 74 percent based on the old structure,” the report reads.

However, information from the Ministry of Health Human Resources for Health Strategic Plan 2020-2030, shows that even the recruited officers are not doing their best with “total absenteeism including absenteeism with approval still averages 50 percent [in public health facilities].”  The unauthorised public sector absenteeism rate is 11 percent and authorised absenteeism is 38 percent, bringing that average to 50 percent.

The absenteeism of the medical staff, coupled with low staffing in public health facilities, means patients will spend more time waiting to be attended to as the few workers handle patients. 
“The health workforce density of 1.6 per 1,000 falls far short of the 4.45 per 1,000 population WHO threshold for progress towards universal health coverage,” the the Ministry further noted in the plan.

“If 38 percent of the 74 percent of health workers are absent then in reality on average only about 46 percent of the health workers in employment are present at the health facility at any one time. Overall, the availability of the health workforce is low,” the ministry added. 
Dr Freddie Ssengooba, an associate professor of health economics and health systems management at Makerere University, said besides having specialists in only major hospitals (regional referral and national referral), government should expedite plans to have specialists in lower health facilities. 

“The question of having specialists in lower facilities, what I call frontline [district/general] hospitals, is twofold; the first is that they are closer to the referral system where patients come from –those health centres III and IV,”  Dr Ssengooba said.
“When you come at this level [district hospital], you expect to find somebody who is a technical leader. In our profession as doctors, a specialist is one who is able to supervise the rest of the doctors in that hospital but also doctors who are working in other facilities that are lower but they are referring [patients],” he added. 
“So they look at who is referring which patient and they can always figure out what training he needs to give to those people. The other way is through mentorship for their career growth and this can lift the standards of these facilities,” he further said. 

Dr Ssengooba said this doesn’t come without challenges to overcome. 
“Of course we have challenges of trying to take specialists in these facilities because they might ask for transport, the care might be there but there is no fuel. They may ask for some allowance which is not there, some may also have their own clinics that they are also trying to add to the mix,” he noted.

“We need to have clear kind of contracts and terms of reference so that they [specialists] work well and serve the interest of the patients while also have their time to do their things,” he added. 
Dr Herbert Luswata, the secretary general of Uganda Medical Association, on the other hand, said implementing the plan would address issues of equity and save more lives. 

“It is very important to have specialists in those lower facilities. The government has approval on this. In the past, we only had specialists in the regional referral hospitals and the national referral hospitals, they were few in number but they have been there,” he said.

“But when you look at new government structure, it is also having position for specialists in district hospitals and they want to deploy a minimum of two specialists. This will be helping to advance the strategy of equity whereby even people in lower facilities will be able to access these specialised care which has not been the case before.”
“District hospitals used to refer patients to regional and national referral hospitals and it would take a very long time for the patients to reach the facilities and some would die on their way to the facility they have been referred to,” he said.

Dr Luswata also said more institutions are now training specialists. “More medical schools have opened up and they are training specialists. Initially we had on Makerere [University], but now we have Mbarara [University of Science and Technology], Kampala International University, and the new ones are Kabale University and Butsitema University,” he said. 

“This means that if we have been having 30 specialists graduating every year, then the numbers are going to be doubling,” he added.  
According to information from the Health ministry, the number of health workers with graduate qualification increased from 45,000 in 2008 to 118,236 in 2020. The ministry also said by 2020, the country had annual enrolment capacity of 260 specialised doctors and dentists but put the average annual production capacity at 15.

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