Why Ugandans die young

About 54 percent of persons in developing countries that are pronounced dead as a result of health emergencies could have been saved, according to a World Health Organization (WHO) 2018 study.
Here in Uganda, the statistics could eclipse the average statistics of developing countries in a country with a moribund health sector—void of emergency services and one of the highest road accidents and alcohol consumption rates in Africa.

In 2022, WHO ranked Uganda among the countries with the highest traffic death rates in the world, estimated at 29 car deaths per 100,000 people. This figure is of concern as it exceeds the 24.1 deaths per 100,000 people for the African continent and 18.0 deaths per 100,000 people globally.
There is also a nexus between gross road carnage and alcohol abuse as those reeking of alcohol lead to a spike in road accidents.
The 2023 WHO statistics cast a pall on Uganda’s society, which is ranked as the highest consumer of alcohol in Africa. On average, each Ugandan consumes 12.21 litres of alcohol annually.

Medical experts, including Dr Tonny Luggya, a critical care specialist at Mulago hospital and head of Emergency Medicine at Makerere University School of Medicine, fear the statistics could be much higher. 
“These are statistics we get from police and it’s not well organised in terms of trauma registry, so there are things we don’t even see reaching the registry and statistics,” he told Sunday Monitor, adding, “The people who drown in the lakes, the people who die in accidents and never reach the hospital.”

Costly delays
Many road traffic accident victims in Uganda and others suffering life-threatening injuries are not able to receive essential surgical care—including trauma, surgery, and anaesthesia care—within an hour, who are predominantly young adult males and school children, studies reveal.
The window of opportunity for a chance at survival is narrow for a severely injured patient as road traffic and other injuries kill more people every year than HIV/Aids, tuberculosis, and malaria combined. 

Time is of the essence in what medical practice terms as the golden hour—a critical period of time immediately after an injury when appropriate life-saving medical or surgical intervention can offer the highest chance of survival for a traumatically injured patient.

Uganda’s road carnage is fuelled by the ailing state of its narrow roads and the chaotic boda boda cyclists given that motorcycle fatalities increased by 51 percent from 2011 to 2016, according to a study by the WHO. 
Additionally, the death-toll on Uganda’s water bodies, where rickety vessels typically not fit for purpose and standard safety protocols such as the provision of life jackets are regularly flouted, contributes significantly to the burden of emergencies. At least 239 deaths were recorded on Uganda’s water bodies, according to the 2020 Annual Police Crime Report. 

A perfect storm
Alcohol consumption also increases the risk of health emergencies such as pancreatitis— a sudden and acute inflammation of the pancreas that requires urgent medical attention.

Furthermore, obstetric and neonatal emergencies contribute significantly to the burden of emergencies given the high, albeit declining pregnancy related mortality ratio of 228 deaths per 100,000 live births as indicated by the 2022 Uganda Demographic Health Survey. There is also an increase in emergencies due to non- communicable diseases such as stroke and cardiac arrests.
Such health emergencies are managed through the provision of emergency medical services, which are defined in the Health ministry policy of 2021 as the “ability to deliver health services for conditions that require rapid interventions to avert death or disability, and for which delays of hours can worsen prognosis or render care less effective.” 

Dr Luggya explains: “[…] statistics show between nine and 10 percent improvement in survival, if the first responders do the basic life support training, which is basic emergency training. When a person is bleeding, put him on the side, put a tourniquet, prevent the bleeding, and take him away from the site. The challenge in Uganda is that the first people on the site take videos for sharing on social media or if it’s a petrol truck, they will be siphoning fuel.”
This medical care encompasses first aid—transportation of the patient from the scene of the emergency to a health facility— the care provided during transportation by paramedics and the care received at the health facility on arrival.

“We did three drills from the airport with CAA (Civil Aviation Authority) where they were timing the ambulances that left Kampala to go to Entebbe for the drill and come back. Going was double the time it took to come back because of [traffic] jam and people not understanding they have to clear the way of the ambulance,” Dr Luggya disclosed.
This suggests that salvageable patients are dying before they reach the hospital. 

Emergency services
Dr David Muganzi is part of the Seed Global Health cohort that is training medical students across universities in Uganda in emergency medicine. He says “emergency care is very important” so much so everyone must have access to it “despite where you come from”.
He adds that, “the system has to be good enough that it can serve a minister, it can serve a farmer, it can serve a teacher.”

The Seed Global Health Uganda country director, Ms Irene Atuhairwe, says, “When you look at our mothers, most of them die because of emergency conditions. We have bleeding, we have hypertension, we have eclampsia, we have sepsis, all results of emergency conditions. The Ministry of Health has now prioritised it. We now have an emergency care policy and things have changed after going through Covid, we have seen the impact that it has on the population, we have been able to prioritise [emergency care] it.”

“More than 70 percent of the deaths that we get in this country, and if you go to Mulago [hospital] most of the injuries that require services are now mainly accidents and emergencies that occur. Emergency is very important, it should be attended to as quickly as you can to save lives, when you delay, you may never save the person. Every minute counts,” Dr Vincent Oketcho, the chairperson of Seed Global Health Advisory board, says.

Troubling findings
In 2018, a research into the state of emergency medical services in Uganda foreshadowed a crisis that could cripple the health sector in the event of a global pandemic outbreak. Barely a year later, the Covid-19 pandemic barrelled across the country, bringing its shambolic services to a shuddering halt. 

The research, whose principal investigator was Dr Olive Kobusingye, a trained surgeon, revealed that Uganda did not have a national policy on emergency medical services and no such policies existed at district level.
For instance, ambulances, which are acutely short in supply, almost universally, lacked the most basic of equipment and medicines both to monitor, and to treat emergency conditions. 
It was discovered that advanced life support equipment within ambulances like vital signs monitor, electrocardiogram machines, defibrillator and Intubation were missing.

The research also revealed that police, laypersons and bystanders were the first responders in the majority of the districts, with figures placing this at 97.4 percent. 
Dr John Nabohe, the Commissioner for Emergency Medical Services at the Health ministry, acknowledges this deficit. 
“About 10 percent of our emergency patients reach the hospital using an ambulance. It’s only in Karamoja where it is now at 25 percent,” he said, adding that the difference is “because of the insurgency that is [in Karamoja]” that has compelled its inhabitants to be more organised than elsewhere.

No equipment
Health facilities in the country are also poorly equipped to manage emergencies. At health centre IVs, general hospitals and regional referral hospitals, there are shortages of medical equipment necessary for assessment of patients presenting with emergency conditions. There are limited numbers of emergency care specialist health workers at the facilities. Uganda’s doctor-patient and nurse-patient ratio is approximately 1:25,000 and 1:11,000 respectively. This is way below the WHO recommended doctor-patient ratio of 1:1,000. 

“Our biggest problem is having one theatre, with one operating bed, which [means] a long period from the time a mother comes you want to take her in for caesarean section but there is no space,” Kabitanya Lukia, a midwife at Mbale Regional Referral Hospital, told Sunday Monitor.
This is worsened by the government’s chronic underfunding of the Health ministry and the failure to allocate 15 percent of the National Budget to the health sector as per the Abuja Declaration. 

This means the public health sector is heavily-reliant on donor funding from development partners such as the United States, which gives the government nearly $1 billion (Shs3.7 trillion) annually, much of which is given to the health sector. 

The funding gap for emergency medical services in Uganda is pronounced given that for every $2 (about Shs7,000) the government of Uganda spends, donors are expected to spend $1 (about Shs3,700). 
Interventions by development partners such as Seed Global Health to train local specialists in emergency care may not be sustainable given the short-term nature of such projects. Critically, the emergency medical services strategic plan is grappling with a shortfall of $82.6 million (about Shs307 billion).

In light of these resource constraints, the role of the community comes into sharp focus as an acute care resource, as Dr Nabohe elaborates.