Pay or die: Ailing health system strips patients bare 

A health worker attends to patients in an ICU ward in Mulago Hospital. PHOTO/PROMISE TWINAMUKYE

What you need to know:

As the Covid-19 pandemic continues to strike at the heart of communities, patients who can afford access to intensive care unit beds stand a chance of survival as public health facilities come under extreme strain. Private ones are charging between Shs2m and Shs5m daily. But even before the pandemic, the chronically under-funded and poorly staffed public—and unchecked private— health system was letting down hundreds of Ugandans, writes Frederic Musisi.

Mr James Kabengwa, a Daily Monitor journalist, is alive today after coming close to death in hospital. His story resonates with those who have faced such a predicament inside Uganda’s broken health system.  
In September 2019, Mr Kabengwa booked himself into Mengo Hospital, a missionary-founded, private-not-for profit facility in Kampala, for a surgery to correct a redundant sigmoid colon—a condition where the large intestine cannot function normally.
The surgeon who diagnosed and operated him has more than 30 years’ experience.
“When you go to his office, on average, you will find not less than 30 patients; he has to attend to all of them, which means more money but it also means he doesn’t get to concentrate,” Mr Kabengwa narrates his ordeal.
Mr Kabengwa recalls that there were missteps during the surgery, leading to waste spilling inside his stomach. 
While in intensive care unit (ICU), he started swelling massively and his body turned pale. His caretakers suspected something was wrong but the nurses shrugged them off.
“In a matter of days, our bill had shot to around Shs15m, so the hospital started worrying that we would not pay, so they stopped medication. Even getting a nurse to check on me proved hard,” Mr Kabengwa recounts.
 “It didn’t matter that it was their mistake which took me in ICU,” he adds.
When his family was financially overwhelmed, they reached out to his colleagues who implored this newspaper’s editors to run a story appealing for help. 
He says it is when doctors learnt that the patient was a journalist that they started caring.
He underwent five unsuccessful surgeries after which doctors told his relatives to “pray to God.” 
Meanwhile, the bill had by this time  grown to Shs31m, which compelled him to check out.
It is until last December that he was recommended to a specialised private facility where he underwent a corrective surgery. It was discovered that a section of his large intestines had irreversibly been bypassed, and as such, he would not digest food properly. 
He was told it would take another three years for his system to adapt again, but not without complications such as interminable diarrhoea and emaciation because food cannot be absorbed easily.
 “I was angry; I was sad; I was helpless. I wanted to sue Mengo but decided to let it go,” Mr Kabengwa says. 
“It is until our colleague—JB (James Bugembe Ssenkubuge, a sports journalist)—died that I decided to speak out, realising that it could have been me.”
Since mid-1990s when government embraced the neo-liberal structural adjustment programmes agenda, including liberalisation, there was a fairly well-funded and functional health system.

Survival for the fittest
The emerging wide-range of private health facilities, the employer of most specialists, have turned into kingpins, charging astronomical fees. 
Those who cannot afford them are condemned to the public health system, rendered dysfunctional by incompetence, mismanagement, understaffing and poor remuneration, and corruption exposing a social-strata fault-line where the wealthy can only afford health services. 

Surgeons in a theatre at Mulago Hospital in 2018. PHOTO/ RACHEL MABALA


Some specialists in the public hospitals also moonlight in private practice, often referring the financially overwhelmed patients to private outfits to buy special drugs, scans and diagnostics and laboratory services, among others.

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Newly-graduated doctors take the Hippocratic Oath before they are released to the public to use their knowledge and skills for the good of humanity. 
The oath binds doctors to protect patients by upholding professional integrity at all times, to do no harm, to care for the patient, and to maintain the utmost level of confidentiality even in death.
But upon arrival at several private facilities, patients are required to pay cash upon the admission. On some occasions, patients or corpses are detained until relatives clear all the outstanding bills. 
Ssenkubuge breathed his last on May 28 at Mengo Hospital. Friends and relatives suspect he could have died the day before, during or shortly after what was supposed to be a life-saving surgery.
JB, as he was fondly known, was admitted to Mengo in the morning of May 27. Upon arrival, the hospital demanded a payment of Shs900,000, which was paid in instalments to conduct a series of tests and scans. 
The doctors later recommended emergency surgery after he was found to have bled in the brain following a burst of veins. 
The surgery and three days of treatment, nurses said, would cumulatively cost about Shs9.9m, including Shs4m professional fees for a surgeon. 
The family agreed to clear the bill and asked the procedure to be expedited, but the Mengo staff said they would only wheel Ssenkubuge into the theatre upon the payment of Shs2m in cash.
The family managed to send Shs1.9m through mobile money transfer but was told to provide cash, which caused further delays. 

Broken system.“A 28-year-old doctor has never seen a medical system working properly, maybe didn’t have appropriate mentoring, or was not well trained. Generations growing up in a system accepting of incompetence, error, negligence, mediocrity, and where heads do not roll; no one loses their job, so it becomes acceptable,” Dr Olive Kobusingye, author of The Patient: Sacrifice, genius, and greed in Uganda’s healthcare system
 


When the money was finally paid, JB was taken to the theatre past 4pm, eight hours after he arrived and several hours after he required emergency surgery, and while visibly unresponsive. 
When the bill was presented, the doctor’s professional fee had, without explanation, increased from Shs4m to Shs4.6m, and the hospital still asked for the Shs9.9m, which they initially charged for the surgery and three-day treatment although the patient breathed his last barely before a day lapsed.
At his burial, relatives and friends said JB died from “negligence and extortion.”
The hospital management regretted the death of the 52 year-old father of three, but declined a request for an interview for this story, saying the “deceased’s admission was handled in line with our core values of professionalism, integrity, and patient confidentiality.”
Another statistic of the country’s moribund health sector where hundreds of grieving relatives usually don’t get answers, while health practitioners are not held accountable.
Families usually don’t seek legal redress or lodge formal complaints to Uganda Medical and Dental Practitioners Council, a body that protects society from abuse of medical and dental practitioners.
Kyamuswa County MP Moses Kabuusu’s 77-year old father was early this year admitted to Mengo Hospital where he was diagnosed with intestinal blockage. 
Mr Kabusu narrated that after surgery, doctors told him they had misdiagnosed the patient; he suffered from pneumonia, and needed a referral.
Barely a week after, their bill was a whopping Shs15m, which they had to pay before being referred elsewhere. 
Upon arriving at Nsambya Hospital, they were told the patient had Covid-19, not pneumonia.
 “Mengo is a missionary-founded hospital but for them to put much emphasis on money was deeply troubling and hurting. How many people can quickly raise even Shs2m; even after telling them I am a Member of Parliament, and I had means to clear to zero balance later, they told me that didn’t matter,” Mr Kabuusu says. 
“Clients come in frequently but most pay in installments. I think Mengo and all these hospitals need to be called to order and professionalism. Attaching value to money than saving life, or the value on which the institutions were established, is intriguing but also killing many Ugandans,” he adds.
Uganda’s health system comprises  public, private-not-for-profit and private-for profit providers as well as traditional and complementary medicine practitioners. 
With the health system liberalised, according to a 2015 USAID report titled, “Uganda’s private health sector: opportunities for growth,” private providers are considered to play a major role, reaching a wide client base.
As such, the report adds that based on one estimate made by a Deloitte study in 2010, there is a potential $427m (Shs1.5 trillion) financing gap for short- and long-term borrowing from this sector making it a significant market opportunity for Uganda’s commercial banks and microfinance institutions.

Account. “In a matter of days, our bill had shot to around Shs15m, so the hospital started worrying that we would not pay, so they stopped medication. Even getting a nurse to check on me proved hard. It didn’t matter that it was their mistake which took me in intensive care unit,” Mr James Kabengwa, Daily Monitor journalist

Statistics
Based on data from Uganda’s Credit Bureau, the report states that the financial sector has been gradually increasing lending to the health sector for the last three years (2011-2013). 
Since 2009, there were 1,682 loans disbursed to 534 health sector businesses, representing Shs222b as of March 2015.
It was determined that hospitals and pharmacies have the best credit history, with historically less than 1 per cent delinquency than the average banking sector’s small and medium-sized lending portfolio.
According to Mr Moses Mulumba, the executive director of the NGO, Centre for Health Human Rights & Development, which advocates for justiciability of the right to health,  with liberalisation, governments ought to play the cardinal role of “regulation” but in Uganda’s case, “government has disenfranchised itself as if they have no role to play.”
“We have a colonial health system of a public health system taking up 50 percent share but providing services to almost 90 per cent of the population, then 20 per cent share taken up by private not for profit facilities, and 30 percent share held by private-for-profit,” Mr Mulumba says. 
“Once you have a substantial size of health system provided by non-government entities, you end up in our situation where people have to pay first. In other cases, patients or corpses are detained until balance is cleared to zero,” he adds.
“The moment we don’t have regulation on pricing, it means hospitals charge as they see fit, and the profiteering system reigns supreme like we see it happening. The National Insurance Bill that once is passed into law is supposed to address some of these gaps is being tossed left and right,” Mr Mulumba says.
Dr Olive Kobusingye, author of a  book, The Patient: Sacrifice, genius, and greed in Uganda’s healthcare system, says medical negligence means somebody was supposed to perform a role, which he didn’t execute, and this is not necessarily unique to Uganda.
“But you have to ask what about the context within which these people work. Most times, it is not individual error, it’s the system. A 28-year-old doctor has never seen a medical system working properly, maybe didn’t have appropriate mentoring, or was not well trained.  Generations growing up in a system accepting of incompetence, error, negligence, mediocrity, and where heads do not roll; no one loses their job, so it becomes acceptable,” Dr Kobusingye says.
“Our top officials, including in ministry of Health, never use public health facilities because they know these things happen. It is scandalous when officials are reluctant to go to the same public health facilities they expect everyone else to go to,” she adds.

Bitter experience. “Mengo is a missionary-founded hospital, but for them to put much emphasis on money was deeply troubling and hurting. How many people can quickly raise even Shs2m, even after telling them I am a Member of Parliament, and I had means to clear to zero balance later, they told me that didn’t matter,” Mr Moses Kabuusu, Kyamuswa County MP
 


What is not in doubt, Dr Kobusigye says is that Uganda’s health system is broken “but if the people who have the mandate to create a functional system don’t ever use it, then a solution is a far cry.”
Ministry of Health officials were not readily available for an interview.  
The government, however, insists the health system has improved, citing Uganda Bureau of Statistics findings that 86 per cent of Ugandans live within 5km of a health facility.
The budgetary allocation to the health sector has increased two-fold over the years to Shs2.5 trillion in the next financial year starting Thursday.
Parliament in April passed the long-awaited National Health Insurance Scheme (NHIS) Bill, which seeks to provide universal healthcare to all Ugandans, which several observers say will address loopholes in the system. 
But the entire health system needs an overhaul if this piece of legislation is meant to cure the defects in the sector.

A broken health system

In the manifesto for his sixth elective term , President Museveni’s ruling NRM party details that the health sector has changed considerably during the last 35 years, owing to, among others, gains made in immunisation, reproductive maternal and child care services and availability of essential medicines and health supplies, as compared to the “post-independence health system designed around provision of curative care with a doctor as the kingpin.”
After independence, Uganda had about 49 hospitals and 1,288 health workers for a population of 7 million. 

Today, the health infrastructure network currently consists of 6,937 health facilities of which 3,133 (45.16 per cent) are government-owned, 2,976 (42 per cent) are private-for-profit, and the rest  are private-not-for-profit. The stock of health workers stood at 107,284 in 2019.
The country doesn’t have a functional emergency response system, and has less than 220 ICU beds, including ventilators, patient monitors, X-rays, and oxygen plants. 
The Covid-19 pandemic has further commoditised the few available facilities.

Speaker of Parliament Jacob Oulanyah was last week flown out of the country for medical treatment, like several other senior ranking officials who flock to hospitals in Europe and Asia, and routinely next door in Nairobi, Kenya, for among others, neurology, advanced cancers, heart conditions, ophthalmology, and gastro-entorology.
 

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