Maternal Deaths Emblematic Of Rot In Uganda’s Healthcare System

Uganda has the uncanny ability of always popping up in the news. The last time my home country captured the imagination of the American public was in early June when the profane, potty-mouthed and hysterical musical “The Book of Mormon” won nine Tony Awards. The happily paradoxical “Book of Mormon” is about two dewy missionaries from Salt Lake City transported to Uganda and their misadventures.
Now the New York Times has come out with this: Maternal Deaths Focus Harsh Light on Uganda.
The article was spot-on. Wielding a slingshot that had its fingers on the pulses of Uganda’s expectant women, the piece threw brickbats at Uganda’s floundering public health system. Foreign aid donors were not spared either as the article questioned the unintended consequences of development aid.
The Birth And Genesis
The embers in the most-recent fiery debate about maternal mortality rates in Uganda were stoked on May 27, 2011 when the Centre for Health Human Rights and Development (CEHURD), a Ugandan NGO, and the families of two mothers who died in government hospitals in 2009 approached the Ugandan Constitutional Court alleging the women’s deaths were caused as a direct result of Uganda’s failing healthcare system. CEHURD, in this landmark petition, alleged that the circumstances that led to the death of these two women were both emblematic and symptomatic of the government’s failure to fulfill its constitutional obligations to provide basic maternal healthcare to expectant mother. They sought to arm-wrestle the government into increasing its budget for maternal healthcare and compensation for the families of the two women.
Accounts of the events that led to the death of the two women are almost the same. Councilor Anguko Jennifer, a civic official in Arua district, sustained a ruptured uterus while waiting for over ten hours to be attended to by a doctor while she was in labor.
She died on the theater table. Sylvia Nalubowa, a mother of seven, was not aware that she was to have twins. The antenatal clinic she attended in her area in central Uganda did not have adequate scanning facilities. When she went into labor, her husband could not raise money to transport her to Mityana Hospital and, according to reports, they had to ‘improvise’ transportation to reach that hospital, 15 kilometers away.
Unable to purchase a Ush 50 000 ($ 25) ‘mama kit’ for use at the hospital’s labor ward, she was left unattended and died. The mama kit package contains a meter piece of cotton cloth, laundry soap, a pair of gloves, a piece of cotton wool, small gauze, cord ligature, and a meter of polythene sheet for the delivery table.
The Sick Life Of Uganda’s Systems
Uganda’s health care system needs CPR. The NY Times story, emphatic in its articulation, painted the picture of a battered, bankrupt and decrepit tragedy.
“At regional hospitals like the one here in Arua, more than half the positions for doctors are vacant, part of a broader shortage that includes midwives and other health workers. A majority of clinics and hospitals reported regularly running out of essential medicines, while only a third of facilities delivering babies are equipped with basics like scissors, cord clamps and disinfectant, according to a 2010 Health Ministry report.”
The government’s response to the joint suit by CEHURD and the families of the two deceased expectant women was telling. Unaccustomed to such Zeus-style thunderbolts on the efficacy of its governance and the healthcare system, government officials dabbled uneasily in obfuscation, saber-rattling and shifting of responsibilities as they guarded their fief.
Uganda has seen rosier times. The Uganda Bureau of Statistics pegged Uganda’s inflation rate at 18.7 percent in July 2011, the highest since February 1993. According to data compiled by Bloomberg, Uganda’s shilling is Africa’s worst performing currency this year after weakening 12 percent against the dollar. Uganda is one of the countries with the highest child mortality rates in the world, according to the State of the World’s Children report.
She holds the 21st last slot out of 189 countries. At least an estimated 45,000 newborn deaths occur in Uganda each year and an equal number are stillborn, making her the country with the fifth highest number of newborn deaths in sub-Saharan Africa.
According to the World Health Organization, Uganda has the world’s highest malaria incidence, with a rate of 478 cases per 1000 population per year. The overall malaria-specific mortality is estimated to be between 70,000 and 100,000 child deaths annually in Uganda, a death toll that far exceeds that of HIV/AIDS. Tuberculosis remains a major public health problem in Uganda, ranking her 18th among the 22 TB high burden countries of the world. About 100,000 new cases of all forms are recorded every year.
A Post-mortem Analysis
Giving handouts to Africa remains one of the biggest ideas of our time — millions march for it, governments are judged by it, celebrities proselytize the need for it. Whenever funds are doled out, press conferences are held and kumbaya moments invoked. What is not ever sufficiently articulated is that development aid has, in some cases, done more harm than good to Africa.
“For every dollar of foreign aid given to the governments of developing nations for health, the governments decreased their own health spending by 43 cents to $1.14, the University of Washington’s Institute for Health Metrics and Evaluation found in a 2010 study. According to the institute’s updated estimates, Uganda put 57 cents less of its own money toward health for each foreign aid dollar it collected.”
In the history of mankind, no country has ever developed by depending on foreign aid. Dambisa Moyo, whose book Dead Aid I plowed through in January 2011, opines that Africa needs to be gradually weaned off development aid and the spigots finally shut off and African governments left to their own devices. Previously a lone dissenting voice, Ms Moyo is garnering a rapidly increasing roster of supporters willing to toll the death knell for foreign aid. More are jumping onto this bandwagon.
What should Uganda do to avert its maternal mortality crisis? Here is a list of suggestions from Ms. Magazine, a blog that prides itself in its ‘fearless feminist’ reporting. Emphasis needs to be placed on adequate remuneration for doctors and other healthcare workers. For a long time, it has been expected that health care workers should toil and serve with their morality’s engines powered by altruism, humanism and nationalism alone. That hasn’t worked. This may be anathema to donors but it needs to be put out there that health care workers with a ‘sufficiently oiled’ vested interest in Uganda are the key to preventing Uganda’s slide into healthcare Armageddon. With that in place, we will probably be seeing the last of the hemorrhage caused by maladies such as absenteeism, presenteeism, healthcare-related corruption and the brain drain. Next would be to institute an overhaul of Uganda’s healthcare system starting with the management of training of healthcare workers being returned to the Ministry of Health from the clearly over-burdened Ministry of Education and Sports.

Uganda Government Never Ready on Maternal Health Issues

The courts adjourned the Constitutional Court case on preventable maternal death in Uganda last week after the government asked for more time to prepare their defense.
It was the only one time in four that the judges raised quorum but had insufficient defense. However, public interest remains high showing the increasing public alertness to their health rights and intolerance of poor health delivery by the government.
In this unprecedented case in East Africa, Civil Society Organisations and families of two women who died in childbirth are suing the Uganda Government for non provision of essential services for pregnant women and their newborns which breaches its fundamental obligation to uphold the Constitution and violates the right to health and the right to life.
David Kabanda the lead counsel said it is important that the government treats the case with the urgency it deserves but lobbying would continue. The next hearing is expected early September this year.
“They have not put in substantial affidavits in reply. But they have acknowledged that the evidence is overwhelming and will need technical support to be able to reply,” said Kabanda. The government said it is waiting for affidavits from the ministry of Health and Finance.
Previously, there was lack of quorum by the judges, a sign that the government was not serious and was not ready but the public turn up was high as about 750 people marching in three spots in Kampala, Arua and Mityana.
“It appears that the case is not being treated with the urgency it warrants despite the life and death issues being considered in this petition,” said Asia Russell from the US-based lobby group, Health Global Access Project (Health GAP).
Uganda’s maternal mortality rate is 435 deaths per 100,000 live births, while the infant mortality rate is estimated at 76 deaths per 1,000 live births.In Uganda, 16 women die everyday in childbirth.
“The mere fact the violation continues is important that the constitutional court hears this case expeditiously. The turn up of a huge number of people in the court cases points to the fact that it is of public interest,” said Moses Mulumba the chief petitioner of the case.
The petition calls upon the judiciary to pronounce the escalating maternal deaths in Uganda as an issue that violates the Constitutional rights of Ugandans.
It highlights the case of Sylvia Nalubowa, a mother of seven children in Mityana and of Jennifer Anguko, a mother of three both of whom died as a result of the government’s failure to fulfill its constitutional obligations to provide basic maternal health care.
In May this year, the Centre for Health Human Rights and Development (CEHURD), a Ugandan NGO, and the families of Sylvia and Jennifer sued the government through the Ugandan Constitutional Court alleging the women’s deaths were caused as a direct result of Uganda’s failing healthcare system.
CEHURD officials urge the Court to declare that the continuous failure to implement effective policies on maternal healthcare, under-staffing, and the non-availability of basic maternal commodities in government hospitals amount to violations of pregnant women’s rights to health and life.
“Years have passed and the population is singing the same song over and over. No drugs, personnel are inadequate, personnel are rude to the sick… and the list continues. Where is government in all this,” asked William Kibaalya a social worker managing social welfare programmes for children in Uganda.
Lobbying the public outside court
But with the no show by the judges, the civil society has devised other ways of putting pressure on the government to pay attention.
Campaigners have initiated an online petition targeting the international community and a book collecting signatures of people affected by maternal deaths in Uganda.
The online petition, with an open letter to President Yoweri Museveni and the speaker of Parliament Rebecca Kadaga is urging the government to pay attention because this is a matter of life and death.
And a book launched two months ago has so far attracted 1,700 signatures from people who have been affected by maternal deaths- orphans, widowers and all those who have had a relative die in childbirth.
“We want to keep the momentum at the grassroots and also build pressure on the government that is why we have the book and now the online petition,” said Mabel Kukunda, advocacy and networking officer, Uganda Network of Health Consumer Organizations (UNHCO).
“We are hopeful that the Justices will acknowledge the plight of mothers in Uganda, and deliver a ruling that compels government to dramatically increases investments in essential medicines, in recruitment and remuneration of health personel and in equipping health facilities so that women get the services they need to survive and thrive before, during and after delivery,” the online petition reads.
Background to the case
Sylvia Nalubowa died on 10 August 2009 from complications of obstructed labor while giving birth to her second twin baby in the eighth pregnancy.
Earlier, her husband Stephen Sebiragala was referred to Mityana district hospital about 15 kilometers away after being turned away twice at health centres with a midwife missing in one and a twin born in another health centre but the case became complicated.
At Mityana Hospital the staff demanded sh50, 000 ($ 20) before Sylvia could be attended to which was meant to purchase a ‘Mama kit’, a requirement of the cost sharing policy in Uganda, where mothers are expected to carry a kit containing basics to be used in the delivery of new babies.
Sebiragala, the widower says that if he had not had to spend so much money transporting his wife, he would have had enough money to save the lives of both Sylvia and his child. But even then, there was no medical doctor in theater so both Sylvia and the second twin died at Mityana hospital.
Jennifer Anguko, a mother of three was admitted to Arua Hospital on December 10 2010 with intense labor pains and waited for 15 hours for a doctor to carry out a caesarean section.
She died of obstructed labor after the uterus ruptured. Four other women died in the maternity ward that same day.
The petitioners argue that the tragic deaths of Sylvia Nalubowa and Anguko Jennifer are but two manifestations of a larger problem of an unacceptably high rate of maternal mortality in Uganda.
“Our hope is in the decision by Constitutional Court to compel government on its obligations to address the crisis of maternal mortality,” said Russell.