Unending battles: Evolution of Ugandan doctors’ strikes

Members of Uganda Medical Association hold placards during a press conference at Mulago Guest House, Kampala on March 30, 2022. PHOTO/ISAAC KASAMANI

What you need to know:

  • Strikes by medical workers seem to have become an annual event in the last 10 years and there are indications that they will not end soon.

Given the frequency of strikes and rumours of strikes by Ugandan doctors, nurses and other medical workers, it would be safe to say industrial action is part of the health service delivery cycle.

Industrial action by medical workers dates back to between the 1990s - 2009 when there were various annual strikes (Bergman L.P., 2014). 

1996 saw the first nationwide doctors’ strike after which the Uganda Medical Workers’ Union was formed. 
In 2015 medical interns went unpaid for four months in Lyantonde and five months in Gulu, leading to industrial action for which some were suspended. 

In 2017 the Uganda Medical Association called for a 100-day strike demanding better pay, adequate equipment and supplies, and the placement of medical interns (JHOs) and senior health officers (SHOs), on the Public Service payroll.  

There was industrial action during the pandemic in 2021 followed by 2023’s Senior House Officers’ strike. It goes without saying that the unmet demand each time was for an enhancement of doctors’ salaries. However, there have been developments. 

Industrial action has evolved in important ways. The demands have become more articulate. As a result, the public is now more aware of how the public health service works. 

It is clear for the first time that interns are qualified doctors undergoing clinical training and SHOs are in training for various specialisations. This fact was revealed in 2021when the Minister for Health, Dr Jane Ruth Aceng, reportedly told striking interns that internship was not work. Therefore, they would not be placed on the public service payroll.  

During the 2017 strike, Ms Aceng, said the Uganda Medical Association (UMA) was an illegal organization despite its registration in 1974. The State Minister for Primary Healthcare, Ms Margaret Muhanga, took a more combative approach calling one doctor a ‘loser’ on social media. Ms Muhanga went on to celebrate the fact that “the most wanted specialists haven’t laid down their tools.”

Well, in February 2023, the specialists in training laid down tools. After a fortnight, the government has been able to pay some of the SHOs who have agreed to suspend the industrial action for a month as more funds are being sought and UMA’s proposed long-term solutions are discussed. 

On Sunday, Dr Robert Lubega on behalf of SHOs, told the media that the government had released allowance arrears for two out of four months (November and December) to some continuing senior house officers.

Dr Lubega, who is from Mulago National Referral Hospital,  said there are 692 SHOs in the country.
“Following this gesture from the ministry of health, the steps taken by National Resistance Movement (NRM) secretary general, Mr Richard Todwong, and the support shown to us by the Parliamentary Health Committee in prioritising our issues, the SHOs held a general assembly this week and resolved to suspend the industrial action for one month,” Dr Lubega said.

He, however,  said  the first years and some continuing SHOs have not been paid  because the  Ministry of Health  said it has a  budget deficit of about Shs8.36 billion per year. The ministry is  thereby not able to pay the more than  600 SHOs.

Dr  Lubega said:  “This will mean that the first years who haven’t received anything now, will have missed payment for five months after the end of this month, which will not be fair for them to continue serving Ugandans on empty stomachs,” Dr Lubega stated.

The UMA leadership team said if the issues are not resolved within a month, they will resume the industrial action.

2017 was pivotal
However, the 2017  strike  was a turning point in industrial action. 
Apart from being well articulated, the list of demands by UMA was widely accessible on electronic and social media. They went beyond pay and addressed the systemic issues leading to frequent breakdowns in discussions between public doctors and their employer. 

UMA demanded placement of medical interns (JHOs) and SHOs on the Public Service payroll. They presented a research-based case comparing their remuneration with that of doctors in neighbouring countries.

The then  President of UMA, Dr Ekwaro Obuku,  reportedly said the only  acceptable outcome of the industrial action was  “a signed collective bargaining agreement which we will use as a point of reference for what is due to Uganda  Medical Association.” 

He said there was a need for the government to enhance allowances of medical workers. These allowances include transport, housing and medical risk among others.   

At the time, the doctors wanted the government to pay medical assistants and teaching assistants Shs 15 million, senior consultants and professors Shs48 million including allowances, a house, vehicle and domestic workers. 

For medical interns, they proposed a  pay rise from Shs 960,000 to Shs 8.5 million.

Dr Obuku, who was a gifted public speaker and not shy of addressing the media – both important in industrial action, said:“When you are setting the agenda, the politics, the problem and the people, need to meet. The problem has been chronic and the people have organised themselves (Observer, November 15, 2017). 

The doctors had come of age. That may be why the 2017 strike was the first in which state brutality was deployed. 

The 2017 industrial action ended without an undertaking by the government to increase equipment and medical supplies at health facilities. 

Neither was a collective bargaining agreement reached. But the aggrieved doctors learnt about effective communication.

In 2021, JHOs under their umbrella organization, the Federation of Ugandan Medical Interns (FUMI), demanded enhanced allowances and required the government to address systemic administrative issues, namely; recurrent shortages of medical supplies, technologies and vaccines, working conditions that lead to burnout,  understaffing, and, unemployment among doctors despite acute shortages in public health facilities. 

They demanded that all vacancies in Health Centre IVs and National Referral Hospitals should be advertised and filled by 31st October 2021. They also asked for the inclusion of JHOs and SHOs in the establishment or salary structure, the deployment of dentists at health centres countrywide and tax reductions on equipment and oral health aids. 

This time, there was solidarity and support from the Makerere University Students’ Guild, SHOs, doctors of Mbarara University, China-Uganda Friendship Hospital Naguru and the Uganda Dental Association. 

The online community also came on board, keeping the industrial action top of the public discourse for several weeks.

Predictably, force was used against doctors demonstrating in public places. The humiliation usually reserved for political activists was meted out against them and the public was treated to the sight of white-coated medics cowering below baton-wielding armed men. 

Again predictably, the strike leaders were invited to State House where the action ended when the government agreed to back-date enhanced allowances for interns, pharmacists, nurses, and midwives. 
Quality of life, inadequacy of medical supplies and vaccines were not mentioned again. 

This year, 2023, the sticky issue has been the 4 months of unpaid allowances of SHOs promised in the 2021 agreement. The government has failed to hold up its end of the bargain. 

In addition to payment of arrears, UMA demands a final resolution of the position of JHOs and SHOs in the public medical service and adequate equipment and supplies.

Still, there has been further indirect civic education. This is important because it may be the only source of widespread civic education because the public has learned that there is a thirty percent shortage of doctors in public health facilities.

It is now known that SHOs currently fill the gap with their sporadically paid labour. What the majority have to look forward to once they complete their training, is postings in hard-to-reach areas at inadequately equipped and under-supplied health facilities with no accommodation. 

Although the issues have not been as well articulated as in 2017 and 2021, a Twitter Space discussion hosted by DrJoel Mirembe on 27th February 2023 threw more light on the situation. 

Despite the absence of invited government officials, listening in was educative. For instance, it had not been public knowledge that Kiruddu National Referral Hospital only has thirty-six percent of the staff it requires and Kawempe National Referral Hospital has less than half of the specialists it needs. 

The gaps in both hospitals are filled by SHOs.
Dr Muhwezi Muhereza, a former Secretary General of UMA and one of the leaders of the 2017 strike was present. He spoke about the health workers’ quality of life and said that even with enhanced pay, postings to areas where there are few amenities such as schools of an acceptable standard for their children, discourage medical practitioners (the same can be said for teachers and other public servants). 

He proposed that the government should devise means of housing doctors and building model schools in the remote areas to which they can send their children. And that is the crux of the matter. 

The public health service cannot thrive without human development in the general population.

Good schools for the children of health workers can only become a reality if they are accessible to the general population.

Decent rental accommodation will not spring up in poor communities simply because doctors have been posted there. 

Family entertainment and extra-curricular activities, all are the fruit of thriving communities. 
In short, the expatriate model will not work. Doctors are poor and deprived because they serve in communities with low human development.

Dr Muhereza said the isolation and total ennui of life in remote areas can be destructive to young people posted there. He said the lack of interaction with peers has led to the adoption of poor lifestyle choices the outcome of which has been alcoholism in some cases.

From a strategic planning point of view, it is arguable (and I stand to be corrected) delivering health services is more successful in educated communities. For example, government says it plans to move Uganda towards preventive medicine. That will require a lot of awareness-raising and education.

The country will need a population able to appreciate for example, the dangers of self-medication and the roles of nutrition and exercise in preventing disease. Dr Yonas Tegegn Woldemariam, the  World Health Organisation country representative, has in the past said that an estimated half of  Uganda’s population (even in rural areas) could be diabetic.

Returning to the recent online discussion, the head of Parliament’s health committee, Dr Charles Ayume, was adamant that the root cause of underfunding in the health sector is poor planning by the Ministry of Finance and the Ministry of Education.

The latter, he said, licenses an elastic number of private institutions to train medical personnel and expects them to be absorbed by the public service. 

Worryingly, Dr Ayume hinted that some private institutions compromise on the quality of their student intake.  
He did not interrogate the issue of corruption and waste and the unnecessarily high cost of administration. This was an oversight if it is correct that Shs32 billion that was supposed to produce vaccine candidates and no vaccines have been produced to date, then it was wasted. 

That amount is close to the annual amount required to remunerate SHOs. However, Dr Ayume concluded correctly that even if the health sector budget share were to be raised from the current 6.8 percent to the Abuja Declaration’s fifteen percent, without addressing the governance issues, the government would be wasting its time. 
This brings us to the critical question, is the government competent to deliver adequate health services? 

Dr Francis Omaswa, a cardiothoracic surgeon who counts co-founding the Uganda Heart Institute among his many achievements, participated in the Twitter Space. 

He shared that the government set up an inter-sectoral task force to resolve the problems within the health sector. He was asked to write a paper for the Prime Minister which he duly delivered but he has heard nothing more about it. 

But with all government commitments, timely payment is not guaranteed. 
Terms of service, working conditions and availability of equipment and supplies are not even on the negotiating table yet.  

But substantial progress since the 1990s and 2000s has been in public engagement. The public has been able to observe just how detached from their needs their government is, and has a better idea of what it will take to extract decent service delivery from it. 

More intentional civic education by UMA is needed to attract a wider circle of solidarity from the public. 
The out-patients waiting in hospitals could have the background to the industrial action explained to them, possibly in leaflets they can later pass on.

The public also needs constant assurance that emergency services are still available. As Dr Ekwaro Obuku said in 2017, “The doctors have provided the leadership and Ugandans have supported them saying this is a problem that needs attention.”  

*The author is a social-political commentator