International University of Africa

Faculty 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 Kasawuli Level 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) with a gross domestic product (GDP) per capita of US$501 and an economy growing at the rate of 5.1 percent (World Bank 2011). The country has an area of 241,000 km2 and a population of 32.2 million with growth rate of 3.2%. With a population density of about 120 persons per km2, Uganda is one of the most densely populated countries in SubSaharan Africa. Eighty eight percent of the population lives in rural areas. Two decades of civil unrest, beginning in the early 1970s, led to a decline in health indices, and had a negative impact on health and other related systems in Uganda. The post-conflict reconstruction has focused on re-establishing a political and economic environment conducive to growth, which has yielded significant and positive results. During this reconstruction period there has also been an increasing amount of funding from the government, as well as from bilateral and multilateral donors, to support the health sector. Health indicators are currently improving, as are economic and many governance indicators, yet improvement is needed in health spending and performance of the health sector (Millenium Challenge Corporation 2011). Significant challenges remain to strengthen the health system sustainably and thereby improve the health status of all Ugandans.

Demographic Information and Population Growth

Rapid population growth can inhibit a countrys ability to raise the standard of living, especially if government revenues do not increase at the same rate. Annual population growth for Uganda between 1960 and 2010 has been consistently and significantly higher than the regional average (World Bank 2010). Ugandas total fertility rate, currently at 6.24 percent, has remained 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 growth rate are maintained, 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 has significantly 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 poverty line as of 2008 (WHO 2008). See Table 1.1 for other selected indicators for Uganda and comparative countries.

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Country Health Indicators Life expectancy is an indicator of the overall health status of a countrys population and of their quality of life, and in Uganda life expectancy has been increasing steadily from 45 in 2003 to 53 years today. This is similar to the SSA average of nearly 54 years, but lower than the LIC average of 58 years (World Bank 2011; World Bank 2010). The infant mortality rate in Uganda remains high, at 76 per 1,000 live births, although there has been a decline from 85 per 1,000 live births in 1995 (World Bank 2010; MoH 2011e). Hospital-based data indicate that 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, prenatal conditions at 7.8 percent, and septicemia at 5 percent (MoH 2011e). The maternal mortality ratio for Uganda has declined significantly in recent years, but is still above the Millennium Development Goals (MDGs) 2015 target of 131; see Table 1.1. According to the 2010/11 Annual Health Sector Performance Report (AHSPR), the maternal mortality in hospitals and health centers was estimated at 200 per 100,000 live births (MoH 2011). This estimate, however, does not capture deaths that occurred outside health facilities, and is likely lower than the national ratio. See Chapter 5 Service Delivery for more analysis of infant and maternal morbidity and mortality.

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TOP CAUSES OF MORBIDITY AND MORTALITY

The burden of disease in Uganda remains predominantly in communicable diseases, although there is also a growing burden of noncommunicable 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 the leading cause of morbidity in Uganda, accounting for close to half of the countrys morbidity. Causes of morbidity are presented in Figure 1.2.

Among the overall causes of mortality, malaria ranks as the single largest cause, followed by HIV/AIDS and pneumonia. Figure 1.3 shows the top 10 leading causes of mortality in Uganda according to facilitybased reported deaths (MoH 2011e)

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HIV, Tuberculosis, and Malaria

HIV, tuberculosis, and malaria are three of the main communicable diseases contributing to mortality in Uganda. Efforts to combat all three diseases also receive significant funding from development partners.

HIV prevalence and access to HIV services:

The HIV/AIDS prevalence rate for people aged 1549 years in Uganda was estimated at 6.5 percent in 2009 (World Bank 2010). The Modes of Transmission Study and sero-behavioral survey estimated in 2005 that HIV prevalence was higher among women compared to men, and that urban residents were significantly more affected than their rural counterparts (Wabwire-Mangen et al. 2009). The June 2010 MoH quarterly report shows that based on the cut-off of 250 CD4, 53.6 percent of eligible 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) was estimated 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. The AHSPR, 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 20092010 (GoU 2010a). Case detection dropped to 54.0 percent in 20102011. The smear-positive tuberculosis TSR was estimated at 70 percent, below the WHO-recommended 85 percent (WHO Global Health Observatory). The TB situation is complicated by an HIV/AIDS co-infection rate of 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 the outpatient burden and 35 percent of hospital admissions (MoH 2010a). Malaria is the leading cause of mortality among all ages in hospitals (MoH 2011e). Children under the age of five years and pregnant women are particularly at high risk. It is estimated that between 70,000 and 100,000 deaths per year occur among children under five years of age, and between 10 and 12 million clinical cases are treated in the public health system alone (GoU 2010b). The proportions of children under five and pregnant women sleeping under an Insecticide Treated Net (ITN) are currently 32 percent and 42 percent respectively (GoU 2010b).

THE REFERRAL SYSTEM

The 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 that facility 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 quickly transferring from one facility to another in the case of referrals. The referral mechanism also faces the challenges of poor road networks or terrain, and lack of referral forms, relevant emergency medicines, and supplies including blood for transfusion at the referral facility (MoH and Macro 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 referral is the inadequate capacity of the health facilities, especially the Health Center IVs, to handle emergency cases such as caesarean sections or blood transfusion. A common practice is that patients, particularly those with more money than the average, bypass the lower level facilities, and self-refer themselves to whatever higher-level facility they perceive as good for them. This leads to congestion of high-level hospitals (like Mulago teaching hospital) with patients with minor ailments that could have been treated at lower levels.

HEALTH CARE WORKERS IN UGANDA

Uganda has an estimated more than 70,000 health care workers. This includes 30,922 public sector workers, a similar number in the PNFP sector (MoH 2011b), and an additional estimated 9,500 in the private, forprofit 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 care workers who also moonlight in the private sector may result in a high number 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 ratio currently stands at approximately 1.8/1,000 (MoH 2011c). While this ratio represents a considerable improvement over just the last 510 years, it is still clear 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 snapshot of the staffing situation in Ugandas public sector as of June 2011. Norms refer to number of total positions, while the filled column refers to the number of norms filled. Central-level institutions include the two national-level hospitals and the regional referral hospitals.

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Manpower
According 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 money as well because it costs more than Shillings 15 million to train one doctor in Uganda. Ministry of Health statistics show a very nerve-racking situationa country seriously short of specialist doctors. 1. Pediatricians born annually
2. Nutritionist

86 for 15 million children under 15 & 1.4 million

` 2 for 32 million people

3. Obstetricians/gynecologists103 for 13 million women 4. Psychiatry 26 for 32 million people 5. Surgery 97 general surgeons for 32 million people
6. Doctors 1:24,000

The ration for general surgeon is 1: 309,278 people. There is only one doctor for about 24,000 peopleone of the biggest patient/doctor ratios in the world. The continental average for sub-Saharan Africa is about 13 doctors per 100,000 people. smwesigye@observer.ug

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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. In terms of nurse absorption, a recent study found about 70 percent was employed within six months after graduation; however, many of these nurses 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 receiving systems for those workers (MoH and private sector). In an ideal situation, the health production system would respond to current and projected needs 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 available at the time of the assessment.

Workforce Licensing and Regulation

There 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 of Parliament. They are independent of the MoH, but governed by health sector 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 study showed that licensure to practice was only provided to 28 percent of the 25,482 nurses and midwives that graduated before 2006 (Spero et al. 2011). The most recent data available indicate that while 42,166 nurses and 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 a nurse would seek a license.

CONCLUSION
The 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, leading to stock-outs of essential medicines and low quality of care. OOP expenditure is high (at over 50 percent of total health expenditure) and there is also high risk of catastrophic health expenditures. Health workers are not yet working in the required numbers in rural districts, and households risk further impoverishment due to informal fees in the public sector or formal fees in the private sector.

RECOMMEDATIONS
a) Increase on the medical scholarship for under/post graduate to different countries b) Funding of African medical Students Association at International University 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 projects e.g. construction of hospitals, clinics and health centers d) A continental health policy that includes interventions designed to address key health system gaps with the help of bodies Like AMSA

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REFERENCES
1. Action Group for Health, Human Rights and HIV/AIDS (AGHA), Uganda. 2007. A Promise Unmet: Access to Essential Medicines in Three New Districts of Uganda. Kampala: AGHA Uganda. 2. Adome, R., et al. 1998. The Community Epidemiology of Drug Use: A Case of Three Districts in Uganda. In conference proceedings of People and Medicines in East Africa, November 2123, Mbale, Uganda. 3. Millenium Challenge Corporation. 2011. Scorecard for Uganda, Fiscal Year 2011. Available at http://www.mcc.gov/documents/scorecards/score-fy11uganda.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 20052020: Responding to Health Sector Strategic Plan and Operationalising the 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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