The sick hospital system in Uganda

The death of Cecilia Nambozo in the labour ward of Mbale Hospital,
last month, mirrors the massive problem health centres are facing all
over the country. She is just one in 16 who die everyday during
labour.

The government last Wednesday outlined a six-point ‘fire-brigade’
response to salvage the country’s ailing health care system after the
death, during labour, of a primary school teacher in Mbale District
sparked public fury countrywide.

On September 6, when Cecilia Nambozo died, 15 other expectant women also passed on, their deaths unreported, since the Health ministry says 16 would-be Ugandan mothers lose their lives in labour daily. Thus the 5,840 annual maternal deaths backpedals the country’s drive to achieve Millennium Development Goal Five of reducing maternal
mortality by three-quarters by 2015.

Nambozo’s case was not particularly unique or the first one to stir
anger. In August 2009, residents attacked Mityana Hospital after
Sylvia Nalubowa of Bussujju village died with her baby during labour
allegedly because staff wanted to take a bribe before they could
assist.

Even in the Mbale case, it was reported that medics asked for
Shs300,000, which relatives of the deceased never paid, although the
allegation is yet to be substantiated. Government’s blue-print issued
by Health minister Christine Ondoa says their preliminary
investigations showed Nambozo died due to “negligence” by the health
workers. She said: “Investigations are still going on and that
disciplinary action will be taken on all health workers implicated in
the incident.”

Already, police arrested senior medical staff that were on duty at
Mbale Hospital that fateful day and the Director of Public
Prosecutions is studying the evidence on file against them to
determine if they should be formally charged in court and prosecuted.
Dr Ondoa, herself a consultant paediatrician, in last Wednesday’s
press statement announced measures to crack the whip on all errant
medical staff while promising to make medical supplies available.

Experts say such willy-nilly pronouncements that render health workers
culpable may be music to the citizens’ ears, but masks the systematic
decay, which is at the core of failing service provision at public
health institutions.

Already public health institutions such as Mbale Hospital routinely
report stock-out of essential drugs and supplies alongside shortage of
already poorly-remunerated but overwhelmed staff. It is understood
that some 12 midwives that the Health Service Commission recruited and posted to Mbale Hospital declined to take up the job.

Our investigations show that on the day Nambozo died, 11 hours after
reporting to the health facility, the hospital was apparently being
manned by interns. It had had no sutures (stitch threads) for more
than two months and every expectant mother was required to come along with stitching threads.

The only medical officer on duty, an obstetrician, Mercy Nassali, had
been in the one-bed theatre from morning and exhausted by the evening hours when the condition of Nambozo, who initially appeared likely to give normal birth, worsened. The obstetrician, with the help of one intern doctor, was at the material time attending to a woman with arm prolapse.

Arm prolapse is a condition during which a baby’s hand presents first
to obstruct labour, making it one of the “most serious” delivery
emergencies, according to Dr Rogers Ayiko, a maternal and child health
specialist, working for Doctors with Africa (CUAMM), an Italian health
organisation.
He said such an emergency can make the unborn baby
suffocate and is usually treated as a first priority to handle. Two
other interns continued handling all patients presenting with labour
complications while one midwife monitored the progress of nine other
women who had reportedly given birth at the hospital.

Dr Daniel Zake, a gynaecologist at Nsambya Hospital, a private
facility, said every maternity bed should be attended to by at least
two midwives. Health workers at public health facilities, however,
told us a midwife at a government facility handles anywhere between
four to 10 expectant women in a day.
This appears to have been the case with the lone midwife on duty at Mbale Health facility on September 6, who was taking care of nine new mothers, resulting in fatigue and diminished quality of care.

Health Minister Ondoa in a separate interview on Friday, said that the
World Health Organisation (WHO) has lately revised its definition of a
health worker to mean a combination of a doctor, nurse and midwife.
Under the health agency’s new guideline, such a cadreship of medical
professionals should handle 1,000 people. “If a country has less than
2.5 health workers per 1, 000 population, that country is in crisis,”
Dr Ondoa said. Uganda is operating significantly below the new WHO
standard.

The minister said the country’s present situation is “bad because we
don’t have enough health workers, but it is looking the future is
going to be good”. Why? Dr Ondoa said in the month of September alone, they recruited 150 health professionals and posted them to health facilities most in need and a total 1, 000 new health workers are
likely to be employed by end of next year if ongoing negotiations with
development partners succeed.

It is understood Nambozo’s uterus ruptured with the overweight baby
around 7pm and she wasted away fast because there was no blood stock at both Mbale Hospital and the Regional Blood Bank to transfuse her.
Her relatives had not bought the required sutures either. The National
Medical Stores that manages the budget for drugs and medical supplies
of all public health facilities had allegedly not supplied the
post-surgery stitch threads to the hospital in more than two months.

This newspaper understands that when Nambozo’s health deteriorated
sharply, the health workers decided to pick sutures from another
patient and rushed her into the theatre. Already acutely anaemic, she
was pronounced dead at 8.30pm.
Her demise, which Ministry of Health Spokesperson Rukia Mbaziira attributes to false starts by the health workers, exposes the many inadequacies and failures in Uganda’s health systems separately documented in an ad hoc report prepared by the Foundation for Human Rights Initiative (FHRI).

Asked why the government has accused the health workers of negligence when they appeared stretched to the limit amid a dearth of medical supplies, Ms Mbaziira, who admitted “some health system challenges”, said it was incumbent upon decision makers there to summon staff who were off-duty once it determined the workload was overwhelming.

In the meantime, she said, the ministry had decided to absorb all of
this year’s intern doctors on one-year temporal arrangement until the
Health Service Commission formally recruits them at a later date.
FRHI’s 2010 report titled, “The Right to Health Care in Uganda”, shows
the government is in default on its commitments to health; its
allocation of 9.8 per cent of the national budget this fiscal year to
the sector, down from 10.3 per cent in the 2009/10 FY, contrasts with
the 2001 Abuja Declaration that obliges African states to dedicate at
least 15 per cent of their revenues, excluding donor financing, to
health.

Uganda had prior to the declaration accelerated its allocation to
health as a share of the national budget from four percent in 1997 to
nearly 17 per cent in 2000 before dropping the vote to below 12 per
cent in 2003 and 2006.

It was within the period of higher funding to the health sector that
the country shone internationally as a poster child for fighting
HIV/Aids, although much of the money came from donors. That
notwithstanding, the positive results showed in part that increased
investment in health – when officials do not pilfer the resources for
self-enrichment – improves citizens’ welfare and productivity. But
this financial year, the government has engaged a reverse gear and
slashed the Ministry of Health allocation to just 9.8 per cent of the
national budget, injecting more money instead into infrastructure
development.

The Regional Network for Equity in Health in East and Southern Africa
(EQUINET), which monitors the implementation of the Abuja Declaration,
in April 2008 reported vast fluctuations. It noted: “This research
demonstrates that some seven years after the Declaration, many of the
countries are still lagging well behind this target…”
That same year, Nobel Peace Prize Winner Archbishop Desmond Tutu, who is the honorary chair of the ‘Africa Public Health Alliance 15 per
cent Now Campaign’, urged African Heads of State and government not to in any way “revise, drop or further delay implementing the Abuja
Declaration”.

Describing the Declaration as the “most important” commitment African
leaders had made towards health financing and development, Archbishop Tutu said: “The continued loss of millions of African lives annually, which can be prevented, is unacceptable and unsustainable. Our leaders know what they have to do. They have already pledged to do it. All they have to do now is actually do it. This is all we ask of them.”

Even when there is marked growth in the number of health facilities,
improving access in parts of Uganda to a four kilometre radius,
according to the 2006 household survey, physical availability of the
infrastructure has not been matched by improved health services
because drugs, diagnostic machines and qualified personnel are
lacking. For example, HRFI researchers found during their study
carried out for six months (January to June 2010), and covering nine
districts, that people in rural areas, frustrated by lack of doctors
and medicines, are increasingly turning to mushrooming yet unregulated
traditional healers for treatment.

Worse still, in most rural areas, as is the case at some urban health
facilities, ambulances are either non-existent, not fueled or in
disrepair to effect transfers during referrals.

The FHRI reported that the government of Uganda is obsessed with
physical presence of health structure but not their functionality. It
also questions the rationale of the National Medical Stores (NMS)
having to manage budgets of all public health institutions when some
lower-tier health centres can hardly quantify their drug requirements
over months, resulting in stock-outs. As such, patients return with
their prescription forms home, staying for sometimes weeks without
medication, and turn up to swamp health centres when they catch wind of delivery of drugs.

The government appears aware of just how the failing health system has exposed it.
In the Wednesday’s press statement, Ondoa announced commencement of maternal and perinatal death audits at health centres to determine their possible causes and recommend implementable control measures.

Many observers say the government knows the hamstrings but is just
dithering to fix it – in the process leading public health institution
that offer treatment on the cheap to atrophy as private ones, many
owned by bureaucrats, thrive.

The good news is that Dr Ondoa says this time around her ministry is
determined to provide mama or delivery kits, unlike presently where
NMS charges for their supplies, to hospitals and all village health
teams at no cost; more health centres will be built and blighted ones
renovated and mass sensitisation undertaken to educate Ugandans on
safe delivery methods.

It is hoped these measures will propel Uganda to the league of nations
that have reduced maternal and child mortality but it is uncertain if
the hand of the first female Health minister will indeed heal Uganda’s
ailing health sector.
Source: Daily Monitor
http://www.monitor.co.ug/Magazines/Health+++Living/-/689846/1247262/-/mc1l4vz/-/index.html

For lack of Shs300,000, teacher bleeds to death in Labour Ward

18th/september/2011
The contractions had started at dawn. Cecilia Nambozo, a teacher at Busamaga Primary School in Mbale Municipality, knew it was time, so she did what was expected—checked into a hospital at 6am so she could give birth with expert attention at her disposal.
But that was not to be, for more than 10 hours after Nambozo checked into Mbale Regional Referral Hospital to bring unto the world a life, she was ignored, neglected and writhing in pain. Her crime? She did not have Shs300,000 the hospital medical staff demanded before they could attend to her. And so she wasted away as her husband, Mr Richard Wesamoyo, made desperate runs around the village to raise the money.
That chilly September 6 still haunts Mr Wesamoyo. Nambozo arrived in the hospital at 6am but was reportedly neglected in the Labour Ward until 8pm when she breathed her last. Even then, it is the hospital cleaners who helped remove the baby from her womb. “The lady could not push because the baby was big. The doctors demanded for Shs300000, which we could not raise,” said Ms Grace Acham, a neighbour who had helped transport her to the hospital.
Ms Acham said they had spent the little money they had to purchase surgical equipment. “And when I came back, I found her in pain, crying, there was no help. The medical workers looked on as they asked for money,” she added. Ms Acham said after three hours of waiting and sensing that Nambozo’s situation was deteriorating, she approached a midwife and asked her to attend to her as the husband ran to the village to sell property and raise the money but the midwife and a doctor allegedly declined.
“At about 6pm, Nambozo started gasping; she fell on the floor and was bleeding. That was when the doctor responded and took her into the theatre but it was too late; her life could not be saved. She died.” she said.
The doctor emerged from the theatre after about 10 minutes and announced that both the child and the mother had died, Ms Acham added.
Mr Wesamoyo told Sunday Monitor that his humiliation was iced when medics abandoned his wife’s body in the Labour Ward with the foetus in her womb. He said the body was removed by cleaners
“They rolled the bed out in the open and started operating her naked for all to see. It was very dehumanising and humiliating for her to be stripped naked by cleaners,” said Mr Wesamoyo. He said they had been going for antenatal check-ups at the hospital and the midwives had told them the baby was big and that it would be difficult for her to have a normal birth. Apparently, the midwives had recommended a caesarian operation for Nambozo.
Police investigate
Dr Bernabas Rubanza, a police surgeon who carried out the postmortem, said the baby weighed 5.2 kilogrammes and that Nambozo died due to failure to push that made the uterus to rapture. He added that due to neglect after the uterus malfunctioned, Nambozo had bled to death.
“This lady reached the hospital at 6am and pleaded with the medical workers for an operation because she knew her status but the medics refused to attend to her until her uterus raptured. This is a pure case of neglect,” said Dr Rubanza. He added: “And this is not the first case at this hospital; many women have died in labour out of neglect.”
Mbale District Police Commander Jacob Opolot said a case has been registered and investigations have started. “We received a complaint and we have opened a file and summoned the medical staffs on duty that night and the day to furnish us with information,” said Mr Opolot.
However, the hospital director, Dr BenonWanume, said at the time of Nambozo’s death, there was another woman undergoing an operation in the theatre and that it was inadvisable to halt the ongoing operation.
“And in any case, it is not the patient who asks for theatre but we examine the patient and recommend. Doctors on duty examined her and by the time they recommended her for theatre she had already raptured her uterus,” he said.
Dr Wanume added: “She was bleeding and we could not save her life. I can’t rule out the issue of asking for money. Some staff do it but we need to investigate this further because it has no proof.”
He said the people who operated Nambozo to remove the foetus where not hospital workers but imposters who sneaked into the hospital.
Source: Daily Monitor
http://www.monitor.co.ug/News/National/-/688334/1237880/-/bj7s7pz/-/index.html

Activists want extra Shs75b health funds

As the Social Services Committee in Parliament prepares to pass Shs1 trillion health budget this afternoon, activists demand that an additional Shs75 billion be passed as a supplementary budget for the health sector to address staff recruitment and remuneration.
This, they say, will be key in curbing the current sorry state of maternal health, with about 6,000 women dying while giving birth annually.
According to the activists, an additional Shs75b is enough to recruit 5,000 professional health workers and enhance their allowances, which is the ministry of health target this year.
The country Director International HIV/Aids Alliance, Mr Leonard Okello, said there was no need to spend money on supervision when there were no workers to oversee the health centres.
“Rural health facilities are understaffed that is why regional and national hospitals are always flooded. Why can’t government facilitate only one supervisor and use the rest of the money to staff health centres?” Mr Okello said.

Source: Daily monitor
www.monitor.co.ug/News/National/-/688334/1232842/-/bjb9w2z/-/index.

Whose interests do the honourable MPs represent?

From a vantage point in the Parliament Watch, I watched with disbelief on Monday as one of the authoritarian chairpersons, Mr Tim Lwanga, hit the roof and evicted journalists from the Budget Committee. The only reason this man gave was that “his” committee was going to discuss “technical matters” and therefore, no need for journalists.
Well, that’s Lwanga for you. But for some of us who have over the years watched MPs come and go, we are reliably informed that by the nature of our training and experience, we are knowledgeable in public spending than some lawmakers.
So, the accusation that the journalists were not needed because the Budget Committee was going to discuss “technical matters” is a complete conjecture whose inner meaning insults journalism and confuses the symbiotic relationship between Parliament and the media.
Well, that’s not all folks! In the face of the current economic crisis and the biting shortages the country is facing, this Budget Committee abandoned free meeting rooms in the House and pitched camp in one of the luxurious hotels on Entebbe Road to discuss the proposed Budget cuts. The Budget Committee has more than 30 members.
According to my sources in Parliament, each MP was paid Shs1 for pocket money. To show how wasteful these MPs are at a time when they were meeting to cut ministries’ wasteful expenditures, for two days, they wasted more than Shs100 million.
What is not clear though is why these MPs decided to blow public funds in expensive hotels yet they could have used Committee rooms at Parliament and save that money for striking teachers and other suffering Ugandans who cannot afford ARVs or even those without drugs.
Why the MPs, including the opposition preach water and drink wine at night, will be a discussion for another day. But this week, let us look at the importance of an open Parliament, focusing on answering a fundamental question: Whose interests do MPs serve?
In the West, there is this idea that unless, public institutions are open to public scrutiny and susceptible to public opinion, true democracy cannot flourish and therefore, progress will always be like a dog chasing its tail.
On account of this principle, as part of the global movement toward more open and accountable government, citizens have become increasingly concerned with obtaining access to information particularly on budgets. In fact, Commonwealth Parliamentary Association (CPA) to which Uganda is a member, recommends unhindered media access to Parliament and its committees.
Similarly, the Inter-Parliamentary Union (IPU) to which Uganda is also a part and is hosting its 126th global summit here next year, believes that for a Parliament to be ‘open’ means, most obviously, that its proceedings are physically open to the public.
This may not always be straight forward in an age when the security of public figures is a pressing concern. However, other serious parliaments have found it possible to strike a balance between openness and security; in such a way that Parliament is manifestly seen to belong to the people as a whole, and not just to its members. This urge is premised on a belief that the best weapon of a dictatorship is secrecy, but the best weapon of a democracy is openness. The inner sense we draw from this counsel is that secrecy, breeds corruption and corruption kills public and private institutions.
Indeed, secrecy, particularly in public offices like Parliament breeds dishonesty, laziness, nepotism, and many other social ills. Certainly, secrecy means evasion, and evasion means a problem to the moral mind.
Why the secrecy?
By locking out the media from covering the Parliament proceedings, our representatives in the 9th Parliament, clearly began their five-year journey off-side. Unfortunately, this weird behaviour in Parliament is gradually eating into the House’s creed and has of late permeated committees, including the Budget Committee, which is supposed to encourage transparency.
When Lwanga evicted journalists from the Budget Committee meeting as if the discussion threatens national security, the Shadow Finance Minister Geoffrey Ekanya tried to plead on behalf of the journalists, but without any success, and in the end our lawmakers discussed the amendments to the budget behind closed doors in one of the lavish hotels outside Parliament building.
However, it should be clearly understood that under Section 20, subject to the Parliament Rules of Procedure, the sittings of Parliament or of its Committees including the one Lwanga chairs shall be public. With exception of Section 20(2) where the Speaker may, with the approval of the House and having regard to national security, order the House to move into closed sitting.
By allowing Mr Lwanga, whose dictatorial leadership appears to have betrayed him in many ways, there was a conspiracy of silence from the rest of the committee members. They purely looked comical especially when their chairperson claimed that they were going to discuss “technical issues” as if the 9th Parliament is the first to discuss the budget. These inexcusable events in Parliament will evidently remind Ugandans how Mr Lwanga’s leadership is a contradiction to Mr William Okecho and Ms Rose Akullo (Bukedea Woman), among others, who venerated an open-door policy in the handling of the Budget.
Call for action
Even so, in this column, we urge the rest of the MPs to see sense in openness and in the same spirit, the office of the Speaker should have a joint meeting with all the committee chairpersons/vice chairpersons to orient them on matters of good governance. Surely, Parliament should be the last institution to be seen promoting secrecy, wastage in government and corruption for that matter.
The lawmakers should know that the overarching purpose of access to information legislation, which is operational, is to facilitate democracy and rule of law. This Act does so in two related ways: It helps to ensure first; that citizens have the information required to participate meaningfully in the democratic process, and secondly, that politicians and bureaucrats remain accountable to the citizenry.
Parliament needs to foster a culture of openness in government. For that matter, the media undertake to work with Parliament to ensure public trust prevails, establish a system of transparency, public participation, and collaboration. Unlike secrecy, openness will strengthen our democracy and promote efficiency, honesty, transparency and accountability and effectiveness in government.
The rising assertiveness of committees is a welcome development. But for those locking out journalists on flimsy grounds need to reverse this naughtiness, it is not helping anyone.
Mr Lwanga and others should know that the media and Parliament share a responsibility to contribute to political, economic and social development in ways consistent with democratic principles by pursuing fact-based, fully substantiated reporting. Ultimately, economic development is best achieved and sustained in societies where the people are democratic and well-informed.

Source: Daily Monitor
http://www.monitor.co.ug/OpEd/OpEdColumnists/YasiinMugerwa/-/878670/1233862/-/item/0/-/yjflij/-/index.html

CSOs recommend Shs75 billion budget reallocation to recruit health workers.

September 8, 2011
A coalition of Civil Society organizations (CSOs)where CEHURD is a member, have demanded parliament to reallocate funds in the 2011-2012 draft budget expected to be passed today afternoon, for recruitment and retention of health workers.
The CSOs have recommended a minimum total of approximately Shs75 billion to cater for the deployment of an additional 5,000 professional health workers and an increase in allowances to motivate them.
This is due to the fact that the increasing shortage of health workers like nurses and midwives at health centres II, III and IV, commonly found in rural areas has greatly contributed to the shoot-up in maternal death rates in Uganda.
According to the press statement read at the conference hosted by Action Group for Health, Human Rights and HIV/AIDS, Uganda (AGHA) on September 8, the Ministry of Health national target for this budget cycle indicates that an additional 5,000 health workers would increase staffing norms from the current 56 per cent to 65 per cent.
The statement further reads, “A report by the Social services committee of parliament recommended an initial reallocation of Shs34 billion and suggested the remaining 41 billion required, to be reallocated from non-essential spending in other sectors’ budgets.”
It however states that recent reports on the discussions of the budget committee indicate that the recommendations of the report may be disregarded, despite the fact that parliament agreed to them.
In reaction to this, the country director, International HIV/AIDS Alliance in Uganda, Mr. Leonard Okello, said, “if the pronouncement of parliament are disregarded in the Appropriations Act of 2011, then Uganda must approve a supplementary budget to correct this needless epidemic of maternal and morbidity.”
He added that, “People are suffering rural women in particular. The time for action is now.”
Mr. Okello requested government to invest in health centers II, III and IV where a bulk of rural women get health assistance, which means that they will be serving majority good and reducing overload in referral hospitals.
He appealed to the President Mr. Yoweri Museveni to respond to the matter by providing supplies, medicine and human resources required by the rural women in payment for voting him back into power since majority of his votes were from these women according to statistics.
The Advocacy and communications manager, Community Health and Information Network (CHAIN), Ms. Dorcas Armoding, said, “This crisis will not be corrected without the nurses, midwives and clinical officers, whose jobs are to save lives.” “Without this reallocation, we are gravely concerned that preventable maternal death rates will continue at a rate of 16 pregnant mothers per day.
The Executive Director, AGHA, Ms Apophia Agiresaasi, expressed her worries on Uganda still having unacceptably high maternal and infant mortality rates, which she says would be improved if there was political will to deliver on the promise of African governments in 2001 to invest at least 15 per cent of their budget in health.”