Healthcare in Uganda

Yesterday we had a seminar about the healthcare system and public health in Uganda, so I thought I’d share some of it with all of you so you can learn a little bit about what it is like here. I apologize for the length of this post but I hope some of you will be interested enough to stick with it! I will break down the system; then I want to talk briefly about the many problems with Ugandan healthcare.

These are the different levels of healthcare facilities and capacities:

•  At the village level, there are Village Health Teams (VHTs): provide anti-malarials and pre-natal care (here it is called antenatal care).
• At the parish level, there are Health Centre IIs: they provide antenatal care and sometimes other types of care. These centers are supposed to be staffed by a nurse, but the nurses often do not show up, and the clinics often are unstocked.
• At the sub-county level, there are Health Centre IIIs: they provide some in-patient care, along with the ability to deliver babies.
• At the county level, there are Health Centre IVs: they have small operating theatres (operating rooms) for minor injuries and procedures, and are staffed by medical officers, the Ugandan equivalent of an American physician’s assistant.
• At the district level, there are hospitals: these are the only government funded health centers that are staffed by doctors, but even at hospitals absenteeism is a large problem. This problem is talked about more in depth below.
• At the national level, the highest level of Ugandan healthcare, is the Mulago Government Hospital in Kampala, the capital of Uganda. Even here, it is reported that around 60% of physicians do not report to work for shifts.

Medical Absenteeism

In Uganda, it is quite common for doctors to be placed at government hospitals, but to also have their own private clinics on the side. Private clinics in Uganda are much nicer than the government-run facilities, because they are usually better staffed. The people who go to private clinics are also more well off than those who go to the government facilities, and can afford to pay more for services (some of them have health insurance through their jobs). The government health facilities are supposed to provide free healthcare (as far as I understand), but there is a good deal of corruption both on the personal end and higher up in the system, which means that patients often have to pay fees they shouldn’t have to pay for a doctor to see them. Because the government hospitals are poorly funded and do not have nearly enough resources or staff, and because the doctors assigned to them make more money working at their private clinics, many simply do not show up for their shifts at the hospital. For the most part, there are no consequences for this, which means that the hospitals are left in the hands of doctors-in-training who cannot handle the number of patients or the types of problems they have. Nurses staff Health Centre IIs (mentioned above), as well as all of the other higher orders of government run facilities. However the government doesn’t always pay the nurses when they are supposed to be payed, so the nurses stop coming to work.

Traditional Healers

Traditional medicine, and especially traditional healers, are a very important part of Ugandan medicine. While it has become somewhat taboo to admit one goes to a healer, roughly 80% of Ugandans still do use healers. There are many reasons for this, one being that the ration of healers to people in a certain region is much higher than the ratio of doctors to residents of the region. Secondly, healers accept many more types of payment other than the form of money; for example, sometimes a family will give a daughter as a bride—many healers have multiple wives, as polygamy is still fairly widely practiced here. In addition, often healers are able to offer spiritual counseling to a client; many who seek out the help of a healer are searching for explanations: why so many relatives are dying or why a daughter is not married yet. I will go more into the culture of traditional medicine here in Uganda after we visit a healer at Lake Bunyonyi next week.

The Bread Basket Paradox

Malnutrition is a huge problem in Uganda. One in three deaths in children under five is caused by chronic malnutrition. I have seen some of this firsthand at the KIHEFO Nutrition and Rehabilitation Clinic, where severely malnourished children and a caretaker can come to stay while the child is treated. The work they do at the clinic is incredible, and they have over an 80% success rate (with children staying nourished after they leave), while most nutrition rehabilitation programs in Uganda have a 20% success rate. What is fascinating to me about the malnutrition in southwestern Uganda, is that this part of the country produces vast amounts of food because there are lush farm lands in the mountains. This area is called the bread basket, however it has the highest number of malnourished children in the country. This is referred to as the “bread basket paradox”. There are a few reasons this is true. First, there is a lack of education for parents about proper nutrition for their children. So while the children are actually getting enough food, they are not getting enough nutrients. There are a lot of sweet potato farms here, and often poorer families will feed the children only raw sweet potatoes, as the mother is responsible for farming, taking care of the children, and doing all of the other household work (this is still hard for me to fathom, as the average number of children per family here is around 6 or 8). The most common form of malnutrition here is protein malnutrition, which, in its extreme form is known as kwashiorkor.

Public Health and Development in Uganda

Uganda’s human development index (HDI), a measure that ranks countries using several variables including life expectancy, places it in the “low human development” category, coming it at 161 out of 187 countries. However, while Uganda clearly has some work to do, the country has been making great strides in recent years. It ranked highest in East Africa on progress towards the Millenium Development Goals (MDGS), which were goals set by the United Nations to be reached by 2015 to help eradicate extreme poverty. Of these eight goals, Uganda struggles most with maternal and child health targets, but has done well with primary education improvement.

One thing that is really neat is that here mental health is not a taboo topic. There are resources and medications readily available, which is rare in a country with such a different culture of medicine than the one in the US.

Some of the things that cause continued public health challenges in Uganda are lack of access to:

1.     clean drinking water

2.     agricultural support

3.     education & training

4.     alternative employment

5.     contraceptives & family planning

Social Determinants of Health in Uganda:

• systematic corruption
• low income level (30-40% of people living in poverty)
• gender (domestic responsibilities/gender violence)
• alcohol consumption
• poor nutrition

Thanks for sticking with it, I know it was a long post!