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HEALTH-UGANDA: Shifting the Weight to Bear the Burden

Wambi Michael

KAMPALA, Apr 7 2009 (IPS) - There is no lunch break for the staff at the Kiswa Health Centre. With the closure of the nearby Mbuya hospital for renovation earlier this year, the six-room centre is offering pre- and antenatal services, HIV/AIDS testing and general healthcare to 400 patients a day.

Molly Busingye is in charge.

"At Kiswa we don’t deliver [babies], because it is not a maternity [ward], but this morning we had to rush a mother into one of our small rooms to deliver. When a mother comes, we have to improvise.

"Today we delivered a mother, yesterday we had two. So the numbers are on increase, yet we have no facilities or health workers. HIV cases… the numbers are too many. Everything, the numbers have tripled," she lamented.

A critical shortage of health workers in Uganda is affecting delivery of health services, with patients waiting long hours before they are attended to. Kiswa has one doctor for the unit, eight other health workers and a couple of volunteers offering HIV/AIDS counselling.

The problem is acute, with staffing levels estimated at only 50 percent for certain types of personnel – like medical assistants and nurses, who are reluctant to work in rural areas.

Over the last six years, Uganda has lost over five hundred medical doctors and thousands of nurses and midwives to countries where medical workers are better remunerated. In Uganda, one doctor treats 22,000 patients.

The government has introduced a policy of "task shifting", where tasks performed by doctors are shifted to nurses and other health workers in hospitals in an effort to resolve the health worker crisis.

Nurses are now taking on new tasks like managing people living with HIV, interpreting tuberculosis sputum tests, and prescribing medicine.

Volunteer health workers have been brought into the public health system, taking up responsibility for immunisation and community management of malaria,which is still the number one killer disease in the country.

Uganda’s health minister, Dr Stephen Malinga, told IPS, "We have realised that some tasks originally performed by doctors can be shifted to lower-ranked officers once we have trained them on the procedure."

Malinga said the ministry also emphasises preventative health at local levels by employing village health teams.

"It is effective. We have tested it out on immunisation because we have realised that health is made at home, and only repaired in health units. So by preventing diseases in communities, we reduce the burden on health units."

Malinga said the magic is that "the lay health workers at the villages know which child in a given household is not immunised. So it is easy to go to that home to immunise that child."

But Member of Parliament Dr Sam Lyomoki told IPS that the measures adopted by the government cannot be sustained.

"The issue is that we need to increase funding to the health sector, and recruit and retain qualified health workers. But the lay health workers have been useful, because without them we would have a worse situation. Though that is not the best way forward, because those are just stop-gap measures."

Patrick Melu, a local politician in the Bududa district in rural eastern Uganda, told IPS that lay health workers feel they should be paid a salary and that the small stipends they receive are insufficient.

Back at the Kiswa Health Centre, Molly Busingye surveys the tiny, congested room devoted to antenatal care. Outside is a long queue of expectant mothers, some sleeping on benches. Women come in for consultations in groups of five.

"Infrastructure is still the same, but the patients are increasing. So you find mothers standing for long. We have seen mothers bleeding because of staying so long in lines. Because the room is too small, there are midwives, mothers are being screened. So we are working in the shade of a tree in the compound, which is not healthy for the health workers and patients," she said.

Mary Obong, a midwife who has worked at Kiswa for over ten years, told IPS, "Here we have antenatal, postnatal and even family planning services in one single room.

"There is a lot of congestion, and there is no privacy. Yet privacy is required because there are some women who have some sicknesses but fear to disclose in presence of other women."

Obong said they sympathise with their patients who come to the centre very early in the morning seeking health services.

"Most of the women come here very early in the morning and they stay here for too long. So we make sure that they are attended to. We have to do it, even when we are suffering. We also see that our situation and theirs is the same, so we have to help them."

The centre also offers voluntary counselling and testing services to young people. Janet Nyakana, who runs the VCT programme, says she needs more staff and more space.

"You see the place is very small, so we face a challenge in that there is no confidentiality yet they are young people. So we are not only limited by the number of health workers, but also by space and drug shortages."

Asked why she had not sought employment abroad like so many of her colleagues, Nyakana said, "At the teenage centre we find that teenagers are having many problems. We feel that we should help these young people whether we are paid or not. I feel more satisfied serving fellow Ugandans, especially the young people."

Kiswa Health Center has just one doctor, supported by nine health workers. Busingye describes the burden the doctor is under: "For a person to clerk over one hundred patients alone… You talk from morning to evening. At the end of the day, you become exhausted and the patients are many. Sometimes that is why one ends up with poor quality of care."

Malinga told IPS that the government is working towards increasing the health sector budget to equip the health facilities and ensure that health workers are better remunerated.

He said the Uganda government in conjunction with the British Department for International Development was testing an arrangement to attract health workers to work in rural Uganda and other hard-to-reach areas of the country by paying them an additional allowance.