In August, Uganda Medical Association will hold a major conference for all doctors in the country focusing on the sustainable development goals and health system in the country. A lot is already being done, especially with the health infrastructure. Mulago hospital is being refurbished, new hospitals have been built and several hospitals along the highways are being rehabilitated. However, a major overhaul of the system is needed for these investments to bear the expected fruits. I suggest 10 areas for the ministries of Health and Finance to invest in.
Preventive healthcare: The major determinants of health includes the environment in which we live and the level of poverty. Many diseases are preventable. Since the introduction of the pentavalent vaccine for infants in 2002 and more recently, the Pneumococcal vaccine, the burden of pneumonia and meningitis in children has fallen dramatically. Similar reduction should be expected with diarrhoeal diseases when we introduce the Rota virus vaccine.
Let us continue to invest in preventive services, including vaccines, hygiene and environmental sanitation and safer roads but also bring back the health inspectorate system to ensure community hygiene and sanitation.
Primary Healthcare: Many Health Centre IIs in the country are not staffed and non-functional. The quality of care is, therefore, often questionable. We should make primary healthcare services work.
Referral system: Many deaths in Uganda occur after patients have had contact with the health service either before referral, on the way, or after reaching the referral unit. The country’s referral system is so weak. The severe lack of resources to support emergency services mean many patients receive below optimal services resulting in preventable deaths.
Medicines supply and management: A few years ago, the Ministry of Health took a policy decision to have the National Medical Stores manage all the sourcing, procurement, ware housing, supply, transportation and delivery of medicines, sundries, equipment and stationery for all public health units in the country.
Although the decision had good intentions, it has had some disastrous consequences. On many occasions and in many health units, life-saving medicines often run out. Either health unit managers delayed to place orders for the medicines, made the orders but NMS delayed delivery, no delivery was made, incorrect specifications were delivered or the health unit was told they had exhausted their funding for the year and so their orders could not be honoured. Between April and August 2015, we hardly had any medicines to control convulsions, treat acute asthma, or severe malaria in the Acute Care Unit of Mulago because we understand the hospital had exhausted its allocated funds. We continue to limp to date. A proper logistics management system and human resources is urgently needed together with increased funding for medicines and supplies.
Health financing: The current financing mechanism is not only inadequate but also untenable. A complete rethink is urgently needed, including sourcing from universal health insurance, re-introduction of the user fees, and a special fund such as the road fund.
Quality standards and guidelines: There are some guidelines for the management of basic health problems but these are inadequate and many times, not adhered to. Most disorders of increasing complexity do not have nationally agreed management guidelines and standards. Moreover, in many cases, therapies listed in the available guidelines are often those that have been relegated in other countries but are used in Uganda because they cost less. Clear and updated guidelines and standards are needed. In addition, a mechanism should be put in place to ensure the practice of medicine according to the agreed guidelines.
Human resources for health; attitudes of personnel, supervision, and quality training: Healthcare is a labour intensive industry. Current staffing levels are grossly inadequate and this is made worse by chronic absenteeism. For example, in an intensive care unit, each bed requires four nurses for a 24-hour period; three to work eight hour shifts and the fourth resting. So, a hospital that has a six intensive care beds will require 24 nurses employed in this unit alone. Secondly, the current public service structure is obsolete.
We now have nurses with Bachelor’s degrees and although this is the trend around the world, there are no positions and tracks for promotion for these nurses. We have several other healthcare specialist with unique skills and trainings such as speech and language therapists for who there are no positions. A review of the human resources is needed.
As health workers, many of us also have problems such as poor pay, inadequate supervision, decadence of morals and values, and attitudes to work and provision of care to patients is often poor. In recent years, there has been a proliferation of training institutions. The quality and skills of the products of some of these institutions is questionable. A review of competencies, staffing levels, continuing education and professional standards is urgently required. This should be supported by meaningful remuneration.
E-health, records and IT: Today, the majority of patients attending outpatients’ services in public health units leave no records behind. Most buy exercise books and their clinical notes are written in this books which they travel with. The health system, therefore, has no records of these activities and other than the registers, there is no systematic collection of data to document trends. Hospitals, however, have the basic infrastructure to host an electronic e-health system and it is time this system implemented.
Emergency preparedness: The Ministry of Health has distinguished itself in responding to epidemics such as Ebola. Our responses to emergencies and disasters is, however, still poor. There are rudimentary signs of a developing ambulance system but even when these reach the health units, the receiving centres have very poor preparedness. Many health workers are neither well trained nor prepared to manage the severely injured. The current rehabilitation programme for hospitals along the highways should be comprehensive enough to cater for these deficiencies.
Specialist high quality care, high-tech medicine and research: Non communicable diseases will be the main health problem tomorrow. Many of these require a system for specialised and high-tech medicine, which we should invest in – infrastructure, human resources and equipment. Let us invest in health research too. Research is critical as it informs tomorrow.
Dr Idro is a senior lecturer, Makerere University and Consultant Paediatrician, Mulago hospital.
ridro1@gmail.com
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