Uganda:More pain than joy in being Ugandan doctor
Each moment in the last 19 years of Dr Margaret Mungerera’s life has felt like a burden. As a senior consultant with the Ministry of Health, Dr Mungerera is one of just a few doctors that this country’s 26.4 million must share out.
As a doctor for the mentally sick at Butabika Referral Hospital, she takes an even bigger burden.
“Having to do work for three or four people, you get burnt out,” Dr Mungerera says.
She understands that faced with a situation like her own, other doctors are opting out — to go work with non- governmental organisations where they get to work a nine-to-five schedule; or simply leaving the country.
But this is the continent’s story.
As a doctor working in one of the poorest countries in the world, she must attend to 23,000 persons; nearly five times more than a doctor in the United States (467 patients), for instance.
And her burden is 12 times heavier than for a doctor in Cuba, the country with the world’s best doctor-patient ratio.
“The public service prescribed working hours for a doctor in Uganda is 48 per week,” Mungherera says.
“But as a result of the shortage, you end up working for 150 hours.”
But the huge workload they have to endure would probably not have been such an issue if it were not for what many doctors perceive as insensitivity on the part of the government.
For the most part, there has been no love lost between Ugandan doctors and government. Over the years, medical workers have demanded better pay; better working conditions and fairness. But these demands, they say, appear to have fallen on deaf ears.
Most recently, medics planned to go on strike for two days last month. They warned that if government did not listen to them, they would stage another strike this month.
But then, they met with President Yoweri Museveni and after accepting a promise from him that their concerns would be addressed, they suspended the action.
Lately, however, something happened that only served to worsen the already strained relationship between the authorities and the medics.
President Museveni said in a statement to the media that he would not have his own family treated by Ugandan doctors because they can’t be trusted; they have got sucked into partisan politics.
The president was writing to justify flying his daughter and daughter-in- law by presidential jet to Germany in August to deliver their babies there.
Needless to say, the statement did not go down well with the doctors and the medics’ union told off the president.
During the various spats that have marked this uneasy relationship, one of the major bones that medics had to pick is the haphazard transfers that they are subjected to.
On their part they see government as a slave driver, while government sees itself as trying to make the best of hard realities.
On March 15, 1997, government issued Posting Order Number 23, a circular that many doctors will never forget.
It stated: “In the interest of the service, the following officers are posted/transferred with immediate effect. The affected should report to their new stations by 30 April 1997.
“The receiving stations should inform this office when the officer reports for duty.”
Mr J.F. Tiromwe signed the circular for the Director General of Health Services.
There were 148 medics on the circular and they had just 15 days to pack their bags and move; some to locations they had to look up on the map.
Number 24 on the list was Ms Margaret Kamondi, a registered midwife and, like half of the medics on the list, was working at Mulago Hospital.
She was ordered to move to Kapchorwa Hospital.
Which might have been all well and good.
Except that particularly prominent on the list was a Dr Sam Lyomoki.
Lyomoki was told to go to a place called Atutur deep inside Soroti. Lyomoki and Kamondi were newly wedded at the time.
And Kapchorwa and Atutur can hardly be described as next-door neighbours.
Lyomoki went on to become a workers’ rights activist; today he is the secretary general of the Uganda Medical Workers Union (UMWU) and also the representative for the Workers in Parliament. But his was not the only family that was going to be split.
Mr Apollo Nyangasi, the president of UMWU says that the people affected included many nurses, midwives, para-medics, dispensers, clinical officers, and other officers.
The transfers, according to Nyangasi, were punitive; with the intention to punish supposed leaders of the national strike at the time that paralysed the country.
The 1996 strike could have brought the country to its knees had the government not ordered Army medics to take over.
“In 1995, after government failing to talk to us, workers decided there should be a strike,” Nyangasi recalls.
“They victimised us, took us to court,” he said.
The doctors were charged with negligence and disobedience of a lawful order by a minister. But government lost its case for it could not prove negligence on the doctors’ part. And the transfers held.
Said Nyangasi: “They transferred about 150 union leaders. They took them here and there, scattered them to Kapchorwa.” Government had won.
Soon the strike fizzled out.
But this ‘displacement’ of senior medics as a way to end the strike would have repercussions that would reverberate through the health sector eight years later.
It catalysed a brain drain that has left Uganda’s health sector a shambles.
Some medics left the public service to start out on their own; others left the country altogether. Lyomoki resigned.
The secretary general of UMWU at the time, one Dr Charles Mondo, reportedly went to China.
A report by the government task force named last month to study salary issues raised by medics warned that the situation could only get worse.
“The global market and demand for health workers is big and if countries do not take sufficient care, losses of health professionals through brain drain will cripple development in the country,” the report said.
For many Ugandans, the popular destinations, according to Dr Mungerera, were Botswana, South Africa, Namibia and Saudi Arabia.
Mr Francis Omaswa, the Director General of Health Services appointed the task force that met on September 2 and 6.
Just before that a Ministry of Public Service circular had been issued revising salaries of government workers.
One reason medics are on demand outside the country is the high cost involved in training one. UMWU estimates that it takes $30,000 (Shs 60m) to train a nurse in Britain.
Nyangasi says, “If they pick these [Ugandan] nurses and retrain, they spend only $3,000 (Shs 6m)”.
Then he adds, “That is why they are …poaching.”
Moreover, Uganda’s medical training is reported to be one of the best in the region.
“It is historical,” Mungerera says. “If you remember, in East Africa I think the Kenyans had engineering and Tanzanians had lawyers. This was the only centre of medical training.”
“We definitely are far ahead. There is more research at postgraduate level,” Mungerera added.
But that they were well trained did not work in the medics’ favour during the strike or in its aftermath.
Interns were reportedly mistreated and threatened with denial of enrolment if they participated in the strike.
“When it came to things like posting, they posted them to distant places. There are hospitals in Kapchorwa, Moroto… They are distant. You are doomed; you will not prosper,” Nyangasi said.
He added, “Some of them went out of the country. Some are in private practice. Some even left medical practice. They are doing their own stuff.”
Yet, even as the brain drain intensified and the health service festered, government remained complacent, sometimes even hostile.
If they could break the strike, you may ask, what incentive did they put to satisfy the medics, even half way?
The task force report says, “It is worth noting that from the industrial action of 1996 to date, government has not adequately and satisfactorily addressed the plight of the health workers including explaining the situation to them through the normal administrative channels.”
One outcome though was a committee appointed by the Ministry of Health to examine the complaints.
This resulted in a job evaluation exercise completed in 2000 in which health workers scored higher than other workers in public service. Government, though, did not rise to the occasion. Instead, they had some health workers downgraded in remuneration.
For instance, entry-level pay for a clinical officer was reduced from Shs 350,160 per month to Shs 186,500.
That of a senior nurse was reduced to Shs 236,411. But there is more.
“The key issues or factors peculiar to the Health sector were either rated low or not included in the instrument,” the report says.
It adds, “Unfortunately, a more pathetic, unrealistic, unreasonable and degrading terms and conditions of service and remuneration were meted out to the health workers.”
A registered nurse was weighted equally with a commercial artist, but the nurse is reportedly paid less than the artist. The artist earns about Shs 400,000.
For the six years that they spend in training and a wealth of experience required to reach their level, senior medical doctors earn about Shs 560,000.
“That forces them to look for what we call candle-lighting, selling tomatoes and selling fish,” Nyangasi adds. Betrayal?
Nyangasi says, “If health workers put self preservation above calling, no one would be working in the current environment. So health workers are over burdened.”
He adds, “When patients die, it appears like neglect yet health workers do all that is possible.”
Because of the high entry points required there are just a few doctors that graduate from Makerere each year. If these only end up leaving the country there’s no telling the likely repercussions and how far- reaching they could be.
Says Nyangasi: “As more and more health workers have to survive, they are going into private practice. And if the private practice is not coordinated, it is a very raw deal to the population.”
Meantime, as a way of addressing the issue of medics’ impoverishment, a task force has been detailed by the union to study the formation of a Cooperative and Savings Credit Union.
The aim is to have health workers save together, buy equipment in bulk and rent out some of the services that are needed in hospitals and in the health sector.
But health workers also demand that a National Health Service be formed or the Health Service Commission be empowered to enforce the terms and conditions of service for health workers as stipulated in the Constitution.
The Omaswa taskforce report says: “Basic salary should reflect the duration and content of training, experience and expert nature of health care compared to other sectors and should be categorised separately from allowances.”
Medical workers don’t have a risk allowance yet they are daily exposed to risk, sometimes even death from diseases contracted in the course of duty.
Mungerera has been working in Butabika for nine years. And a patient attacking her is the one thing she dreads.
“There is a risk of being battered,” she says. “I have been working in Butabika, there is a risk of being battered. We have a few cases of workers who have been stabbed.”
Other risks include HIV, Cholera, Ebola, TB and stress related illnesses – all of which, the medics say, reduce their life expectancy.
“I think the needle prick injuries are very common,” Mungherera says. “And basically one can contract hepatitis, HIV, etc.”
The case of Dr Mathew Lukwiya who contracted and died of Ebola in 2000 is still very fresh in the mind.
The report says: “Risk allowance will facilitate health workers’ purchase of personal protective gear.”
It also points out that the lack of transport allowance has meant that many cannot be available during emergencies at awkward hours – yet they are required to be.
They don’t have a medical allowance, yet they say the environment in which they work is saturated with infections.
Many of them don’t have accommodation near the place of work though they put in time at night and on weekends.
They don’t have a lunch allowance. And no time allocated as ‘lunchtime’.
They receive no teaching allowance; yet they are expected to train at all times and keep abreast with the emerging diseases.
They don’t have an extra-duty allowance yet they work almost all the time.
“They are called upon to work even at night, on public holidays and over the weekends,” says the report. “Even when not physically on duty, they are on call.”
If accepted, the proposals by the Omaswa taskforce would push the annual wage bill of senior level medics to Shs 3.28bn – at Shs 7.2m for each of the 440 of them.
It would push the annual wage bill for mid level workers to Shs 12.2bn – at Shs 3.7m each for 3,000 of them.
And it would push the annual wage bill for the lower level workers to Shs 22.5bn — Shs 550,000 for each of the 10,000 of them.
The total increase in wages would be Shs 455.78bn, which would double the current $250 million (Shs 500bn) health sector wage bill.
The parliamentary committee of social services has reportedly recommended improving remuneration and incentives to health workers in its 2003/4 financial year report.
The cabinet sub-committee on health workers’ grievances in 1996 arrived at the same conclusion. But eight years later, the same problems dog the health sector.
Yet, government can substantially cut the doctor-to-patient ratio by merely cutting money spent on political tax levied in the form a multitude of irrelevant political appointees.
A Resident District Commissioner earns Shs 20,526,168 annually; the deputy earns Shs 11,824,884, and the assistant Shs 7,886,496.
This means that for each district some Shs 40.2 million is paid out to the president’s representatives.
For the 56 districts, Shs 2.3 billion is spent maintaining these politicians. There are 36 presidential advisors who cost an estimated Shs 1.08bn a year.
The total paid to these two groups of appointees comes to Shs 3.4bn a year. This could pay salaries for an extra 505 senior doctors each year at the current rate of Shs 560,000 a month.
It can pay salaries for 1,198 senior nurses at the current salary of about Shs 236,411 a month. President Museveni is not blind to the medics’ hardships.
At the height of the presidential campaigns in 2001, in his manifesto, the president wrote: “Doctors, too, have got a very tedious and sometimes dangerous job, as tragically shown by the recent Ebola epidemic.
“Previously, doctors had become infected with Aids from handling the blood of sick people.
“Somebody stands for the whole day carrying out four operations, for instance.
“This [is] very tedious and a moral burden on these lifesavers. Therefore, the theory of ‘democratic suffering’ needs to be tempered with some form of positive discrimination, based on realistic job evaluation.”
The remarks made the medics optimistic.
But two years later, in October, Museveni made reference to Ugandan medics as “enemies of our people’s destiny.”
The bill for his daughter and daughter-in-law’s trip to the Germany is estimated at Shs 360m.
In a statement last week, Mungherera said: “The Uganda Medical Association detest being referred to as enemies of the people. We are not that kind of people.”
UMA groups together doctors.
Mungerera said that while there might be incompetence in some instances, it is probably because medics’ appeals for government help to strengthen the profession have over time fallen on deaf ears. Nyangasi says, “I think workers and health professionals deserve an apology because they are working under ever harder conditions.”
He adds that this is an insult not just to medics, but to all Ugandans.
“How many of the 25 million are able to fly out? It is like the 25 million Ugandans don’t matter?”
Ironically, just days after the president’s outburst, government called upon medics to implement the measles immunisation campaign.
Nyangasi wonders why government did not just “import” mercenaries for this campaign. He adds, “We have the will and desire to work. We don’t have the necessary resources.”
If the brain drain is hurting the health service, a ban on recruitment only made it worse.
In 1996, just as the health industry emerged out of the strike, government banned recruitment of health professionals.
Uganda’s population is estimated at about 25 million, up from about 21 million in 1996. Consequently, the doctor-patient ratio grows worse, not better.
According to this ban, Mungerera says, a district “can only replace doctors who have died or those who have gone to study. You are not allowed to get new doctors. That has caused a lot of under staffing.”
The ban on recruitment also means that doctors no longer have a promise of a job upon graduation, as was once the case.
This means that an incentive to study medicine no longer exists. This, in a country in need of more doctors.
Even on the government’s part, this is a double tragedy; it spends millions training medics — an estimated Shs 8m per medical student at Makerere University — then it cannot put them to use.
“After training them, the medic leaves,” Nyangasi said rather tersely.
Those receiving the departing doctors are said to be the happiest. For, good training at Makerere University makes it easier for Ugandan doctors to adapt in the West.
“That is why doctors here quickly catch up abroad. The training is still of very high standard,” Mungerera says. She hopes that government will not let the situation deteriorate anymore.
She says of the recruitment ban, “It has to be lifted. Then, hospitals can employ more doctors.”
Source: The Monitor Publications