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Monitor investigation reveals health sector in a sorry state

Standards of public health care are in free fall as fresh evidence now points at the acute shortage of sick-beds, especially in intensive care units, forcing doctors to discharge patients prematurely.

A Daily Monitor investigation has found that there are only 37 intensive care unit beds in the country, with 12 in Mulago National Referral Hospital. The hospital beds (per 1,000 people) were last reported at 0.50 in 2010, according to a 2012 World Bank report.

A doctor in Mulago who only agreed to speak off the record, said “discharge decisions are made with bed-capacity constraints in mind.” The doctor said the push to get patients out of the beds is based on the crucial need to save “those who are badly off” using the few resources available.

Some patients with serious illnesses are left unattended to for weeks and access to drugs and feeding in public hospitals remains a challenge for many.

Premier Amama Mbabazi told Parliament on Thursday that government is aware of the challenges in the health sector and blamed the crisis on a “limited resource envelope”. The country’s growing budget is now at Shs11.4 trillion but has yet to find a panacea for the overburdened public healthcare system.

At public hospitals, the few doctors and nurses available are struggling to cope.Arua Regional Referral Hospital, which covers all West Nile districts and also DR Congo and Southern Sudan, has only 15 doctors, including the director, who is mostly doing administrative work.

This means that the doctor to patient ratio is 1:178,600, while the recommended World Health Organisation ratio is 1:12,500. There were 56 vacancies at the hospital most of which were critical in service delivery.

In Kabale Hospital, the situation is not different. The hospital on average admits 1,805 patients yet it had only 310 beds. One doctor attends to over 9,000 patients and one nurse supervises over 400 people.

The hospital also lacks adequate space in the maternity ward, an accident and emergency unit and incinerator to safely dispose of bio-waste. The old sewage system and toilet facilities cannot match the ever increasing number of patients.

Jinja hospital risks disconnection after it accumulated domestic arrears of Shs.454.1m in respect of water bills out of which Shs93.2m relate to 2010/11 financial year.
While this situation severely undermines public health service dispensation, the management of Arua hospital said they had reported the matter to the Health ministry but no action has been taken to fill the vacant posts for doctors.

The government has slapped a ban on recruitment of health workers citing financial constraints. This means that undermanned hospitals, can only recruit to replace those who have either resigned or died in the line of duty.

The March 2012 report of the Auditor General calls for radical action to reorganise hospital care so that “Ugandans receive the care they deserve”. Three-quarters of doctors are under more pressure now than they were 10 years ago, and nurses report an unmanageable workload.

Health Service Commission Chairman Pius Okong has warned of a “disaster” if government doesn’t lift the ban on recruitment.

While appearing before the Health Committee of Parliament, Prof. Okong said: “If we don’t recruit, the manpower crisis in the health sector will be compounded. Some facilities have less than 30 per cent staffing level which is untenable.”

The Director General of Health Services, Dr Jane Aceng, puts medical staffing levels at 58 per cent. Dr Sam Lyomoki, the chairperson of Health Committee, has proposed that an additional Shs260b be allocated to the health sector to boost staffing level to at least 66 percent.
Parliament heard last week that the hospital care was under intense pressure, leading to unnecessary indignity and distress. But government insists it needs more time to agree to the Shs39.2b the House Budget Committee found from cuts out of the Shs260b needed to fix the system.


More than 500 abortions in Gulu last year, says report

By Cissy Makumbi 

Gulu hospital management has called for government intervention following the release of a report showing an increase in cases of abortion in the district.

The report released on Wednesday shows that up to 568 babies were aborted in the year 2011/2012.

The authorities, who compiled the report, say there is need to save the unborn babies from the practice, common among girls who have unprotected sex for money.

In 2010/2011, about 500 unborn babies were terminated, according to the same report, although it still remains unclear whether the culprits were brought to book, since the practice is a crime under the law.

The director of the hospital, Dr Anthony Onyach, however, attributed the increase in the vice to failure by many mothers to use family planning methods, thus conceiving against their will.

“Most abortions occur among girls who report to the hospital when they are very sick after administering herbs and other drugs on themselves, while others seek help from shrines,” Mr Onyach said.

The same report indicates a drastic decline in the number of mothers seeking family planning services at the health facility. It shows that although in 2010/2011 there were at least 1,239 mothers who visited the hospital’s family planning unit, in 2011/2012, the number reduced to only 770.

Health experts attribute the increasing number of women with cervical cancer to unsafe abortions. Under the law, abortion is illegal and punishable, a situation that sees many women do it undercover with support from ill-equipped health personnel and traditional healers.

The Ministry of Health is considering the recommendations of a report it commissioned into the safety and legality of abortion. The report proposes legalising abortion in specific cases such as rape.

However, the debate on legalising abortion has not been met with open arms, with the proposal opposed by many Ugandans, most arguments based on religious, cultural and moral grounds


Limp courts have potential to undermine human rights


IF you want to see what a toothless court looks like – and what happens when such a court guards people’s rights – turn your eyes northwards to Uganda. Its appeal court, which doubles as a constitutional court when required, has delivered a decision that makes for sobering reading.

It deals with a “petition” brought by, among others, relatives of two women who died in childbirth under horrific circumstances at state health institutions.

The petition has made legal history as it’s the first challenge to government health policies and practices brought under Uganda’s 1995 constitution.

An estimated 100 Ugandan women die in childbirth every week, a statistic that prompted the Centre for Health, Human Rights and Development to compile an extensive constitutional petition citing international law and human rights conventions as well as Uganda’s own constitution.

Two months ago, five judges, headed by the deputy chief justice, considered the petition but refused to deal with it.

The petition said the public was affected by the non-provision of crucial resources for women giving birth in government health facilities, as well as by the “unethical behaviour” of doctors and nurses towards expectant mothers, and asked that the situation be declared unconstitutional.

Backed by more than 50 non-government organisations, the petition included a list of constitutional sections infringed by the inadequate provision of proper health services for women giving birth.

There’s no shortage of clauses to which you could appeal in making such a petition – the right to life, for one – plus there’s a section saying that anyone who alleges that an “act or omission by any person or authority is inconsistent with or in contravention” of the constitution, may “petition the constitutional court for a declaration to that effect and for redress where appropriate”.

When the case was argued, however, the state attorney said the petition should be rejected on the basis of the “political question” doctrine, without even getting to the merits of the issues involved.

If the court agreed to deal with the petition, she argued, it would be “interfering with political discretion by which law is a preserve of the executive and the legislature”.

The constitutional court agreed: it might be true that not enough resources had been allocated to maternal health care services, but the court “has no power to determine or enforce its jurisdiction on matters that require analysis of the health sector government policies, (or) it will be substituting its discretion for that of the executive”.

The judge said a different approach should have been adopted with an application to the high court for redress – suing the state, in other words.

After the court threw out the case, human rights activists said it had at least “raised awareness” of the problem. Perhaps, but not where it matters most.

A month afterwards, Hajara Katusabe, 24, died in labour when the midwife at a health centre refused to emerge to help her because she “had a heavy workload” and was tired.

After Katusabe died, members of the local community are reported to have stormed the health centre, threatening to lynch the midwife.

She was rescued by riot police, but has since been charged with negligence.

Now those behind the original petition have appealed to Uganda’s highest tribunal, the supreme court. Lobbyists say if they lose here, too, they will approach the African court on human and people’s rights.

Perhaps under Ugandan jurisprudence the constitutional court was indeed correct – and it’s not the apex court on such matters as in SA. The supreme court might rule differently.

But reading the judgment made me pause: suppose

our Constitutional Court had refused to rule in the Treatment Action Campaign case, to name just one.

Imagine that instead of saying that it was unreasonable for the government to provide life-sustaining medicine at just a few pilot sites instead of being widely available, the court had said it could not intervene in policy matters.

How many people, alive now, would have died?

When it comes to socio-economic and environmental rights, our Constitutional Court is crucial to ensuring that the state carries out its duty, that these rights are not neglected and that the poorest or most vulnerable, often without the political clout that would ensure attention from a ruling party, also benefit from the promises of the constitution.


350,000 abortions in Uganda are induced – experts

Article by Catherine Mwesigwa Kizza ( New Vision)

Infanticide, child abandonment and abuse — the Ugandan media is full of the stories. The missing story though is that the abused and murdered children are most probably survivors of induced abortion.

“There are over two million conceptions in Uganda every year. 200,000 to 300,000 of these miscarry or abort spontaneously but 350,000 abortions in Uganda are induced,” said Dr. Charles Kiggundu an obstetrician and gynecologist at a breakfast meeting convened by the Center for Reproductive Rights and Centre for Human Rights and Development in Kampala Wednesday, to discuss the laws and policies on abortion in Uganda.

“90,000 of the induced abortions end up with severe complications but only a half of them access post abortion services,” he added.

“Only half of the women with complications seek medical care. A few survive but many others die,” he added.

Joy Asaasira of CEHURD said of the 20 women in Uganda who die due to pregnancy and childbirth-related complications every day, four to five of these are due to induced abortion.

Dr. Kiggundu says these are needless deaths. The policy environment allows women to receive healthcare for post- abortion complications, however, studies have shown that when they seek care, it takes about 44 hours for them to get attention compared to 35 to 45 minutes other women spend in hospital before getting a service.

“Health workers do not want to treat women with abortion complications because they do not want to be seen to be accomplices to the termination of pregnancy,” he said.

He also pointed out that phrases on hospital documents like “Police notify” worry health workers and are a deterrent to provision of care for women.

‘Health workers do not want to get involved with police. They want to do their work unencumbered,” he said.

Women induce abortions due to unwanted pregnancies due to wrong timing of pregnancy or economic and social hardships.

“Some men tell their wives to abort because ‘they stopped having children’ and yet did nothing about it,” Dr. Kiggundu said.

Those who survive death end up with chronic pain, anemia, and infertility among other complications.

He said safe abortion services were available but hidden to the poor.

“You must be connected and well-oiled to access the services. Some women fly to South Africa to terminate pregnancies and return,” he revealed.

The consequences for the majority who go to quacks or unskilled medical workers working undercover are dire.

“We recover forks, pens, knitting needles, bed springs, sticks, herbs from women who run to us with botched abortions. Some of these things kill the woman before they even kill the foetus,” he said.

Treatment for those who survive death is expensive. According to CEHURD, sh17.6bn is spent on treating abortion complications.

Not only can this money be saved and spent on worthwhile health causes but women’s lives can be saved as well.

According to Dr. Kiggundu, the Ministry of Health’s comprehensive abortion care includes sexuality education to promote safe sex practices, family planning use including access to emergency contraception, reducing fertility, providing safe abortion services and quality post-abortion care.

Government is also training nurses and giving them skills to perform manual evacuation procedures to attend to women with incomplete abortions.

“There are still many gaps,” said Dr. Kiggundu. “Uganda still produces health workers for export and retains only a few.”

He revealed that only 30% of the vacancies for skilled health personnel required to provide safe motherhood are filled.

It is no wonder that despite government commitments, advocacy efforts, plans and policies to reduce maternal deaths in the country, there has been no progress in this indicator in the past five years.

New data from the Uganda Demographic Health Survey report of 2011 show that the maternal mortality ratio increased from 435 deaths per 100,000 live births in 2006 to 438 deaths, though other international studies show a decline to 310 deaths per 100,000 live births.

“26% of these deaths are due to unsafe abortion,” said Elisa Slattery the Regional Director, Africa Program Center for Reproductive Rights.

Once addressed, reduction in unsafe abortion contributes to reduction in maternal death.

Slattery said studies on the law on abortion in Uganda have found that “abortion is permitted where a mother has severe illnesses threatening her health like cardiac disease, renal disease, eclampsia.”

The Centre for Reproductive Rights study also found that healthcare providers are not required under the Uganda law to consult one or more providers to get their consent before terminating pregnancy as has been previously believed.

The organization is calling on government to broaden access of information among healthcare professionals and the public as a means of stopping the tragedy.


UN official lauds Uganda on local drug production


posted Saturday, August 25 2012 at 18:21
The Ugandan model of local commercial production of medicines presents a long-term solution of access to treatment in developing countries, a UN official has said.

In a strong critique, however, Anand Grove said locally manufactured drugs should not cost twice as much as the imported ones and suggested that WHO prequalifies QCIL so that it can supply drugs to non-government organisations like the Global Fund and the US President’s Emergency Plan for Aids Relief (Pepfar).

The Centre for Health, Human Rights and Development under the umbrella of the Uganda Coalition on Access to Medicines convened the meeting in which civil society organisations presented the current challenges on access to medicines in Uganda.

“The visit of the UN Special Rappoteur offers us a rare opportunity to elevate our voices to the international level, which the government pays more attention to,” noted Moses Mulumba, director for Centre for Health, Human Rights and Development.

Civil society cautioned on the pricing, procurement, distribution, use and domestic production of medicines, as well as the unclear situation on the right to health for Ugandans.

Leonard Okello, the country director, International HIV/Aids Alliance in Uganda, emphasised the need to promote more generic manufacturers in Africa.

One of the concerns was to push the Uganda government, which only buys drugs worth Ush10 billion ($4 million) annually, to procure the locally produced medicines by Quality Chemicals, which would then drive the prices down.

Uganda’s uncertain position on the right to health was also raised, comparing it with Kenya whose new Constitution recognises health as a right.

“We need to recognise it in our Constitution to make it easier for the citizens to take the government to task on the right to health care,” said Okello.

On previous visits to Uganda, Mr Grover, made recommendations to government to put in place a human rights desk at the Ministry of Health and a Right to Health Unit at Uganda Human Rights Commission to address health rights violations.