Our Side of the Story - VSO

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Our Side of the Story: The lived experience and opinions of Ugandan health workersThe next tier up is the general hospital at district level, to whicha health centre IV should refer patients it cannot serve. TheMinistry of Health’s inventory shows that 15 out of 80 districtshad no hospital. The problem of providing a district-levelhospital has become more acute since the number of districtsreached 112 in mid-2010. A general hospital is expected torefer patients to the nearest of the 13 government-sectorregional referral hospitals for services not available at generalhospitals. Current policy does not allow not-for-profit orprivate hospitals to be designated as regional referral hospitals,although in practice some not-for-profit general hospitals fulfilthat role. The main national referral hospital stands at the top ofthe pyramid and provides specialist services. 45 Patients may, andoften do, by-pass lower levels and go direct a referral hospital.The central government oversees the semi-autonomousnational and regional referral hospitals. Since decentralisationin 2006, district health offices oversee general hospitals andhealth centres. Health sub-districts are expected to plan,conduct in-service training, coordinate service delivery andsupervise their lower-level health units. They are normallyheaded by a medical doctor at a general hospital or anupgraded health centre IV.All local government health centres and hospitals must havea Health Unit Management Committee (HUMC) which shouldoversee the running of the facility. Committee memberscan be selected by the District Council, locally elected orappointed because they hold other positions. They havebeen recommended as vehicles for community participation,46 47but have been reported as not functioning as expected.HUMCs had a chequered reputation in the past, believed tobe implicated in disappearance of medicines and distrustedby local communities. 48 They rarely met after the abolition ofuser fees in government facilities. 49 The Ministry of Health,with support from the USAID-supported Capacity Programme,has embarked on a training programme for HUMC members inboth government and not-for-profit facilities. 50Patterns of use of health facilitiesThe vast majority of Ugandans, 93%, seek treatment forsickness. 51 Ugandans turn to private clinics and drug shops forwalk-in healthcare and medication, and favour health centresand hospitals for more serious conditions and in-patient care. 52Well over half (58%) go to drug shops and private clinics, 28%to health centres and nine% to hospitals; considerably higherproportions of rural than urban dwellers use health centres,while higher proportions of urban dwellers use hospitals. 53The poorer you are in Uganda, the more likely you are to go toa government health centre. Almost half of the poorest tenthof the population use a government health centre, comparedwith only 12% of the richest tenth. Moreover, the pooresttenth almost doubled their use over a five-year period, whilethe richest 10% increased use only marginally. 54 In 2010, overone in four Ugandans (28%) lived more than five kilometresfrom the nearest health facility. 55 The government has investedin improving physical access to healthcare by building morehealth units. By 2009-10 the average distance to a governmenthealth centre was 4.6 kilometres, which the majority of peoplewalk (75%) or cycle (14%). 56Children and pregnant women are the largest groups of healthfacility patients: 38% are children aged 0-14, with the majority(97%) seeking immunisation services; and 38% are womenseeking antenatal and delivery care services. 57 The proportionof deliveries in government and not-for-profit facilities in2009-10 was 33%. 58 In contrast, traditional birth attendantsassisted 23% of deliveries, and relatives or other unskilledhelpers 25% in 2005-06. 5945. The other national referral hospital is a psychiatric hospital.46. Kapiriri et al 200347. Rutebemberawa et al 200948. Azfar et al n.d49. Burnham et al 200450. Kidder 201051. Uganda Bureau of Statistics 200852. Konde-Lule et al 200753. Baryahirwa 201054. Ministry of Finance, Planning and Economic Development 201055. Ministry of Health 2010b56. Baguma 201057. Uganda Bureau of Statistics 200858. Republic of Uganda 201059. Uganda Bureau of Statistics 200620
Our Side of the Story: The lived experience and opinions of Ugandan health workers2.3 The Ugandan health workforceThere are no available up-to-date data on the constitution ofthe Ugandan health workforce. The prime source is the 2002Population and Housing Census. 60 The census recorded peoplewho had worked paid or unpaid in a health occupation in theprevious seven days. Most commentary relies on the censusdata. 61 In addition, WHO has produced estimates for 2004 and2005. 62 These cover people working full-time in paid activitiesin organisations whose primary intent is to improve health, aswell as those whose personal actions are primarily intended toimprove health but who work for other types of organisation.Occupations: numbers and densityThis chapter focuses on the main occupational groups (Box 1).Box 1The medical doctor hierarchy includes intern (junior house officer), medical officer, medical officer special grade(specialist with a few years’ experience), consultant (specialist with at least five years’ post-specialisation experience)and senior consultant (consultant with many years experience). Appointment as consultant and senior consultantdepends on the availability of posts. 63The clinical officer is a distinct cadre in Uganda, termed medical assistant prior to 1996. Clinical officers undergothree years’ training in specialist schools. Their clinical work has expanded from diagnosis and treatment, includingprescribing, in primary healthcare to cover outpatient treatment and admission in district and regional hospitals.At the better-equipped health centres and at district hospitals, they carry out minor surgical procedures. When a healthcentre IV lacks a medical doctor, the clinical officer provides both outpatient and inpatient services, except for major64 65surgery. Clinical officers are often responsible for administration as the person ‘in charge’ of a health centre.Nurses and midwives fall into three groups within the Ugandan health system: registered nurses, registered midwivesor those doubly registered as nurse and midwife (that is, with a diploma or degree in nursing); enrolled nurses, enrolledmidwives or those enrolled as both (that is, having completed a certificate programme); and comprehensive nurses, eitherregistered or enrolled. The registered comprehensive nurse and the enrolled comprehensive nurse training programmes,started in 1994 and 2003 respectively, were intended to create a multi-purpose nurse with competencies in generalnursing, midwifery, public health, psychiatry, paediatrics and management, and able to provide basic health services inprimary healthcare. Enrolled comprehensive nurse training programmes have replaced the traditional enrolled nursing andenrolled midwifery training programmes in all government-owned health training institutions, and have been introducedinto many not-for-profit training institutes. The future of comprehensive nurse training is under review. 66Nursing aides, who have no formal training, have over time upgraded into nursing assistants through short formal courses,though the workforce still contains significant numbers of untrained nursing aides. The initial strategy was to train nursingaides as a temporary solution until more qualified staff were trained and made available. 67 The current policy is to graduallyphase out the nursing assistant/aide position and ban recruitment and formal training, though new training institutionshave continued to emerge. 68 Regulation of nursing assistants has been difficult, as the Nurses and Midwifery Council doesnot recognise the cadre. 6960. Uganda Bureau of Statistics 200261. Eg Ministry of Health 2006; Uganda Ministry of Health and The Capacity Project 2008; Africa Health Workforce Observatory 2009; Ministry of Health 2010b;Nabudere et al 201062. World Health Organisation Global Atlas of the Health Workforce63. East, Central, and Southern African Health Community 201064. Banerjee et al 200565. East, Central, and Southern African Health Community 201066. UNFPA 201067. Ministry of Health 200468. Republic of Uganda 201069. East, Central, and Southern African Health Community 201021
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Our Side of the Story - VSO

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