amsa-iua: conference proceedings_jan 2013: 4. uganda

8/13/2019 AMSA-IUA: Conference Proceedings_Jan 2013: 4. Uganda

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International University of AfricaFaculty of Medicine and Health Sciences

African Medical Students Association Health Problems in Africa: Is there any

hope left?10 11 January 2013 AD/ 28 -29 Safar 1434 AH

Khartoum - Sudan

Major Health Problems in East Africa

Uganda

Prepared by:

Jamadah KasawuliLevel 3, Faculty of Oral and Dental Health IUA


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COUNTRY BACKGROUND Uganda is located within the sub-Saharan Africa region (SSA), in

the East African community. Uganda is a low-income country (LIC) witha gross domestic product (GDP) per capita of US$501 and an economygrowing at the rate of 5.1 percent (World Bank 2011). The country has anarea of 241,000 km2 and a population of 32.2 million with growth rate of3.2%. With a population density of about 120 persons per km2, Uganda isone of the most densely populated countries in Sub Saharan Africa. Eightyeight percent of the population lives in rural areas.

Two decades of civil unrest, beginning in the early 1970s, led to adecline in health indices, and had a negative impact on health and otherrelated systems in Uganda. The post-conflict reconstruction has focusedon re-establishing a political and economic environment conducive togrowth, which has yielded significant and positive results. During thisreconstruction period there has also been an increasing amount of fundingfrom the government, as well as from bilateral and multilateral donors, tosupport the health sector. Health indicators are currently improving, as areeconomic and many governance indicators, yet improvement is needed inhealth spending and performance of the health sector (MilleniumChallenge Corporation 2011). Significant challenges remain to strengthenthe health system sustainably and thereby improve the health status of allUgandans.

Demographic Information and Population GrowthRapid population growth can inhibit a countrys ability to raise the

standard of living, especially if government revenues do not increase at thesame rate. Annual population growth for Uganda between 1960 and 2010 has

been consistently and significantly higher than the regional average (WorldBank 2010). Ugandas total fertility rate, currently at 6.24 percent, hasremained high and relatively stagnant for over six decades. While the urban

population is growing rapidly, at a rate of 5.6 percent per annum, the largest proportion of the population (86.7 percent) is rural (World Bank 2011).Additionally, nearly half of the current population (49 percent) is under 14

years old (World Bank 2010). If the current fertility rate and annual growthrate are maintaine d, Ugandas population is expected to increase to 44 million by 2020, raising the population density from 120 to 164 per km2, and placing


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more demands on the health sector (MoH 2010f). One positive trend is that

the proportion of people living below the poverty line in Uganda hassignificantly decreased, from 52.0 percent in 1992 to 24.5 percent in 2009(World Bank 2010). There is evidence of significant inequality, however.

Northern Uganda, afflicted by conflict since the late 1980s, remains the poorest region, with 61.0 percent of the population living below the povertyline as of 2008 (WHO 2008). See Table 1.1 for other selected indicators forUganda and comparative countries.


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Country Health Indicators

Life expectancy is an indicator of the overall health status of acountrys population and of their quality of life, and in Uganda lifeexpectancy has been increasing steadily from 45 in 2003 to 53 yearstoday. This is similar to the SSA average of nearly 54 years, but lowerthan the LIC average of 58 years (World Bank 2011; World Bank 2010).

The infant mortality rate in Uganda remains high, at 76 per 1,000live births, although there has been a decline from 85 per 1,000 live birthsin 1995 (World Bank 2010; MoH 2011e). Hospital-based data indicatethat malaria is the leading cause of under-five death, at 27.2 percent,followed by anemia at 12.1 percent, pneumonia at 11.4 percent, prenatalconditions at 7.8 percent, and septicemia at 5 percent (MoH 2011e).

The maternal mortality ratio for Uganda has declined significantly inrecent years, but is still above the Millennium Development Goals(MDGs) 2015 target of 131; see Table 1.1. According to the 2010/11Annual Health Sector Performance Report (AHSPR), the maternalmortality in hospitals and health centers was estimated at 200 per 100,000live births (MoH 2011). This estimate, however, does not capture deathsthat occurred outside health facilities, and is likely lower than the nationalratio. See Chapter 5 Service Delivery for more analysis of infant andmaternal morbidity and mortality.


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TOP CAUSES OF MORBIDITY AND MORTALITYThe burden of disease in Uganda remains predominantly in

communicable diseases, although there is also a growing burden of non-communicable diseases (NCDs), including mental health disorders.Maternal and prenatal conditions contribute to the high mortality.

Neglected Tropical Diseases remain a big problem in the country,affecting mainly rural poor communities (WHO 2006). Malaria is theleading cause of morbidity in Uganda, accounting for close to half of thecountrys morbidity. Causes of morbidity are presented in Figure 1.2.

Among the overall causes of mortality, malaria ranks as the singlelargest cause, followed by HIV/AIDS and pneumonia. Figure 1.3 showsthe top 10 leading causes of mortality in Uganda according to facility-

based reported deaths (MoH 2011e)


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HIV, Tuberculosis, and MalariaHIV , tuberculosis, and malaria are three of the main communicable

diseases contributing to mortality in Uganda. Efforts to combat all three diseasesalso receive significant funding from development partners.

HIV prevalence and access to HIV services:The HIV/AIDS prevalence rate for people aged 15 49 years in Uganda was

estimated at 6.5 percent in 2009 (World Bank 2010). The Modes of TransmissionStudy and sero-behavioral survey estimated in 2005 that HIV prevalence was higheramong women compared to men, and that urban residents were significantly moreaffected than their rural counterparts (Wabwire-Mangen et al. 2009). The June 2010MoH quarterly report shows that based on the cut-off of 250 CD4, 53.6 percent ofeligible individuals were accessing treatment, but this was reduced to 43.9 percent

when the eligibility criteria was set at the 350 CD4 count.


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TB prevalence and outcomes:

The incidence of tuberculosis (per 100,000 population per year) wasestimated at 311 in 2008 (WHO Global Health Observatory). In the same year,the prevalence of tuberculosis (per 100,000 population) was estimated at 281.According to the WHO report, indicators for the TB case detection rate are 49.6

percent, well below the WHO tuberculosis control targets of 70.0 percent. TheAHSPR, however, reports an improvement in the case detection rate, from 50.3

percent to 57.4 percent, and in the treatment success rate (TSR), from 68.4 percent to 75.1 percent in 2009 2010 (GoU 2010a). Case detection dropped to54.0 percent in 2010 2011. The smear-positive tuberculosis TSR was estimatedat 70 percent, below the WHO-recommended 85 percent (WHO Global HealthObservatory). The TB situation is complicated by an HIV/AIDS co-infection rateof 60 percent among TB patients (GoU 2010a).

Prevalence and death rates associated with malaria:Malaria transmission is perennial in approximately 95 percent of Uganda

and malaria is the leading cause of morbidity, contributing to 50 percent of theoutpatient burden and 35 percent of hospital admissions (MoH 2010a). Malaria isthe leading cause of mortality among all ages in hospitals (MoH 2011e). Childrenunder the age of five years and pregnant women are particularly at high risk. It isestimated that between 70,000 and 100,000 deaths per year occur among childrenunder five years of age, and between 10 and 12 million clinical cases are treatedin the public health system alone (GoU 2010b). The proportions of childrenunder five and pregnant women sleeping under an Insecticide Treated Net (ITN)are currently 32 percent and 42 percent respectively (GoU 2010b).

THE REFERRAL SYSTEMThe referral system is a formalized system that requires a patient from a

lower level facility to obtain a referral note from the health workers in thatfacility in order to go to the relevant higher level facility. In practice however,the referral system in Uganda is not very effective.

Lack of ambulances, fuel, or both prevents patients from quicklytransferring from one facility to another in the case of referrals. Thereferral mechanism also faces the challenges of poor road networks orterrain, and lack of referral forms, relevant emergency medicines, andsupplies including blood for transfusion at the referral facility (MoH andMacro International 2008; GoU 2010b). In addition, people often have to


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pay for emergency care, and inability to pay for the services might delay

access to or provision of referred services. A critical challenge for referralis the inadequate capacity of the health facilities, especially the HealthCenter IVs, to handle emergency cases such as caesarean sections or bloodtransfusion.

A common practice is that patients, particularly those with moremoney than the average, bypass the lower level facilities, and self-referthemselves to whatever higher-level facility they perceive as good forthem. This leads to congestion of high-level hospitals (like Mulagoteaching hospital) with patients with minor ailments that could have beentreated at lower levels.

HEALTH CARE WORKERS IN UGANDAUganda has an estimated more than 70,000 health care workers. This

includes 30,922 public sector workers, a similar number in the PNFPsector (MoH 2011b), and an additional estimated 9,500 in the private, for-

profit sector (Mandelli et al. 2005).Current private workforce statistics are hard to come by and

somewhat unreliable. In addition, the high percentage of public health careworkers who also moonlight in the private sector may result in a highnumber of double-counts.

WHO recommends a ratio of 2.3 health care workers per 1,000 population

as a minimum to meet the millennium development health goals. Ugandas ratiocurrently stands at approximately 1.8/1,000 (MoH 2011c). While this ratiorepresents a considerable improvement over just the last 5 10 years, it is stillclear that the absolute number of health care workers in Uganda is too low.

Table 4.1, adapted from the 2011 HRH Audit Report, provides a snapshotof the staffing situation in Ugandas public sector as of June 2011. Norms refer tonumber of total positions, while the filled column refers to the number of normsfilled. Central-level institutions include the two national-level hospitals and theregional referral hospitals.


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ManpowerAccording to line minister, Dr. Stephen Mallinga, there are 250 Ugandan

doctors working in South Africa and 30 in Lesotho where they are paid much better than at home. Not only is the country losing manpower, it is losing moneyas well because it costs more than Shillings 15 million to train one doctor inUganda. Ministry of Health statistics show a very nerve-racking situation acountry seriously short of specialist doctors.

1. Pediatricians 86 for 15 million children under 15 & 1.4 million born annually

2. Nutritionist ` 2 for 32 million people3. Obstetricians/gynecologists103 for 13 million women4. Psychiatry 26 for 32 million people5. Surgery 97 general surgeons for 32 million

people6. Doctors 1:24,000

The ration for general surgeon is 1: 309,278 people. There is onlyone doctor for about 24,000 people one of the biggest patient/doctor

ratios in the world. The continental average for sub-Saharan Africa isabout 13 doctors per 100,000 people. [email protected]
mailto:[email protected]:[email protected]:[email protected]:[email protected]


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Training, Education, and Licensing There were 66 health training institutions 32 owned by

governments, 29 by PNFPs, and 5 founded on a private for-profit basis. Interms of nurse absorption, a recent study found about 70 percent wasemployed within six months after graduation; however, many of thesenurses do not find work in the public sector (Uys et al. 2010).

As mentioned above, there is a clear disconnect in the health system between institutions producing new health care workers, and the receivingsystems for those workers (MoH and private sector). In an ideal situation,the health production system would respond to current and projectedneeds in the workforce. The skill mix in the pipeline and the annual

outputs are shown in Figure 4.5. More up-to-date data were not availableat the time of the assessment.

Workforce Licensing and RegulationThere are four health professional councils in Uganda: the Uganda

Nurses and Midwives Council; the Uganda Medical and Dental


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Practitioners Council; the Allied Health Professionals Council; and the

Pharmacy Council. These are all autonomous bodies created by an act ofParliament. They are independent of the MoH, but governed by healthsector policy. Ratification of the Pharmacy Council Act is still pending,

but it is fully functional as the registering body.There is evidence that the Uganda Nurses and Midwives Council is

under-resourced and unable to provide effective regulation. One studyshowed that licensure to practice was only provided to 28 percent of the25,482 nurses and midwives that graduated before 2006 (Spero et al.2011). The most recent data available indicate that while 42,166 nursesand midwives total have been registered, only 17,582 (41 percent) have

been licensed. While fees for licenses may play a part in low licensure percentages, the ability to practice without a license raises the question of why anurse would seek a license.

CONCLUSIONThe health system could go much further and respond more

deliberately to the majority of Ugandans, who live in rural poverty.Currently, the essential package of health services is underfunded, leadingto stock-outs of essential medicines and low quality of care. OOPexpenditure is high (at over 50 percent of total health expenditure) andthere is also high risk of catastrophic health expenditures. Health workers

are not yet working in the required numbers in rural districts, andhouseholds risk further impoverishment due to informal fees in the publicsector or formal fees in the private sector.

RECOMMEDATIONS

a) Increase on the medical scholarship for under/post graduate todifferent countries

b) Funding of African medical Students Assoc iation at InternationalUniversity of Africa (IUA)


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c) Follow-up of graduates in their respective countries to improve on

the continental health sector through sponsoring medical projectse.g. construction of hospitals, clinics and health centers

d) A continental health policy that includes interventions designed toaddress key health system gaps with the help of bodies Like AMSA


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REFERENCES1.

Action Group for Health, Human Rights and HIV/AIDS (AGHA), Uganda.2007. A Promise Unmet: Access to Essential Medicines in Three New Districtsof Uganda . Kampala: AGHA Uganda.

2. Adome, R., et al. 1998. The Community Epidemiology of Drug Use: A Case ofThre e Districts in Uganda. In conference proceedings of People and Medicinesin East Africa , November 21 23, Mbale, Uganda.

3. Millenium Challenge Corporation. 2011. Scorecard for Uganda, Fiscal Year2011 . Available at http://www.mcc.gov/documents/scorecards/score-fy11-uganda.pdf.

4. Ministry of Finance, Planning and Economic Development (MoFPED). 2006. Development Cooperation Uganda 2005/06 Report . Kampala: MoFPED,Republic of Uganda.

5. Ministry of Finance, Planning and Economic Development. 2010. Reference

forthcoming.6. Ministry of Health. 2004. Human Resource Inventory in the Health Sector .

Kampala.7. Ministry of Health. 2005a. Annual Health Sector Performance Report:

Financial Year 2004/2005. Kampala.8. Ministry of Health. 2006. Annual Health Sector Performance Report: Financial

Year 2005/2006. Kampala.9. Ministry of Health. 2007a. Uganda Human Resources for Health Strategic Plan

2005 2020: Responding to Health Sector Strategic Plan and Operationalisingthe HRH Policy. Kampala.

10. Ministry of Health. 2007b. Annual Health Sector Performance Report: Financial Year 2006/2007. Kampala

11. Ministry of Health 2011 annual report.

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