Health centre IIs: To phase them out or not

Countrywide. In a bid to reduce expenditure, the government is moving to phase-out health centre IIs (HC IIs), the public health facilities located at parishes.
Dr Asuman Lukwago, the permanent secretary, Ministry of Health, says the implementation could start next year if the necessary funds are availed.
Although there are 7,000 parishes across the country, there are only 2,730 functional HC IIs, according to Dr Lukwago. This means 4,270 parishes don’t have HC II facilities.

On June 23, President Museveni said of health workers at HC IIs: “…HC IIs would have added another army of, I think, 63,000 workers that would have simply (eaten) our money with no significant value addition in terms of health care. The Sub-county is not too far. Let us consolidate our health delivery there.”
Each HC II is supposed to have nine government employees; an enrolled nurse, a midwife, two nursing assistants, two potters, two guards and a health assistant.
This means the 2,730 functional HC IIs are supposed to have a total of 24,570 employees. However, majority of them are understaffed.
The public health services delivery starts with Village Health Teams (VHTs), Heath Centre IIs, health centre IIIs, and health centre IVs, district hospitals, regional referral hospitals and national referral hospitals.

Dr Lukwago says HC IIs are going to be replaced by two parish health extension workers. HC IIs that exist in sub-counties where there are no HC IIIs will be elevated to that level. The HC IIs infrastructure, Dr Lukwago says, will be used by the health extension workers to conduct their work.
“We are going to replace them with two community extension health workers, who will be moving around in homes advising patients to go and seek treatment at health centre IIIs. This is cheaper because currently, you need nine employees at each health centre II. These extension workers will be enforcing other health and sanitation practices like construction of toilets.
The health centre IIs are only giving outpatient services and doing support supervision,” Dr Lukwago told Sunday Monitor on Monday.

What is on ground?
Although many of the health facilities are poorly functioning, accounts by medical workers and community members to this newspaper paint a picture of uncertainty.
For example, in Ankole sub-region, which has 10 districts, 32.8 per cent of homes are located 5kms or more away from a public health facility.
The percentage is higher in districts such as Kiruhura (51.6), (Buhweju (55.6) and Ntungamo (38. 3), according to National Housing and Population Census 2014 data.
Kyarwabuganda HC II in Kakoma Parish, Kakiika Sub-county, Mbarara District, has only two health workers handling patients from the neigbouring 16 cells.
On October 21 (Friday), the officer-in-charge, Ms Loyce Nuwabiine and her counterpart, were out of the station. At around 11 am, 10 patients turned up and went back disappointed. Ms Nuwabiine told this newspaper she was away conducting immunisation in schools.
Dr Peter Sebutinde, the Mbarara District health officer (DHO), says staffing in the health sector is at 43.7 and the most affected are HC IIs.

Kyarwabuganda HC II receives about 30 patients a day, according to Mr Bashemuka. The facility, however, does not serve the purpose due to shortage of drugs.
“Treating you here is by chance, most of the times there are no drugs,” says Ms Maria-Gorette Bainomugisha, who had come to seek malaria treatment together with her nine-year-old son.
“What brings me here is because I don’t have money. When they give you the little drugs they have, you go and take that because you don’t have money to buy from a [private] clinic.”

The alternative for these patients is Mbarara Municipal Council HC IV and Mbarara Regional Referral Hospital, about 12 kilometers away.
Ntungamo DHO, Dr Richard Bakamuturaki, says six of the 23 government HC IIs closed due to lack of staff, and the rest are struggling due to inadequate workers. While the ministry guidelines were that each parish was to have a HC II, 88 parishes and wards in the district don’t have the facilities.
“In fact, some of our health centre IIs serve as health centre IIIs and we have been pushing to have them elevated to that status. It is not good to phase them out,” says Dr Bakamuturaki.

Iterero Health Centre II in Bwongyera Sub-county Kajara, located 6kms from Bwongyera Health Centre III, in Kabale District, receives an average of 50 patients daily with illnesses such as malaria, cough and flue, according to the officer-in-charge, Mr Charles Byarugaba. There are only four staff; an enrolled nurse (Byarugaba), a health assistant and two support employees.
“We received a communication from government to retain the existing health centre IIs but we were directed not to spend money on constructing new ones or completing ones that have been under construction,” says Mr Abert Mutungwire, the Kabale District Chief Administrative Officer.

He adds: “These health centres are so useful to the communities in promoting good health by giving treatment to the sick near them. I have a feeling that once phased out, there will be a big gap in health service delivery and patients shall be walking long distances to get services at health center IIIs.”
The acting Kabale District health officer, Sr Immaculate Mandela, shares the same view. There are 70 health centre IIs. Kitunga HC II in Rukiga, for example, receives an average of 35 patients per day, according to Ms Gloria Nahabwe, the officer-in-charge.
“Health centre IIs here are doing a good job and I have no problem with their operations because they offer timely health services to patients, the fact that they are located closer to communities. If it is a government plan, let’s wait for the official communication,” said Sr Mandela.
Dr Michael Adrawa, the acting Moyo District health officer, fears that mothers might resort to traditional birth attendants because of the long distance to health facilities.

Ms Rosemary Bayoa, who has been accessing services at a health centre II in Vura Opi village in Moyo Sub-county, says the facilities reduce congestion at health centre IIIs and hospitals, and on the distance covered to access health services.
The Nebbi District health officer, Dr Jakor Oryema, says: “Although there has been no formal communication on the planned phase out of the facilities, their closure will affect access to health services and works against intentions to improve health in communities.
“We have 20 health centre IIs with 74 staff. We still need to have these centres in order to maintain the access to health services,” he says.

Buliisa District health officer, Dr Francis Onyaiti, says they have three public health centre IIs and three private ones. Each serves the entire Sub-county population.
The officer-in-charge of Kigwera HC II, Ms Alice Katusabe, says the facility receives an average of 130 patients daily. They offer HIV/Aids services, general treatment, antenatal services deliveries and immunisation outreaches. Though the staffing is at 90 per cent, they are, however, overwhelmed by the number of patients.
Avogera and Butyaba health centre IIs offer services supposed to be offered by health centre IIIs,” says Dr Onyaiti.
Health service stakeholders in Acholi sub-region too have rejected the proposal.

The Gulu District health officer, Dr Paul Onek, says government should instead deggazate the many districts it has created so that more funds are used to run the HC IIs. HC IIIs, he says, are far away from majority of the people who stay in remote areas.
“We shouldn’t shut down health centre IIs because we don’t have the funding. Vulnerable mothers and children are accessing malaria, hepatitis B treatment, delivery and post-natal services,” Dr Onek says.
Dr Patrick Odong Olwedo, the Amuru District health officer, where there are 17 HC IIs, says eliminating the facilities will be tragic.

The Ministry of Health, he says, should instead look at strengthening these units for easy access to health services by rural people.
Ms Theresa Abuut, an enrolled midwife at Abwoch health centre II in Kock-ongako Sub-county in Omoro District, wonders how residents will access health services once HC IIs are closed.
“We receive more than 120 patients daily with different ailments; some are emergencies that VHTs refer. Local people find it difficult to travel to the referral hospital in Gulu Town,” Ms Abuut says.

She adds that in the past four months, they de-wormed 2,268 children, treated 2,470 under the age of five, while 8,305 patients above the age of five were diagnosed and treated with different sicknesses.
Ms Martha Lakot, a patient who was at Abwoch health centre II last Monday, says closing down health centre II is wastage of taxpayers’ money.
Mr Gerald Egou, the officer-in-charge of St Luke health centre II at Koro-abili, Koro Sub- county, Omoro says the number of clients they receive daily has doubled to 40 in the last two months, increasing the work load of the only two health workers at the facility. He says more resources need to be channeled to lower health units instead of withdrawing them.

The assistant Chief Administrative Officer in charge of Health, Mpigi District, Mr Michael Lutalo, says communities get early diagnosis and treatment for common illnesses through outpatient care and community outreach services from these health centre IIs. There are 13 health centre IIs in the district of which four are privately owned, but supported by government.
“Our survey indicates that on average, 70 patients visit each of the health centres daily and they are bridging a big gap in health service delivery in the district,” he says.
Dr Ronald Reagan Mutebi, the Kalungu District health officer, says: “I think we still need these units since they play a big role in many activities such as immunisation as they are located close to the communities.”

The facilities in Oyam District; 17 HC IIs, three HC IIIs and one HC IV are overwhelmed and have inadequate manpower. The acting district health officer, Ms Caroline Agaro, says phasing out health centre IIs would exacerbate the pressure.
Residents of Opeta, Magoro Sub-county in Katakwi District, who receive treatment from Opeta HC II, which also serves people from Tisai in Kumi District, have described the proposal as suicidal. They say accessing HC IIIs is much hustle because of long distance.
Ms Charles Obale, a resident of Opeta village, says the HC II is the nearest health facility helping them treat persistent trachoma outbreaks that is as a result of the closeness to Lake Bisina.

Mr Muhammad Mafabi, the Mbale District speaker, says government is making a big blunder in trying to phase out HC IIs. “If we are to have a robust health system that can respond to health care needs of the population, then government needs to just improve on the HC IIs,” said Mr Mafabi.
The Tororo District chairperson, Mr Apollo Jaramogi, said phasing out of the facilities is uncalled for because it’s against the decentralisation policy, which puts emphasis to bringing services nearer to the people.
Ms Lilian Cherotwo, a nurse at Kwoti health centre II, says closure of the facility, which serves Kapchorwa and Kween districts, is suicidal.
Mr Stephen Twalla acknowledges, that the centre serves 30 people daily and saves residents from walking 10 kilometres away.

Supporting the move
The Kabarole District assistant health officer, Sr Elizabeth Manimake, says phasing out HC IIs is a good idea because they are not giving services. She says health workers are rarely at the facilities.
“If government strengthens services in health centre IIIs, there will be no need of health centre IIs because their existence has no impact on the community,” she argues.
Dr Emmanuel Otto, the Agago District health officer, says the community health extension workers that will be made to man the units should be carefully selected and subjected to serious training.

“I have tried to analyse the proposal and I think people should not mistake the proposal for a total closure. The ministry wants to ensure 100 per cent staffing in health centre IIIs by shifting health centre II staff to health centre III and letting the structures run by community health extension workers,” said Dr Otto.
Masaka District health officer, Dr Stuart Musisi, says the move would improve health service delivery.

“We are looking at strengthening of health centres and this will be more beneficial, especially in the sub-counties that didn’t have health Centre IIIs before,” he said.
According to Dr Edward Mwesigye, the Bushenyi District health officer, where there are 15 HC IIs, the infrastructure will be the launch pads for new strategy of health promotion aimed at disease prevention. “We are going to have wellness clinics from where people will only be taught how to keep healthy rather than waiting to breakdown in their homes. I think primary health care is actually the best strategy for low income countries because treating diseases is more expensive than preventing them,” Dr Mwesigye says.

Compiled by Alfred Tumushabe, Robert Muhereza, Zadock Amanyisa, Perez Rumanzi, Scovia Atuhaire, Francis Mugerwa, Fednand Tuhame, Brian Mugenyi, Al-Mahdi Ssenkabirwa, Malik Fahad Jjingo, Sadat Mbogo, Joseph Kiggundu, James Kabengwa, Shamim Nakawooya, Gertude Mutyaba, Joseph Omollo, Fred Wambede, Olivier Mukaaya, Felix Warom, Ibrahim Adubango, Scovin Iceta,Simon Emwamu, Sandra Babirye, Bill Oketch, Joyce Chemitai & Tobbias JollyOwiny.

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