Safety turns into a lottery at Uganda’s ailing health sector

A ntenyi Namukwaya checked herself into St Kizito Health Centre Health Centre III, in Wakiso District to give birth. She was accompanied to hospital by her step-daughter. 

After the last lap of labour pangs, she gave birth towards midnight, which brought bundles of joy. But what happened shortly after changed the course of her life and her step-daughter, and left a stain on the conscience of health-care providers.

“I was woken up by something held firm to my neck. There was a man standing next to my bed trying to stop me [from making any sound],” Namukwaya recounted, an incident that continues to haunt her.  “He was holding what I noticed later was a panga.”

Too weak and too numb, a shell-shocked Namukwaya gathered some strength to beg for mercy.

“He tried to remove the blanket when he heard the baby cry. He told us not to make noise or he would chop us into pieces. He pressed for money but I told him we didn’t have anything because I had come the previous evening to give birth.”
The commotion woke up her step-daughter whom the assailant hadn’t seen yet.

“She attempted to speed to the door but the assailant turned the panga on her. He warned us not to scream. He told her to remove her clothes; I tried begging him to spare her because she is a minor but he raised the panga at me. I told her to do as told,” a teary Namukwaya detailed.

The forceful penetration elicited a loud scream from the 11-year old girl and attracted the attention of the midwife on duty and the hospital security. 

By the time police and area leaders were called to the scene, the assailant had fled.
Upon Namukwaya describing the assailant’s physique, the former area local councillor, Mr Pafras Mugooha, immediately recognised the suspect. 

They raided his home later that morning and was found with a “red mask” which belonged to the victim.
Prosecution of the suspect later stalled for lack of sufficient evidence. 
The state attorney told the victim’s family that despite the police doctor and an independent doctor confirming penetration without semen, they did not have a good case. It was until early this year that the suspect allegedly raped two waitresses who were returning from work one night that detectives commenced investigations.

This episode has scarred Namukwaya, her husband, Katumba, says.
 “For my daughter, it is even worse; the episode affected her self-esteem. Sometimes her peers use it against her and who knows how she will end up.”

The health centre immediately treated the minor for sexually transmitted infections. They promised psychosocial help for both Namukwaya and her step-daughter but did not live up to their promise.
Katumba said it is until he heard on radio a programme on patient and healthcare awareness by one the NGOs that he decided to seek help and compel the negligent St Kizito Health Centre to compensate the victim.
Jane Namaganda Kibira, a legal officer at the NGO, Centre for Health Human Rights and Development (CEHURD) told Daily Monitor that they engaged the health facility to settle matter amicably.

“We are only asking them to correct what went wrong in their own facility; to help the family get over the incident,” she said.
We reached out to St. Kizito Health Centre, which is Church-based, for a comment but we got no response.
Namukwaya’s case is symptomatic of the inadequacy of up-to date security systems at many— poorly regulated private and public health facilities in the country, which exposes patients and caretakers to grave risk.

At Iganga General Hospital last September, a man posing as a security guard raped six women in a single day. 
The hospital offered immediate treatment against possible infections, especially HIV and tried to conceal the matter until NGOs lifted the veil off the scandal.

One year later, security at the hospital remains lax just like other hospitals we visited in Jinja, Butambala Butaleja, Bundibugyo, and Arua.

Stories are abounding of an assault of either a patient or health worker, medical negligence—among others wrong diagnosis, an error far more common than mistakes during surgery. 
Often, daring criminals have raided hospitals and stolen or swapped newly born babies. 
Patients have also died as hospitals ask for prior payment before patients are treated, a practice that violates the Hippocratic Oath.

Even at the recently refurbished regional referral hospitals (RRHs), the safety of patients and caretakers is compromised.
“Safety is an all-encompassing theme. There are mistakes—errors being made because of this and that; the most important thing is to ensure they don’t happen again,” Dr Martin Ssendyona, the acting commissioner for standards, compliance, and patient protection in the Health ministry, said.

According to a March semi-annual review report of implementation of the ministry’s work plan for July to December during last FY2020/2021, several programmes relating to safety are donor-funded largely by USAID.

The unit to follow-up on safety compliance, the report details, has 12 officers sharing one office amid lack of transport for fieldwork and delayed processing of funds for activities.

“Patients safety is one of the core things in any health facility. Sometimes we are told to put on special clothes when entering into wards but then internally you reach a level when it is unsafe, where safety is compromised by external factors resulting in sexual assault, property is stolen, and so forth,” Mr Moses Mulumba, the executive director of the Centre for Health, Human rights and Development (CEHURD), said.

With the system to ensure safety not properly streamlined, several affected persons either suffer in silence or some complaints wind up at the Uganda Medical and Dental Practitioners Council (UMDPC), the medical profession’s umpire.

In her first address for commemoration of the World Patient Safety Day in 2019, the Health minister, Dr Jane Ruth Aceng, said if healthcare itself poses a threat to people’s health, the benefit of increased health coverage is completely lost, and that unsafe care erodes trust in public health systems and deters patients from seeking care.

Adverse events, near misses and errors
The issue of medical errors too is reflective for safety, Dr Ssendyona argues. 
“Key here is to raise awareness among both the practitioners and consumers to be cautious.”

In public health facilities, however remote, Dr Ssendyona said safety issues are easy to follow up sometimes through the network of regional referral hospitals, which serve as the apex for the lower health centres. 
 The proliferation of private health facilities across the country to compliment the ailing public health system has made regulation and follow-up to ensure adherence a challenge.

Uganda’s health infrastructure, according to Health ministry estimates, 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—a majority being in Kampala and the central region— and the rest are private not-for profit.  

According to a Sauti za Wananchi survey done between November 2020 and December 2020 by Twaweza, an NGO, more than half of citizens (56%) say they went to or took their loved ones to a government hospital. 

Yet while there, they mostly found lack of medicines or related supplies, wasted a lot of time and did not get warm reception.

Largely, the survey also showed that poorer citizens were more likely than wealthier citizens to go to government health facilities, and wealthier citizens are more likely to turn to private facilities, which  has led to their rise.

“It is true people come out of nowhere and start a healthcare business, sometimes without knowing what they are doing and this is people’s lives they are dealing with,” Dr Ssendyona said.

“And awareness also remains a big challenge. Other challenges compromising safety could be system issues which require a lot of resources that are not available for the time being but we do budget and prioritise. We have also done a lot such as refurbishing and equipping the regional referral hospitals to ensure safety for all.”

The UMDPC’s registrar, Dr Katumba Ssentongo, said they usually register complaints in three categories.
 “If it is criminal like sexual arrest; mind you even health workers are assaulted but you don’t hear these talked about, the matter is handled by police. We also get many complaints when parties are feuding with health workers over personal issues but are dressed as safety complaints. Then we also deal with professional issues, which is our direct mandate,” he said.

Not all mistakes are individuals’ making, Dr Ssentongo explained. 
“There many which are as a result of the system but due to the limited knowledge, you see blame targeted at only health workers. Health system is a chain, so there are issues as a result of a facility, a health worker, the district, and even the Health ministry but these issues are usually mixed up.”

Punishments for both health workers and health facilities also vary, ranging from a warning to deregistering, depending on the gravity of the issues.

According the last annual 2020 report, UMDPC is constrained by lack of transport and infrastructure, office, infrastructure and funding. 

The recurrent complaints include unlicensed facilities, poor waste management, poor infection prevention and control practices, inadequate PPEs, poor prescription practices, poor record keeping, inadequate qualified staff or the services offered, and poor laboratories often providing inaccurate results, which all affect patient and caretakers in one way or the other.

Among the cases investigated, medical negligence tops the list with 47, followed by professional misconduct, professional incompetence, abandonment, unprofessionalism, issuance of false medical reports, and illegal practice. 
There are also 16 cases relating to fitness to practice—the principle that for one to practice, one must be physically and mentally sound. 

Six health workers were recently found mentally unfit, eight used drugs, and five abused alcohol.

No escape route
Part of the problem, Mr Mulumba said is a limited knowledge gap about patient safety.
“We think about safety as the last issue and yet it is the first. The World Health Organisation (WHO) gave us a guideline and if a country was serious …It does not require much investment, rather to change the way we operate. Safety is about regulation/things that we want to see happen. It requires [re]changing the system but starting by doing things better, the same things we do every day,” he said.

WHO defines patient safety as the prevention of errors and adverse effects to patients associated with healthcare.
The recent second wave of Covid-19 further exposed the fragilities of the country’s public health system long ignored by policy makers who routinely seek treatment at private hospitals or travel out of the country for treatment at first world hospitals where billions of shillings of taxpayer funds are spent annually to secure their treatment.

Hospitals were stretched to the limits, compelling some to limit treatment to only Covid-19 patients barring others with diseases such as malaria, cancer, tuberculosis and heart diseases.

This, as hospital bills piled for poor families that could barely afford treatment.  Vincent Muziiki, 70, a resident of Butoogo Village, Buseru Parish in Bundibugyo District travelled to Bundibugyo General Hospital to seek treatment. 

He was diagnosed with acute respiratory complications, which are weighing down the functionality of his kidneys. 
Doctors recommended an advanced scan, which he can barely afford. The hospital’s 1970s model CT scan and its parts, which was donated by the Japanese government broke down three years ago. 

The hospital medical superintendent, Dr Amon Bwambale, says the Health ministry is aware of the hospital’s predicament but is yet to repair the vital equipment.

Aware of the hospital’s dysfunctional x-ray/CT scan, which until 2018 served an average of 12-20 patients, one private provider put up one ranging from Shs30,000 but it’s too costly for a majority of patients. 
The cheaper option is to travel 83km to the Fort Portal Regional Referral Hospital.

“We have made a lot of communications with the Ministry of Health during the first Covid-19 wave (2020) the x-ray was among the urgent interventions we needed. When the PS (Diana Atwine) came over this year in April, she promised to do something,” Dr Bwambale said.

“An x-ray is integral in treatment; the downside of not having it is when you refer patients to Fort Portal, few can make it; the rest don’t return or you learn later they died.” 

The sight at the hospital’s premise resembles that at Busolwe General Hospital in Butaleja District where no safety is guaranteed. 

One is welcomed at the gate by an eerie sight of broken ambulances, and derelict hospital structure, constructed in 1970, which has barely seen a fresh coat of paint. The staff quarters are also in a sorry state. 

The wards are hauntingly unsuitable for patients peppered with crumbling ceilings and walls, and broken beds. 
The hospital’s mortuary was closed five years ago after wild animals scoured the area for corpses.

The newest complex was constructed by the UK Prime Minister’s envoy to Rwanda and Uganda, Mr Dolar Popat in memory of his mother.

The Health ministry was supposed to equip the 40-bed facility worth Shs540m after commissioning it in 2019; but today, it is a white elephant and has been converted into a makeshift mortuary.
At Arua Hospital, the psychiatric ward was last year turned into a containment area for Covid-19 patients. 

Today, psychiatric patients are crammed inside the Ear-Nose-Throat (ENT) ward; the result has been near disorder as patients fight.

At Bundibugyo Hospital, Dr Bwambale said they don’t have any specialists despite their comparatively better staffing level, which stands at 82 per cent. 

At Gombe Hospital in Butambala District just like Uganda Cancer Institute in Kampala, patients queue every morning for services; when night falls, they improvise to sleep on the concrete slabs at the verandas to be able to wake up early the following day.

“Ministry of health will tell you how many millions of dollars they have invested in health infrastructure but are we seeing the desired results….do these new facilities have the basics?” Mr Mulumba asked rhetorically.

Top cases investigated

According to the annual 2020 report, Uganda Medical and Dental Practitioners Council, among the cases investigated, medical negligence tops the list with 47, followed by professional misconduct, professional incompetence, abandonment, unprofessionalism, issuance of false medical reports, and illegal practice.

There are also 16 cases relating to fitness to practice—the principle that for one to practice, one must be physically and mentally sound. 

Covid-19 factor

The recent second wave of Covid-19 further exposed the fragilities of the country’s public health system long ignored by policy makers who routinely seek treatment at private hospitals or travel out of the country for treatment at first world hospitals where billions of shillings of taxpayer funds are spent annually to secure their treatment.

Hospitals were stretched to the limits, compelling some to limit treatment to only Covid-19 patients barring others with diseases such as malaria, cancer, tuberculosis and heart diseases. This, as hospital bills piled for poor families that could barely afford treatment.