FACTS ABOUT UGANDA AND
ITS HEALTH CARE SYSTEM
THE COUNTRY
Uganda is a country in East Africa, about the same size as England, located to the north and west of Lake Victoria . It is bisected by the equator but because most of the country lies about 5000ft above sea level the climate is just pleasantly hot. You may experience torrential rainstorms but they don’t last very long. The international airport at Entebbe on the shores of Lake Vicotria is about an hour’s drive from the capital Kampala, a city about the size of Bristol. Provincial towns are generally no bigger than Alton. Ninety percent of the population make their living from subsistence farming in small villages.
HISTORY
Uganda was a British Protectorate from 1890 until independence in 1962. Unlike Kenya, which was a colony, foreigners were never allowed to own land and this is still the case today. This may be why there is no anti-British feeling and why Ugandans will ask whether you support Man U, Arsenal or Liverpool. Their civil and legal systems are based on the British model. After independence, the country fell into the hands of Milton Obote and Idi Amin. Civil administration and health services simply fell apart. The current president, Museveni, restored order through a one-party government in 1987. Opposition parties are now allowed and there is freedom of the newspaper reporting but it cannot be described as being a full democracy.
Tribal tensions persist. The ‘Lords Resistance Army’ conflict in the north of the country never affected Hoima or the south. It is not yet certain that it has been resolved and you should take advice about going anywhere north of the Murchison Falls area. Tribal tensions also surfaced during riots in Kampala in 2009. We monitor the Foreign and Commonwealth Office advice on terrorism, health and other aspects of safety.
The Hoima region is host to large numbers of refugees from the Democratic Republic of Congo on its western border along Lake Albert close to Hoima. DRC has never had an effective government. There are known to be large oil reserves beneath Lake Albert which could be an advantage to Hoima as they are developed but there are many political uncertainties.
ECONOMICS AND STATISTICS Uganda UK
Population (2007) 30.8m 60.7m
Population growth rate 3.8% per annum 0.4% per annum
Neonatal mortality rate (2004) 30/1000 3/1000
Infant mortality rate (2007) 82/1000 8/1000
Under 5 mortality rate (2007) 130/1000 6/1000
Maternal mortality rate (2000 – 2007 reported) 440/100,000 7/100,000
GNP per capita (USD, 2007) 340 42,740
Life expectancy at birth (2007) 51 years 79 years
HIV prevalence rate (15-49) 5.4 0.2
The numbers speak for themselves. There is a whole lot more at http://www.unicef.org/infobycountry
EDUCATION
Primary school education is free. Children can start from the age of five but often don’t start till they are nine and are therefore still in primary school at the age of fourteen. Drop out rates are high, particularly for girls. Secondary education has to be paid for. It’s a sad fact of life that once you get to know a Ugandan family quite well, the next thing that happens is that you are asked to help pay for school fees. They believe, of course, that our streets are paved with gold and that it’s always worth a try. It is unwise to enter into such an agreement. Better to do it through a registered charity if you want to. The escape route is to say that you are already supporting x,y, and z and you can do no more.
The doctors and nurses you will meet have made it through to higher education. They are amongst the privileged few.
UGANDAN HEALTH SERVICES
The national ‘Health Sector Strategic Plan’ is paid for by general taxation and foreign aid, driven by the World Health Organisation (WHO) and the major donors to deliver a ‘basic health care package’ free of charge to all citizens. It operates at six levels in a hierarchy.
Health Centre 1 Village level. A nurse who gives health education and advice.
Health Centre 2 Outpatient facilities staffed by nurses.
Health Centre 3 Outpatient facilities and normal deliveries staffed by nurses and a clinical officer.*
Health centre 4 A facility with a resident doctor, inpatient beds and capacity for emergency surgery/Caesarian section and (supposedly) blood transfusion.
District hospital A hospital with medical, surgical, paediatric and obstetric facilities. Basic diagnostic facilities.
Regional referral hospitals A hospital with all the specialities you would expect in the UK; psychiatry, dermatology, oncology, rehabilitation and so on.
*Clinical officers have a three year medical training. They are poorly paid by comparison with fully
qualified doctors but are often the backbone of the service especially in orthopaedics and anaesthetics.
Most of these facilities have now been built but not all have been funded or staffed. Hoima was designated as a regional referral hospital in 1995 but without any funding to go with its new status.
There is no ‘General Practice’ as we understand it. The ‘basic health care package’ includes antenatal care, vaccinations, child health, AIDS awareness and treatment, nutrition and health education. It is funded (or not) by government to be delivered by ‘outreach’ from the hospitals to HC4’s and HC3’s. It depends crucially on having vehicles that work.
About half the District Hospitals in Uganda are faith based, either Protestant, Catholic or Muslim. They are subsidised by foreign donations but patients are charged user fees. They claim that clinical standards are higher and that patients are not subjected to ‘under the counter’ payments that are common in government hospitals to obtain services that are supposed to be free. Despite user fees they are generally popular.
There are teaching hospitals for medical students at Mulago in Kampala, Mbarara and Gulu. Mulago used to be one of the best hospitals in Africa but has never recovered its former reputation.
UNDERSTANDING CULTURAL DIFFERENCES
Progress
Ever since the Renaissance, Western Europeans have believed that man can shape his own future for the better. This was a change from the medieval belief that everything that happens is the will of God. Almost everyone in the West believes in ‘progress’ and ‘human development’ and, until recently, we have probably never questioned whether this belief is justified. But many would now argue that Britain has in fact gone backwards over the past 50 years with increasing corruption, consumerism and a collapse of moral values. Nevertheless, we strive to change things for the better.
People of other cultures do not necessarily share our belief in progress and may be more ready than we are to accept life as it is and make the best of it. Everyone notices that although most Ugandans are poor and disadvantaged they always seem to be cheerful.
Sharing
Ugandans are also very generous with what little they have. Bishop Nathan writes, ‘The reasons are more cultural than economic. It is courteous for Ugandans to share whatever we have with others. However poor one may be, no one is so poor that they have nothing to share.’ We should be humbled by that. Both cultures are altruistic but in different ways. Ugandans share widely with the extended family and within a village. We tend to give to needy people unknown to ourselves and we can afford to.
The future
If you believe in change for the better you plan ahead. Life is a lot more precarious for many Ugandans than it is for us. If the future is very uncertain it may not seem sensible to make plans. There are enough problems just dealing with the present. Making plans and sticking to them is not, in general, what Ugandans do best. We need to understand why.
Bishop Nathan writes, ‘When the rule of law and social systems broke down, ‘everyone for themselves’ became the order of the day; it took us from 1972 to 1986 for a sensible restoration of order to begin and we are still struggling with that now. Remember that generations have come who have never lived in an organised society. That is why so many promises are never fulfilled. There is a lot of mistrust. For plans to be honoured all parties have to be disciplined and do their part.’
Civil rights
We live in a consumer society and know our rights. We think life ought to be fair. If our rights are breached we can get justice. Most Ugandans probably don’t know their rights and the poor have less chance of access to justice than in the UK. So they have little expectation that life will be fair. There are, however, increasing numbers of NGO’s devoted to civil rights issues and the press appears free to report abuses. This is one area where ‘culture’ seems to be changing.
The welfare state
We know that if the worst comes to the worst the state will make sure we have something to eat and a roof over our heads. In Uganda there is no welfare state – no unemployment benefit, no sickness benefit and, until very recently, no pensions. So, if you don’t make a living somehow and have no family, you starve. There is a myth that Africans just sit under a tree and wait for foreign aid to arrive. In Uganda this simply is not true. They are very innovative at finding ways to make a living and being poor is very hard work.
Kinship
It is not surprising, therefore, ‘that for most Ugandans, the extended family, tribe and marriage provide the framework of daily life and access to the most significant resources. Farming is largely a family enterprise; land and labour are available primarily through kinship. Those in paid work are expected to share their wage with extended family members if need be’ 3. If a cousin dies, it would be expected that a wage earner would take in the orphaned children. A hospital professional may be the only wage earner in a large extended family and expected to pay for many school fees. Ugandans find it hard to understand why we, who have so much, don’t look after our own families in the same way.
Social status
Social status is determined by land ownership, money, employment and qualifications. Secondary schooling and higher education has to be paid for and is a source of status. Doctors and nurses therefore enjoy high social status even though they are poorly paid in government service. So do the clergy. They get involved in local government and provide a means of settling disputes’3
Gender
‘Men have authority in the family; household tasks are divided among women and older girls. Many women are economically dependent on the male next of kin (husband, father, or brother). Dependence on men deprives many women of influence in family and community matters, and ties them to male relationships for sustenance and the survival of their children. In more traditional areas, women may be denied their legal right to own and inherit land. Boys are more likely to be educated to secondary level than are girls. Among the 62 percent of the population that is literate, nearly three-quarters are men.’3 We should remember that equal legal and voting rights for women in Britain took over 100 years to achieve. In Uganda, this is another area where things do seem to be changing at least in more urban communities.
Hierarchy
Ugandans have greater respect for authority and hierarchy than we do, within the family, at school and at work. Relationships are more formal in the way they were in Britain 50 years ago. In hospitals, there tends to be a greater ‘power distance’ between the top managers and the workforce and between doctors and nurses/midwives. It would be very difficult even for a senior nurse to question the actions of a doctor. This discourages teamwork and initiative though I believe this is beginning to change in Hoima. We are less hierarchical and have less respect for authority. A year ago last August we saw rioting and looting on our streets. I wonder what Ugandans made of that.
Exerting authority
Paradoxically, however, those in authority seem to have difficulty in maintaining discipline and dealing with problems such as laziness, absenteeism or incompetence. One factor in hospitals is that half the posts are unfilled: if managers get too tough they may find themselves with no staff at all. Some people also seem very reluctant take responsibility and be accountable or to take initiative if there is any doubt in their minds about whether they have the authority to do so. We should be careful, therefore, about barging in and doing things on our own initiative. It undermines the authority of those who are in charge.
Politeness
It isn’t polite to question or criticise especially if the person you are talking about is of a different tribe, is older than you or is a man and you are a woman.3 We are very used to open and frank debate of issues. To them this may sound like personal criticism. We have to be very careful about what we say and write.
Ugandans are always polite to respected visitors who have come a long way to give them some help. This sometimes means they tell us what they think we would like to hear. If you ask, ‘Do you have an infection control committee?’ and the answer is ‘Yes’, it could mean
- Yes we really do.
- We are working towards setting one up when we can get round to it.
- We know we ought to have one and wish we did.
So we need to be careful about taking things at face value. Ugandans are also very unlikely to tell us if anything we have done or said has upset them. We always need to check that what we are doing is OK.
Public service
You may come across examples of patients having to make ‘under-the counter’ payments for services which are supposed to be free in government hospitals. Some volunteers have been very shocked by that so we need to understand it better.
In Britain we assume that public servants will apply the rules to all citizens without favour, without realising that this is a peculiarly British idea. ‘In societies based strongly on kinship this idea may seem strange. It would be expected that you would use your position to benefit your family and clan. Citizens expect that personal ties with officials are needed to get anything done and think it quite appropriate to reward helpful officials with gifts and tips. The official rhetoric may be that you are accountable for the job you do but, when wages in public service are low, this may be trumped by the need to provide for your extended family’5. President Museveni has admitted in Parliament that there is endemic corruption in hospitals6 but it is doubtful whether either patients or professionals would see it that way.
It is also well known that doctors in government service spend more of their time in private practice than is allowed and sometimes are only available in the mornings. The background to this is that in the days of Amin and Obote, doctors and nurses in public hospitals were not paid. The hospitals only stayed open by the professionals charging their patients. When wages were restored they were very low and it is only recently that they have been paid on time. (The news in Nov 2012 was that salaries were, once again, 2 months in arrears.) We are told that doctors and nurses can earn three times more in neighbouring Kenya and Ruanda and there is a real sense of grievance about pay. When this occurs, people try to get other rewards from the system. Remember the MP’s expenses scandal at Westminster?
We also know that some donated equipment has mysteriously disappeared. We should always log donated equipment into the hospital store so that it can be accounted for. In the past we have been somewhat naïve in giving things directly to the wards. Our donors expect us to make sure that what they give goes to benefit those most in need.
These things happen in Britain too. Did you know that prosecutions for fraud in the NHS have recovered £674M in the last 13 years?
Mortality
Mortality rates are high in Uganda, especially in childbirth and for neonates and children under five. It has been like that since the world began and is accepted as normal both by families and professionals, just as it was in Britain years ago. Their feelings of loss and bereavement are just the same as ours but it happens to them more often. When we see women and children dying for preventable reasons we get upset about it because it is now so unusual at home. We should not be surprised if our Ugandan colleagues seem to show less obvious concern simply because it is part of their daily experience.
Time
Ugandans tend to be very relaxed about time. They joke about it and say, ‘The mzungus (white people) have the watches and we have the time.’ We joke about it and say, ‘If you are organising a meeting for 10 am, tell the Europeans it will start at ten, tell the Indians it will start at 9 and tell the Africans it will start at 8!’ That’s just the way it is. We might be happier if we didn’t get so stressed about being on time and get more achieved as a result. Nevertheless, if we say something starts at ten we should all be there at ten. It is part of British politeness not to keep others waiting around for us. There is nothing wrong with that.
Privacy
Volunteers often comment on the lack of privacy for patients at the hospital and want to do something about it. But when you think that a family of eight may only have two rooms and spend much of their time in the communal space outside, you realize they are less concerned about privacy than we are. The hospital would like to improve privacy but the real problem is overcrowding which is not going to be solved for several years.
Communication
Ugandans much prefer face-to face communication. We need to remember that there are many different languages spoken in Uganda. English is generally not their first language but is necessary so that people from different tribal/ethnic groups can talk to each other. Most Ugandan professionals speak very good English but it is not always so. In any discussion it is always worth recapitulating to ensure that what we think has been agreed is correct.
We are obsessed by written communication and spend much of our time at work writing case notes, care plans, letters and so on. We find their written records very skimpy but their workload is such that they simply do not have the time. They also wonder why we spend so much time writing and so little time talking to people.
Even when Ugandans have e-mail, connections tend to be extremely slow, they have to contend with power cuts and their computers tend to be ridden with viruses because they can’t afford virus protection. It isn’t the way they like to communicate anyway.