What you need to know:
- In a bare-knuckle interview with Nation Media Group-Uganda’s Walter Mwesigye, Health minister Dr Jane Ruth Aceng presents the front-line strategies put in place to handle any epidemics and the roadmap to quality health services.
In a bare-knuckle interview with Nation Media Group-Uganda’s Walter Mwesigye, Health minister Dr Jane Ruth Aceng presents the front-line strategies put in place to handle any epidemics and the roadmap to quality health services.
Uganda is considered a hotspot for emerging and re-emerging infectious disease epidemics. Previously you mentioned that while we are dealing with Ebola and Covid-19, we are also dealing with the risk of Monkeypox, we still have Malaria and HIV. Basically we still have high alert disease burdens. We have also experienced several Haemorrhagic Fevers such as Crimean-Congo, Marburg, among others. The epidemics have overwhelmed the health system, devastated the economy and caused global health insecurity. What kind of approach are you taking as the Ministry of Health to control these outbreaks?
You are absolutely right when you say Uganda is prone to disease outbreaks and every year we respond to outbreaks. The most important thing moving forward is to completely provide information to the population. What I mean by this is to carry out intensive community sensitisation because epidemics occur in the community and end in the community. Whether it is Ebola, Marburg, Malaria or Covid, they all start from the community and one of the measures the ministry is taking is promoting community health education on disease outbreaks and how they can quickly detect them, and also how to respond in the event that they occur.
Second, we are scaling up our programme of community health extension workers. These are people that are trained for six months, two per parish, to quickly support the communities by providing health information because they live among the communities. For example, if the family notices something funny or in the village people are dying, these are the people we expect to report in real-time so that we can respond. We have already started this training in eastern and northern Uganda and we want to scale it up in the entire country so that we can have two community health extension workers per parish, one male and one female. They will not only be handling the disease outbreaks, but they will also be handling all the health problems that we have in the country including environmental health and sanitation.
Third, we are emphasising infection prevention and control in the facilities because many times when we get a case, the health workers are taken unaware because of very poor infection prevention and control measures. We noticed this during the Ebola epidemic. You will recall that many of our cases were occurring in private facilities among health workers. So, the structures that we have put up like the Ebola treatment unit, we are not dismantling them even if we don’t get any cases after January 11. We will maintain them for training purposes and we want to train health workers in every region so that we don’t move them from one region to another to control an outbreak.
We also want to build a capacity in every region so that at any one time they are on high alert. In addition, every health worker has to ensure that we maintain our protective wear like hand washing and masks, for examining every patient so that if there is a disease which we are unaware of, at least health workers are protected.
Uganda’s disease burden is topped by neonatal disorders, Malaria and HIV in the top three and we lose 16 children to malaria, 14 mothers to preventable causes, an average of 46 people each day to HIV/Aids. What have you not done right to control the spread because these figures are soaring up?
In regards to HIV, we have come a long way and we have managed to reduce new infections to 54,000 annually though that is not too good, we need to bring them down even further. We are still seeing new infections mainly among the younger age group between 15 and 49 years and majorly among females.
What we need to do moving forward, is to emphasise prevention, but also ensure that those who are on treatment adhere to their treatment because we know that treatment is also prevention.
President Museveni also set up a programme to end Aids by 2030 and one of the interventions is to seriously engage the youth as well as the men but also to make sure that we have adequate commodities including test kits because everyone needs to be tested and know their statuses.
In regards to neonatal mortality, we have a programme where we have been training midwives for safe delivery and encouraging every mother to deliver from a health facility.
However, we also have a programme to set up neonatal intensive care units in every region in Uganda, especially in regional referrals, to make sure that these newborn babies are attended to.
The challenges we have are deliveries that are carried out outside health facilities and when there is a problem, they are brought to health facilities and sometimes they have already got infections which are difficult to manage.
In addition, there are mothers who go into labour and come to facilities late. This will be addressed by community health extension facility workers linking mothers to health facilities.
Indeed malaria is a big challenge and mortality is high. There are several things we have seen and are trying to address. One of them is that, whereas we distribute mosquito nets every two years, only 70 percent of people consistently use these nets.
The second thing we have observed is that whereas we used to know from science that the mosquito that causes malaria only bites indoors, currently science has revealed that even outdoors, they are biting.
The third thing we have observed is that even the current parasite seems to have changed a little bit of its structure. So some RTDs (rapid diagnostic tests) are not detecting malaria parasites in people who have fever. So we have brought back the microscope. If the RTDs don’t review we bring the microscope.
There is also some degree of resistance to the anti-malarias because of abuse of the drugs whereby some people go and buy drugs off the counter and do not complete their dozes. So where we see some resistance, we have to bring on board treatment with intravenous quinine. This means that together we have to scale up lave siding to completely attack the vectors outdoors, we also need to scale up indoor residual spraying but with chemicals that work on the vectors because some chemicals that come on the market are not so good, and people need to go to health facilities early when they get fever and not wait a little bit too long like we are seeing in eastern Uganda where we are having cases of black water fever after malaria.
Black water fever is when the body breaks down its own blood cells and then passes out a Coca Cola coloured-urine and we end up with high mortality. Most importantly, we need to clear the bushes around our homes, remove the stagnant waters and also provide information to all our families to sleep under mosquito nets.
We still have a shortage of health workers and the challenges were exacerbated by the outbreak of Covid-19. What is stifling the minister’s effort to increase the numbers even when we have hundreds of unemployed health workers on the street?
There are several things. First, you know we recruit based on the structures that we provide to our health facilities and structures that are approved by the Ministry of Public Service. Currently, we have been operating with the structures that were made 10 years ago. These structures no longer hold. They are limited in terms of specialist numbers and in terms of a range of cadres. We started the revision of the structures about three months ago and we are nearly concluded. We are expanding the structures and providing all kinds of cadres to be recruited.
Second, is the Wage Bill. You may be aware that the government enhanced salaries recently and salaries alone take up 22.5 percent of our entire country’s budget. So we cannot keep on recruiting all the time because we might end up doing no other work apart from paying salaries.
Third, we have to recruit people who have been trained, tested and have the skills and position them in the areas where they are required. So, this needs the district and service commissions and health service commissions to be active and in place. However, some districts do not have that yet, especially the newly-created ones.
We hope to recruit people when we have an adequate Wage Bill and when we have concluded the restructuring, and we hope to conclude the restructuring by early February so that we are ready for any recruitment in the new financial year.
For the last two to three years, for some of us who had time to see Covid-19 taking the world by storm, as we tried to weed it away, we saw the outbreak of Ebola. What is the update on both outbreaks?
To start with Ebola, we have had 142 confirmed cases, 87 recoveries and about 56 deaths. We don’t have any other case on admission and we don’t have any contact on follow-up. All the treatment units are empty and today we are on day 23 of our countdown to the [end of the] 42[-day period with no case to declare the country free of Ebola]. However, we remain on alert with the epidemiologists in all seven districts where we had the outbreak. The village health teams are on higher alert. We continue to remove samples from the alert cases. In addition, we have a surveillance tool for Ebola that is rolled out in the entire country. That tool has a tick-off where if anybody comes down with the fever, we interview you, so when we have many ticks, we remove a sample from you and also test for Ebola. It is a screening tool and we want to utilise it for 90 days of intensive surveillance to make sure that there are no more cases of Ebola. The situation generally is promising but we remain on higher alert.
Then for the Covid-19, our positivity rate is 1.1 percent. We see about eight cases of Covid every week. We don’t have any case on admission, we don’t have severe cases. However, our vaccination coverage remains low at 43 percent of 28.5 million people. The 28.5 million people include 22 million people who are 18 years and above and six million people are 12 to 17 years.
We have vaccines in all vaccination centres in the country and we want to encourage the population to get vaccinated because we see Covid cases are on the rise in countries like China, USA and some countries in East Africa. So, this means that Uganda is still at risk. We need to scale up vaccination so that we can be safe. The vaccines are available in every facility where we do routine immunisation.
I know the trials for Ebola vaccines have been pushed to January because of lack of qualified people to take part in the trial. What is the impact on Uganda and also to plans and the hopes to find a possible candidate for the Ebola Vaccine?
Well, the protocol to the trials was designed in such a way that the vaccines would be given to contacts. Currently, we don’t have contacts. However, as a country, we would not want that research to stale and put aside. Our scientists are having a discussion on how to progress with this trial because what we need to know is whether the vaccine can produce the antibodies that can protect the people. So we are leaving the scientists to analyse the situation as we proceed with the countdown. If there are no more cases on [January] 11, we shall declare [that we are Ebola-free] but the scientists will come up with the protocol on how we can proceed because even when we still have vaccines coming into the country this week, from Mark and Oxford and we want to utilise this opportunity because we know for sure that in the future, we will get another Ebola outbreak and we do not want to be taken by surprise.
Funding for Ebola was quite problematic. The country did not come out to provide substantial funding even when they put in a request for money to deal with Ebola. What does this say about our preparedness as a country?
It is not true that the government did not provide money. The government did provide $6m (about Shs21.3b) which was part of the funding that had already been provided for us to respond to Covid. The government allowed us to re-programme this money to respond to Ebola.
Epidemics are difficult to predict. You will never know when they will occur. One of the weaknesses we have as a country is having readily available funds that are not affected by the end of the financial year where the public management act clearly states that money has to go back into the treasury. That makes it difficult because you never know when the epidemic will occur
However, the government has also allowed us to work on a law where Uganda can create a National Public Health Institute like the Ugandan CDC that can readily have the available funds to respond to the epidemics. We are working on this and hopefully, when it is done, we can find a way of having some funds re-faced to respond to epidemics. Currently, it is difficult.
We have facilities like Mulago Specialised Women’s Hospital that have been operating silently above 50 percent of the expectations and they receive funding every year. Would you consider them a white elephant?
No, I wouldn’t consider it as a white elephant. I think women’s hospitals still have challenges but it can do better. It has challenges in terms of funding which is not adequate to run a big facility like that. It has challenges in human resources and specialists to run the facilities. It has challenges in terms of marketing itself, for the population to understand that we have such a facility and can provide a wide range of services. But also has challenges regarding the management of services. So we are addressing this together with the board. [Public] Service Commission is committed to recruit more personnel as soon as the Wage Bill is increased and also we are looking at ways of making it
The population needs to understand that specialised facilities cannot be filled up 100 percent because they offer specialised services and these services are not cheap, they are extremely expensive. So a women’s hospital to be filled up with patients, it is not something that will ever happen. However, what we want from it is timely and better service offered to the population.
The ministry is still struggling with funding year in and year out. The funding that goes to the Ministry of Health has never come to the expectation. It has never met the Abuja Declaration of 15 percent on the national budget. Where do our priorities rely in terms of creating a preventive stance to health other than a curative one?
Prevention is actually our main emphasis as the Ministry of Health. That is why we are talking about sensitising the communities and community health extension workers because this will cover the 75 percent of the disease burden that is preventable and leave us with 25 percent that will go to the health facilities for repair of their health when it is damaged.
These community extension workers that we are talking about are trained for six months to handle all aspects of diseases and the community engagement. We are talking about sensitising the community on all aspects of diseases. That is what we mean by health promotion and disease prevention
However, the sensitisation of the community is not something cheap to do rather it requires more funds to put in clinic treatment. It has to be done with the help of the community extension health workers, media among others. So, now we are ensuring that every district runs this programme
How much do you need to do this sensitisation exercise?
I don’t know how much we need because media houses are not cheap and I can’t tell you how much we need currently because we are still working wholly on this in terms of costing.
On a lighter note, you went from Covid to Ebola and other times you were urging the scientists not to go far away from their work stations. Is there a point in time when you felt fatigued?
Walter, we are tired, all of us are tired. Everybody is preparing for a festive season and I am deploying epidemiologists in the field and the message they are having from me is stay in the field. They cannot come home. We are all tired but we have nothing to do. We need to ensure that all people have good health. So, we have to continue doing our work because it is a calling. Hopefully, the year will end and we don’t get another epidemic so that we can take some rest but the truth is all my health workers are tired.
Your last word
Fellow Ugandans, allow me to congratulate you on reaching the end of the year and, especially this festive season when we celebrate the birth of Christ. My appeal to all of you is to be responsible. Each and every one of us are responsible for our health, please take care. Remember we still have HIV, we are not yet out of the woods with Ebola. Therefore, we need to remain on alert but also remember to wash your hands and avoid hugging one another, however happy you are. Celebrate in the mood that is responsible.
Some tools Uganda used to fight Ebola
Lockdowns, contact tracing.
The government put several districts under lockdown, including Mubende where the outbreak was first detected.
Those who died of Ebola were buried under strict anti-transmission protocols.
The US embassy in Uganda supported a vaccine trial on humans, combining the antiviral Remdesivir with monoclonal antibody MBP-134 to use against the Sudan strain. The first shipment of MBP-134 arrived in Uganda in early October and was administered to patients, according to the embassy.
Transcribed by Dorothy Nagitta