6,172 Health Workers to be Recruited

It seems that the Government of Uganda has agreed the need to recruit more healthcare workers. That’s really good news and something that should be positively received. The Ministry of Health will need to make sure that matters affecting morale are also tackled; salaries are too low, health centres are often in a poor state of repair lacking equipment and medical supplies. These issues all contribute to poor morale and staff seeking alternative opportunities. These extra six thousand will not be sufficient to bring the numbers of healthcare workers to the levels that WHO suggest are required, or even to the average in the Africa region. If all 6,172 new recruits are doctors (very unlikely), Uganda would have 1.8 per 10,000 citizens; the average in the Africa region is 2.2.

Toward an AIDS-Free Generation

U.S. Chargé d’Affaires, Virginia Blaser made a statement recently about the on-going support by the USA for healthcare in Uganda and for the fight against HIV/AIDS in particular. You can read the statement in full here.

This statement of support comes at an interesting point in time. The Uganda Ministry of Health has just recently announced that a recent survey shows the prevalence of HIV has increased to 7.3% of adults, that’s about 1.2m people, more than double the number estimated 7 years ago.

In Uganda, with the support of Target TB, Touch Namuwongo (IMF) has improved access to health education and HIV testing in the community through outreach work. Here a fully trained community healthworker undertakes blood tests at a mobile clinic.

In June the Government of Uganda announced that the allocation of national budget to the Healthcare sector would be reduced from 9.8% in 2011/12 to just 7.6% this year. Depending on the exchange rate this is equivalent to about $307m.

In her statement, Blaser starts by reminding us that since 2004, the American people have invested over $1.7 billion in support of the national HIV response in Uganda. Most of this has been channelled through PEPFAR, for which we should always give a note of thanks to former President George W. Bush.

In 2003, Bush launched the President’s Emergency Plan for AIDS Relief (PEPFAR), pledging $15 billion to end the suffering and save lives threatened by the AIDS epidemic. In 2008, Congress agreed to provide $38 billion more.

In Uganda an estimated 600,000 people living with HIV need to be treated with ARVs but only 330,000 are currently receiving these life-saving drugs and of those the USA directly supports funding for 314,000. Antiretroviral treatment, ART, means that a person living with HIV can expect to live as long as their fellow countrymen who are HIV infection free.

We know that ensuring early and sustained access to ART for all those that need it will be a very significant intervention in the fight to reduce the growing numbers of new infections. So it is good to hear Blaser state:

the PEPFAR program in Uganda will review its programs to ensure that we prioritise treatment expansion to ensure all who need ART receive it

On July 5th Blaser stated that $425m will be given in Aid to boost Uganda’s health sector. This is more than 60% of the total Aid being given by USA to Uganda and is some 40% more than the GoU budget allocation.

That budget allocation is coming under increasing scrutiny. Blaser urges the GoU to increase the allocation to the 15% committed in the Abuja Declaration. Whether or not the country can afford to reach that target, it should perhaps be a little more circumspect before revealing that it spends some $150m to send VIPs overseas for healthcare treatment.

It is clear to me that fighting HIV is more than just about GoU budget or Aid from USA. That budget and Aid need to be used more effectively, we need to focus our attention on proven interventions that we know will work. Implementation will involve many different partners from all parts of the health sector and as Blaser says:

By working together, we can free Uganda from this terrible epidemic.  Let us all fight together for an “AIDS-free generation.”

Nursing Your Lungs – Don’t Smoke

NursingYourLungsDrew shared a very interesting infographic about Smoking.


1.1 billion people in the world are smokers.


Smoking is the leading cause of preventable deaths in the USA.


Annually Tobacco use is responsible for one in five deaths.


Resulting in a death every 6.5 seconds.


6.3 trillion cigarettes are produced each year.


That’s 900 cigarettes for every man, woman and child.


Click here to view the graphic full size.

Decoding Medical Bills

I have an interest in the Business of Healthcare and in particular how different countries fund healthcare for their citizens.

Jen sent me the following infographic which, I think, gives a very interesting insight into healthcare costs in the USA.


The US spends more per capita on health care than any other country in the world. Americans can’t afford health care. While politicians are trying to find an answer to this crisis, people are struggling to find a way to pay for their medical bills. The average American family spends $19,393 annually for health care coverage. 60% of personal bankruptcies are linked to medical bills.

Click here or on the image to view the full Infographic.


Created by: MedicalBillingAndCodingCertification.net

Healthcare Funding in UK and Uganda

Healthcare Funding is one of those polarising topics that generates a lot of debate; people tend to feel quite strongly about their particular view on how this should be done. Just consider the debates raging today in the USA about Obamacare, in the UK about NHS reforms and in Uganda about the recent cut in the share of government budget allocated to the healthcare sector (down to 7.6% from 9.8% last year).

The Guardian recently presented data showing the spend on healthcare for 193 countries. Now we may have seen these data before but this time I noticed that the UK and Uganda spend almost the same when measured as a percentage of GDP.

Health spending as a % of GDP

Such a measure or that showing the comparative per capita spend will of course highlight just parts of a complex whole. These are measures of Input and do not tell us about the resulting Outcomes.

One of the problems in measuring just the spend is that we cannot easily tell how such spend is shared across the whole population. We know that the rich tend to access more than a fair share of the healthcare services and we can also see that in each country there are many who cannot always afford necessary care.

UK Uganda
Healthcare spending,
% of GDP
                  9.6                   9.0
Government spending on health as % of all health spending                    84                    22
Private spending on health as % of all health spending                    16                    78
Per capita total spending on health
(PPP int. $)
              3,480                  124
Nurses and midwives per 10,000 population                  101                    13
Doctors per 10,000 population                    27                      1

The Guardian says that it intends to add indicators of Outcomes that may help to make useful comparisons and give some sense of which country is doing best or which approach to healthcare funding is most effective.

In the meantime it has published the number of doctors, nurses and midwives per 10,000 population. Now this is not a direct measure of outcome but one would hope that it is a significant driver of good outcomes?

What I don’t understand is how these two countries can be spending similar percentages of GDP and yet the numbers of clinical staff being provided are very different.

It must mean that the budget is being allocated across various costs in very different ways. Perhaps the cost of drugs and treatments requires a higher percentage allocation in Uganda? Perhaps more of the budget is spent on central administration or on capital developments? Perhaps there is just a general lack of cost efficiencies or insufficient management and accountability of the monies being allocated.

In September 2011, in response to the UN General Assembly held in New York, the Uganda Ministry of Health stated that the country had a gap of more than 2,000 midwives, needed to help improve maternal and child health. Adding such a number would simply move the number of nurses and midwives per 10,000 population to 14.

If you would like to access the WHO data for Healthcare Funding in 193 countries and the comparative indicators discussed above then please use this link: http://bit.ly/LpJJMd

The BBC has a good explanation of what GDP is and how it is measured.

Patients Want Good Customer Care

Yesterday I had the privilege of attending a meeting with more than two dozen community leaders from the zones surrounding Hope Clinic Lukuli.

BlackBerry in a dark room with light coming from the other end makes it difficult to get a good photo.

BlackBerry in a dark room with light coming from the other end makes it difficult to get a good photo.

Hope Clinic was established in 2000 and some of the leaders attending had been accessing services for more than 10 years. The clinic is located right in the heart of the community, within a short walking distance for those that it serves; so it is ACCESSIBLE.

The clinic is able to provide some services free, depending upon Ministry of Health, Donor and Charity support. Other services are priced simply to cover costs; HCL is a not-for-profit organisation. Against many measures its services are AFFORDABLE.

Services provided include comprehensive maternal healthcare and HIV testing and treatment. Patients are attended to by trained clinical staff, supported by experienced laboratory technicians and a well stocked pharmacy. So, unlike many public centres, HCL is appropriately staffed and supplied. Required services are AVAILABLE.


I came to the meeting expecting some push-back about costs or about the lack of hospital services (HCL is essentially an outpatient clinic, with Midwife led in-patient services for normal deliveries.) I was therefore quite surprised when the overwhelming feedback was that local people preferred to go to the local drug shops and traditional birth attendants because these provided much better “customer care”.

It seems that Cost is not the most important factor for patients, but rather how friendly and caring the staff are. I’m ashamed that after 3 years here in Uganda I’m caught by surprise by this. I’m sorry if I thought that those with less income would be content with the quality of healthcare service being provided and the fact that it was accessible and affordable. This is is an eye-opener.

Professionals in the Healthcare sector often think little or even disparagingly of the TBAs and Drug Shops. We often say that they are not providing sufficient quality of care, they don’t practice evidence based medicine and perhaps even that they are not safe. What I now see is that the patients who seek care and treatment are better able to judge the quality of customer care and they value friendly, caring service perhaps more than the quality and safety of the clinical services provided. That I think is because they can judge when customer service is good, easier than judging when the clinical care is good.

Perhaps we need to design a Health System in which the professionals judge the patient safety and quality of care and the patients judge the customer satisfaction?


Mark dies and Benton leaves

This was a traumatic week; Dr. Benton decided to leave ER to spend more time with his family and Dr. Mark died.

Pamela and I are just catching up on some ER DVDs, almost 10 years old now, but some of the issues travel far and long.

It is hard to plan and manage hospital operations when we are so reliant on good medical personnel. Uganda has a huge shortage of doctors and even in the last week we lost one of our in-house OB/GYN to a hospital in Botswana; the “Brain Drain” is very real.

This Country needs to quickly train more MOs and to explore more seriously how it can safely “task shift” to lesser credentialed, specifically trained cadres; e.g. we need Clinical Officers who can safely and legally perform C-Sections and Nurse Practitioners who can take on more clinical work. Our Clients need to be more willing to accept that some services can and should be provided by Midwives rather than Obstetricians.

Oh and the day after Dr. Mark died, the ER continued on as normal; sure his friends were sad and missed him but neither Mark nor any of us are indispensible.


Response to Affordability, Rationing and Aid

Tony writes:

I have read this article with great interest, and concern as its such a complex problem but need to be solved by us all as world citizens.

Yes times are very hard at the moment, yes the UK can be proud of its record of being one of the first countries in line to give aid to those most needing it, but as the article says funds are not unlimited and services have to be rationed, the dilemma is to who.

Those people who have to make these heart breaking decisions have a terrible task as how do you turn away a mother and child who is sick and needing help, more so if you know the cost of the actual treatment can be so low in western standards but if money is not there !!!!!

All governments of the world should do more to solve these ongoing problems which are not solved by money alone, as the need to educate and to show the way forward for self-sufficiency is the utmost priority or these problems just occur year in year out as we have all seen

However we can all help but I think from a funding point of view (General Public) there is a willingness to give more but adverse press about diversion of funds (corruption) misuse of money, or just waste caused by local infrastructure problems deters many people from giving more.

At this time of severe economic problems the questions are raised all the time as to why the UK should give to say :- India (5th largest Industrial country in the world) and others who are seen to have more available money themselves than us, but who turn their back on providing funds and services to their own people’s needs.

Of course the arguments are put forward that it’s in our commercial interests to give and no doubt that’s true but many countries in the same position give nothing or very little so yes the UK should be proud of its people’s efforts in spite of concerns about the use of the money given.

Maybe, if the General Public funds could be seen to be directed at the problems, and where people themselves could monitor the progress their money was achieving, then I think some of the hesitation would go and more money would flow.

Whatever the solution is, Now is not the time to stop giving as surely we all have a Duty of Care to each other and 0.7% of National Income is a small price to bear for the help it gives to saving so many lives.

Affordability, Rationing and Aid

Over the last few weeks I’ve been reviewing the cost and affordability of our Community Based healthcare services, which are often given free or at a heavily subsidised, low cost to the patient.

During this review, it has become obvious that if we want these programmes to be sustainable then we will have to ration the services being provided and be more selective about the population being served. These have not been easy decisions to make and in many ways are very similar to those being faced by health planners in the UK and USA. I read a thought-provoking, or perhaps simply provoking, article by Peter Singer on the subject “Why We Must Ration Healthcare”; well worth a quick skim.

Affordability is a complex study; we may immediately think that this is simply about how much the patient can afford to pay, but there are many other interested and affected parties.

The actual cost of providing Primary Healthcare in these communities might be as much as £30 per person per year; those receiving care may only be able to afford £1-2 per visit, probably no more than £5-10 per year, per household. A lot has been written about the pros and cons of user fees and the need for patients to contribute at the point of receiving service. This remains a matter that divides opinion.

When we make healthcare affordable for the poor, we have to also consider the impact this has on others who are subsidising that cost. These include tax payers who contribute, and may be asked to pay more, to the government budget. Other government sectors, such as education, may be squeezed if the government increases its budget allocation to the health sector.

Donor funds and Charitable giving are not limitless and deserve to be used in the most effective and efficient manner. We need to ensure that these very necessary funds are put to best use but, because they are limited, there is a tension between use for Prevention or use for Treatment and also in the selection of the most worthy diseases. There are divided opinions about how these limited funds should be shared between e.g. Health, Education and Infrastructure.

Mothers attending baby clinic at Charis

Many health service providers serving these communities are operating from a faith or humanitarian basis and want to help serve the poor and needy. They are not doing it for profit and they depend on funds from all of the various sources: the user, the government, charitable giving and donor funds. When these funds are not enough and the sick continue to arrive at the centre, then what should the facility owner do? Do we turn them away or do we treat and dig deep into our own pockets to meet the shortfalls?

Times are hard, perhaps global economies are still getting worse, rather than better, and many in the UK are saying that it would be wrong for the Government to meet our pledge to raise overseas aid to £10.6 billion in 2014-15. Why should we persist in giving to other countries when there are so many problems at home?

The Telegraph writes that Bill Gates, when interviewed on Radio 4, urged Britons to be proud of the positive impact our donations are having on the world’s poorest people.

I agree, we should be proud and now is not a time to consider cutting back. The 0.7% of national income proposed as overseas aid impacts the lives of many millions in ways that are often life-changing.

Just in this last week new research shows that the numbers of deaths from Malaria are actually double what we had thought; now estimated at 1.24m a year. Many of these are children under 5, for whom Malaria causes 24% of all deaths.

Sophie putting IV into baby Job with severe malaria

When we discussed and agreed our proposed approach to rationing we decided to focus attention on prevention and treatments for Children under 5. We know that Malaria is a significant problem for this population and in the week we decide to ration, we now learn that the numbers of those affected may be double what we thought!