The poor Patient

Recently at a coffee bar,I overheard a doctor say that his monthly taxes  to the national revenue authority via the Pay as you Earn (P.A.Y.E) mandatory tax deductions could buy hypertension ( high blood pressure)  drugs for two, level two health centers in Uganda for about half a year.  A level four health center in Uganda is meant to serve a population of about 10,000 people. Estimating from the  national prevalence survey in Uganda that showed  26.5% of adults in Uganda to have hypertension.This is to say this professor’s taxes of 1 month can improve lives and prevent cardiovascular complications like stroke for about 60 people for 6 months. One doctor. But it remains to know whether this was a medical doctor or simply a PhD doctor.

Last week, while visiting a health center III in southwestern Uganda, I asked the incharge about their biggest health challenge in the surrounding communities. While I expected her to give me a wide range of examples, especially among infectious diseases, she was quick to say, “Far from infections, our biggest challenge here is drug stock outs”. When you go to the District Health Information Software (DHIS2), the rates of drug stock outs in our public facilities is still quite alarming.

When you look at our health financing system as a country, donor funding contribute 41%, private funding done by individuals as out of pocket payments contribute 41%, and the government only contributes 17%. The national heath budget has been cut from time to time, with the latest allocation being about  5%.   When you read the book, The Patient by Olive Kobusingye, she clearly details what the state of health care has been like in Uganda since the early 90s. It is almost obvious that health care systems were better back then compared to how it is today. Our health system  should be getting better.

Where exactly is the problem? As a medical student, I trained at a regional refferal hospital and I remember patients constantly having to buy stuff ranging from medication, syringes, strapping, urinary catheters, gloves, cannulars etc. A visiting doctor who had been planning to do their residency at the hospital observed a scenario where midway a cesarian section, a caretaker who was waiting outside theater for his wife was sent mid way the surgery to buy a suture after the ones he had bought were finished. How different would the scenario have played out if he didn’t have any money left?

Efforts to make the national health insurance scheme work are struggling, and haven’t effected since it was passed in parliament some years back. A friend and I once made a rough estimate of the amount of money public hospitals would collect if they made a compulsory 10,000 UGX payment for all patients at each admission in exchange for complete offer of health services at the facility. You might say some patients don’t have the 10,000, but patients are paying 200,000 UGX and more to buy medicine and other supplies when admitted at public hospitals.  Related alternatives already work for private not for profit hospitals like Kisiizi and Lacor hospital. These are award winning service delivery hospitals in the country.  The state of most of our public hospitals is that consultation is free, the bed is free, but the rest are paid for. And that’s the fact of the matter!

I’m a doctor, and I will tell you that the best doctors, the most senior and usually the most experienced doctors are at regional and national referral hospitals, and many people would ideally want to be treated by those. But how do we break the existing bottle necks? The long lines, the under staffing, the drug stocks outs, etc.  Should hospitals come up with institution based systems to make things better?

What can we do? And to who do we take our suggestions because our state of health care is still alarming.

Violah & Asiphas