KAMPALA, 18 September 2012 (IRIN) - Free healthcare is, in theory, available to everyone in Uganda but in practice, the state system, where thousands of doctors' and nurses' positions are unfilled, is so run-down that patients are increasingly turning to private facilities.
The crisis in the public health sector has led to threats by members of parliament to block next year's budget unless the government finds an additional 260 billion Uganda shillings (US$103 million) to recruit staff and upgrade dilapidated health centres.
"We need to bring in some money to stop the deaths of mothers," said Sam Lyomoki, who chairs the Parliamentary Social Services Committee. Uganda's high maternal mortality rate, at over 430 deaths per 100,000 live births [ http://www.measuredhs.com/pubs/pdf/FR194/FR194.pdf ], has led activists to sue the government [ http://www.irinnews.org/Report/95659/UGANDA-Activists-to-pursue-maternal-health-case-against-government ].
According to Lyomoki, the health sector accounts for 8 percent of government expenditures, barely half of its obligations under the 2001 Abuja Declaration [ http://www.who.int/healthsystems/publications/abuja_declaration/en/index.html ], in which African leaders pledged to spend 15 percent of their national budgets on healthcare.
"Really serious, serious action" is needed, according to Diana Atwine, director of the country's Medicines and Health Service Delivery Monitoring Unit.
John Okwonga, the health inspector in the northern Amuru District, which has a single state-employed doctor for a population of 234,000, said, "Most of the health units in villages are understaffed. They do not have enough health staff to diagnose and administer treatment to people who are ill... The health centres run out of drugs.
"Do you think it's easy for a doctor to come and work in such a place, without accommodation, medical equipment, and supporting staff?" he asked.
Paying for free care
Corruption is widespread, according to the Medicines and Health Service Delivery Monitoring Unit, which noted in its 2011 report [ http://www.mhu.go.ug/Docs/MHSDMU%20LATEST%20REPORT%20FRM%20NEWVISION.pdf ] that, despite the free healthcare policy in public hospitals, several facilities were found to be "charging patients even for basic services".
"When you come for treatment, the doctors will say the hospital is out of drugs, but they will direct you to a clinic where you can buy the drugs," recounted Kimulula Semanda, a resident of Wakiso District in central Uganda. For his child's supposedly free medical consultation, Semanda had to pay the doctor the equivalent of $10.
"Those who can afford to normally go to private clinics for treatment," Okwonga added.
Private healthcare providers account for 46 percent of all health facilities in Uganda, according to government figures [ http://www.health.go.ug/docs/HSSP_III_2010.pdf ].
"The fact of the matter is, the private sector is a lot more efficient than government," said Ian Clarke, who chairs the board of Uganda Healthcare Federation (UHF) [ http://www.uhfug.org/about-us.php ], an umbrella group of health companies and associations.
"You can take the same amount of funds, and you can probably make the delivery much better," he added.
Imperfect private healthcare
But not everyone is in agreement; a study [ http://www.plosmedicine.org/article/info%3Adoi%2F10.1371%2Fjournal.pmed.1001244 ] published in PLoS Medicine in June found no support for the theory that the private sector was "more efficient, accountable or medically effective" than the public sector in low- and middle-income countries.
And the standards of care can vary wildly: In Uganda, the amorphous private sector includes private clinics, large hospitals, drug shops and traditional healers without one specific oversight body.
The authors of a 2010 study [ http://www.biomedcentral.com/content/pdf/1472-698X-10-29.pdf ] on public and private healthcare in rural Uganda found that private providers played "a major role in health care delivery in rural Uganda", but noted that there was a need for a policy to address "quality and affordability issues" in the sector.
Clarke says the UHF is looking to introduce cross-cutting ethical standards and begin self-regulating so that it can ensure patients a reliable level of care if they go to certified facilities.
A third way
While the for-profit health industry is a boon to middle- and upper-class Ugandans who can afford the services, it does not address the needs of the country's poorest. Some donors, looking to circumvent public healthcare shortcomings, are investing in not-for-profit private practitioners to help reduce their costs and improve their services.
"The critical end of this is to ensure service delivery... [so] that the lowest person will be able to access health services," said Tadeo Atuhura, the communications specialist at Strides for Family Health [ http://strides.sacitsolar.com ], a US Agency for International Development-funded organization that offers performance-based contracts to private health facilities in areas where government services are lacking. The subcontractors are provided with incentives to reach specific health targets and reduce costs so more of the population is able to visit private facilities.
Strides funding has allowed Suubi Medical Centre, based in the Lake Victoria fishing village of Busu, to expand rapidly - eclipsing the basic health services offered at the local government health centre.
One of the centre's patients, 17-year-old Kate Namuloki, went into labour two months ahead of schedule, a spontaneous delivery caused by a bout of malaria. The government health centre has been without a midwife for more than a year, so to deliver in a fully staffed government facility she would have had to travel from for more than two hours over unpaved roads.
Instead, she delivered her daughter at Suubi; her grandmother sold a duck to pay for the delivery, which cost about $4.
Stanley Kwiri, a laboratory technologist, started Suubi in 2011; he said he is offering 11 different services with the funding from Strides, including the antenatal, delivery and postnatal care that the government health centre down the road cannot. He even helps supplement state programmes, providing government teams with transportation when they go out for routine immunization campaigns.
Dr Christine Kirunga Tashobya, the public-private partnership in health desk officer at the Ministry of Health said subsidized private healthcare could also help ease the pressure on public health facilities. "You could say if people who can afford [private healthcare] go to public facilities and get free services, there is leakage of public resources to people who could afford to look after themselves," she said.
The government has even encouraged the growth of the for-profit health sector by allowing health workers in public facilities to moonlight in private clinics. Tashobya said without this policy, the majority of doctors, nurses and midwives would opt to work in higher-paid private facilities, leaching the public system of the limited health workers it does have.
Fixing public healthcare is key
But according to Margaret Mungherera, president of the Uganda Medical Association, a professional association for health workers, this is already happening; she says high rates of absenteeism at public health facilities are caused by health workers "running around trying to supplement their income" by working at private facilities where they can command better pay.
Speaking alongside Lyomoki during the announcement of parliament's plan to block Uganda's pending budget, Mungherera she said the only lasting solution to the country's health system woes must involve lifting the salary freeze on current health workers and finding the money to recruit new ones.