Dr. Nick Wooding kindly asked me to write a preface for a book about to be published by International Health Sciences University which discusses the many aspects and issues related to the delivery of primary healthcare in the developing world, and in Uganda specifically.
PHC in East Africa: Preface
If you are a healthcare practitioner or student you will know that there are already thousands of books exploring and expounding each and every aspect of Primary Health Care. So why have we added another one?
It may be wrong to claim that specific health issues facing Uganda are unique but perhaps we can at least say that when combined together in the local context they become unique. It is that local context that we have set out to explore more fully in this book. We have written about primary healthcare as it applies to Uganda and we have written it for those that are providing, and for those that hope to provide, healthcare services to its people.
Healthcare policy in Uganda is very well designed and documented. The second National Health Policy (NHP II), issued in 2010, lays out those elements that are a particular focus for the period up to 2015. This policy seeks to prioritise the effective delivery of the Uganda National Minimum Health Care Package (UNMHCP) and the policy is operationalised in the third Health Sector Strategic Plan (HSSP III). These two documents detail the services that should be provided and the organisational structure required for delivery. There is a very close fit to the key principles proposed in the Alma-Ata Declaration on Primary Health Care. UNMHCP comprises these four clusters:
i. Health Promotion, Disease Prevention and Community Health Initiatives
ii. Maternal and Child Health
iii. Prevention and Control of Communicable Diseases
iv. Prevention and Control of Non-Communicable Diseases.
The HSSP III outlines the organisational architecture, strongly promoting a decentralised structure in which delivery starts in the community through specially trained volunteers (VHT) who are supervised by, and can refer to, nurse/midwife led health centres (HCII) which are located very close to each community. In turn the HCII can refer patients needing specific medical care, e.g. c-sections, to a nearby HCIV. District and referral hospitals complete the structure and are tasked with general surgery and an expanding set of tertiary services. The strategy details the services that should be provided at each level, the cadres and numbers of staff that each level of facility should have and the numbers of each different type of facility needed to serve the whole population, ensuring equitable access for all, in the most efficient manner possible.
NHP II clearly states that seventy five percent of the total disease burden in Uganda is still preventable through health promotion and disease prevention. The above strategies and plans are designed for doing exactly that. So why then is the country still struggling to reduce the very high rates of mortality and morbidity? Why are we seeing slow progress on reducing the under-5 and maternal mortality rates that are measured by the Millennium Development Goals 4 and 5? Why is the country still suffering under a very high burden of malaria, which significantly impacts the quality of life for the individual and the economic performance of the country as a whole? This is measured in MDG 6, as is the prevalence of HIV, which after some notable reductions during the 1990s and early 2000s is now beginning to rise again.
What’s going wrong and what must we do to make it right?
We don’t need to look any further than the NHP II; it lays out quite clearly what many consider to be the major cause for the failure in implementation, a very simple lack of adequate funding. The current cost of delivering UNMHCP in all facilities across the country, serving the whole population, is estimated at almost $48 per capita, per annum. The Government of Uganda allocates just less than 10% of its budget to healthcare, which equates to approximately $10 per capita. So even if the government kept its commitment to meet the Abuja Declaration target of 15%, that would still only meet about one third of the estimated cost for delivery.
This significant gap in budget causes many operational problems in the public facilities; badly maintained facilities without adequate staff and even when staff are there, they often lack equipment, consumables and drugs to enable the provision of necessary care and treatment. In Uganda the private sector provides more than half of the total health services delivered, but that still falls far short of ensuring equitable and universal access for all. These private organisations need to charge for the services provided, which even after subsidy from donors, means that essential, basic services are not affordable for the vast proportion of the population. Current estimates indicate that the out-of-pocket health expenditure is about 9% of household budgets and a growing number of households in Uganda are being pushed into impoverishment because of medical bills. As the demographic shift continues to increase the number of those financially dependent on others, this is just going to get worse.
Private Health Insurance and pre-paid Health Membership Schemes are available and are being used to meet the costs of high quality healthcare services, but only for 150,000 of the population. The annual premiums for these schemes are currently far beyond the reach of those Ugandans who are not employed by the larger private corporates or International NGOs.
Uganda is planning to implement a National Health Insurance Scheme, which it suggests will address this budget shortfall. Like the national health strategy and policy, the NHIS is well designed and has much to be commended. Except for one major flaw; the national tax base is far too small. There are just one million employees in the formal sector, from whom the government can levy taxes (the overall population is about 34m). It is proposed that a total of 8% will be raised in additional taxes, to be shared between the employees and their employers. That would be enough to provide a good level of service to these one million. It might even be possible to use some of the funds raised to provide some basic services for their households, but it is definitely not enough to make up any of the shortfall for the remaining 85-90% of households.
We need to find some way to increase the GoU budget allocation, perhaps by reallocating budget from other sectors or from future oil revenues? Alternatively we need well designed community based, risk-pooling schemes that can make better use of the monies that households are already spending out-of-pocket. That, however, may take quite some time to gain sufficient conceptual understanding and acceptance by those in the communities. Experience to date tells us that, in particular, the concept of paying before you become sick and that of pooling monies to be shared out with others, is difficult for many to understand and accept.
We need to conduct a detailed review of how budgets and donor funds are currently being allocated. It may be that too much is being spent at the referral hospitals for tertiary services that are clearly much more expensive and serving a very small number of the population. These specialist, tertiary services are not included in those to be delivered by the UNMHCP. These same funds spent on much needed primary healthcare could benefit a much larger number of patients. Any such debate on rationing, and the re-allocation from expensive tertiary medical services to public health and primary healthcare, is bound to be difficult and divisive, but nonetheless it has to be done.
One aspect of PHC that Uganda should focus more on is that of Reproductive Health, with a specific aim of reducing the very high rates of infant and maternal mortality. The State of Uganda Population Report 2011, outlines the commitment that Uganda made at the UN General Assembly in September 2011, specifically to focus on the following:
i. Increasing comprehensive Emergency Obstetric and Newborn Care (EmONC) in hospitals from 70% to 100% and in health centres from 17% to 50%; ensure that basic EmONC services are available in all health centres; and that skilled providers are available in hard to reach/hard to serve areas.
ii. Reducing unmet need for family planning from current 40% to 20%
iii. Ensuring that Emergency obstetric and neonatal care services are available in all health centres
iv. Increasing focused antenatal care from 42% to 75% with special emphasis on Prevention of Mother-to Child Transmission (PMTCT) and treatment of HIV.
Uganda has one of the highest fertility rates in the world at 6.7, leading to a very significant demographic shift; already more than half of the population are below the age of 18. This high fertility rate is a prime driver for the very high rates of maternal and infant mortality and birth related morbidity. The population is doubling every 20 years and development of the economy, essential infrastructure and public services are simply not keeping pace. Perhaps it is not surprising to learn that Uganda also has the highest unmet need for modern contraception, as noted in ii. above. Measured another way, the unmet need among those women who want access to family planning is as high as two-thirds. Research by the Guttmacher Institute indicates that meeting this demand could reduce overall fertility by one third and make a very significant improvement in the mortality rates.
So surely that’s pretty simple then, we just make family planning more readily accessible and the health indicators will start to improve. As you continue to read, you will perhaps start to see that resolving these issues is not so simple, not so straightforward as one might initially think. As PHC practitioners we will find ourselves challenged to be much more considered and detailed in our thinking about possible solutions and interventions. The above at first seems very easy to fix, until you learn that the country has a gap of more than 2,000 adequately trained midwifes to deliver these services and that very often essential medical staff don’t want to move out of the large towns to stay and work in the rural villages, where the need is greatest.
The challenge of providing Uganda with universal access to basic primary healthcare is very demanding, it will be very difficult to achieve but the difference that we can make and the outcomes that we can influence are enormous. So let’s keep pushing on…
Chief Executive Officer
International Medical Group
PO Box 8177