Bitter truths about Ugandan doctors, nurses

By Ronald Musoke

World Bank responds to ‘incompetent Ugandan doctors’ report

On March 21, the Uganda Medical and Dental Practitioners Council disputed a World Bank survey report which measured the competence of Uganda’s health service providers.

The Service Delivery Indicators report had noted that “doctors in Uganda performed at about the same level as Kenyan nurses on both diagnostic accuracy and the capability to provide full treatment.”

Ugandan health workers were not happy.

“Grossly inaccurate,” is how the Chairperson of the UMDPC, Prof. Joel Okullo, described the report entitled, ‘Education and Health Services in Uganda; Data for Results and Accountability’.

“If the report is true,” Prof. Okullo said, “why is it that Ugandan doctors are in high demand elsewhere?”

He cited a request by the Caribbean state of Trinidad and Tobago to Uganda to export 110 Ugandan doctors.

“Evidence around the world shows that when Ugandan doctors go abroad, they perform far better, and so it is not an issue of knowledge or competence but may actually be a result of the poor working environment.”

Okullo added: “This is not to say that we don’t have challenges of incompetence, but not as worse as the World Bank wants the world to believe.”

Dr. Katumba Ssentongo, the UMDPC registrar said the World Bank’s methodology was also ‘questionable’ since it is unusual for a study to compare people in different categories (doctors and nurses).

The Independent has tracked down Waly Wane, the World Bank senior economist and lead author of the report, to explain.

Wane says, as in other five countries where the Service Delivery Indicators (SDI) survey has been done so far, it is intended to provide a snapshot of the state of health systems and should not be viewed “narrowly as a criticism of the health providers”.

The World Bank survey is part of an Africa-wide initiative that collects data from schools and health centres to gauge the quality of service delivery in primary education and basic health services. The objective of the authors is to enable governments and citizens identify gaps and track progress over time.

The report was first released in Kampala by the World Bank and Makerere University’s Economic Policy Research Centre (EPRC) on Nov.20, 2013.

Wane said it was based on surveys of 400 health facilities, and nearly 739 health providers of which 27 were doctors, 134 clinical officers, 404 nurses and mid-wives, and 174 other health professionals.

“The survey therefore captured the experience of the vast majority of Ugandans seeking care,” Wane told The Independent in an email.

Wane however admitted that because the sample size of the health providers who self-identified themselves as ‘medical officer’ or ‘specialist,’ the results on doctors may specifically have had ‘large standard errors’ or may not be ‘highly precise.’ He said the SDI report never referred to the Ugandan doctors as incompetent.

“For the six countries where the SDI was done, the results show that for diagnostic accuracy, Ugandan health providers are second only to Kenya, but performed at par with Tanzania and outperformed countries like Senegal, Nigeria, or Togo,” Wane said.

“Ugandan health providers score better at adhering to guidelines than their Kenyan counterparts,” he said.

The SDI report clearly notes that Ugandan health providers are working in challenging conditions when it comes to the availability of drugs and proper infrastructure especially when compared to Kenya.

Better off in town

The quality of service in the health sector was assessed using indicators such as adherence to clinical guidelines in five tracer conditions and management of maternal and newborn complications. Tracer conditions were defined by the World Health Organization as common health problems for which injections appear to be used often while they are not medically justified.

Three of the tracer conditions were childhood conditions (malaria with anaemia, acute diarrhoea with severe dehydration, and pneumonia), and two were adult conditions (pulmonary tuberculosis and diabetes mellitus).

Two other conditions were included; post-partum haemorrhage, the most common cause of maternal death during birth; and neonatal asphyxia, the most common cause of neonatal death during birth.

The survey which was first done in Kenya in July, 2013 showed that only 56% of Ugandan medics do give accurate diagnosis, compared to 72% in Kenya, and 57% in Tanzania. Uganda service providers performed better than those of Senegal where only 34% of diagnosis is accurate.

The SDI survey also found that service providers in government health facilities had slightly less diagnostic accuracy than those in private practice at 56% compared to 60%, while those in towns were better than those in rural areas at 70% compared to 50%.

The report notes that the “correct treatment was recommended in only 36% of the cases, reflecting weak provider knowledge.”

Alarming observations

“It is ‘alarming’ to note that although almost 9 out of 10 (88%) providers were able to correctly diagnose pulmonary tuberculosis, nearly half (47%) did not prescribe the correct treatment required,” the report reads in part.

The health providers’ knowledge and treatment also varied across conditions, with malaria and anemia being the least likely to be correctly diagnosed and less than one in 10 (8%) receiving the correct treatment.

The report noted that it was worrying that so few health providers were able to even diagnose potentially deadly conditions such as malaria and diarrhoea.

The report further says that although Uganda’s health facilities have some of the basic inputs and equipment to function properly, only 44% of these had all six of Uganda’s essential drugs and the adequate availability of priority drugs for mothers and children remains a challenge with only 39% and 23% respectively available in public facilities.

There were also large differences across regions with health providers in the northern region scoring lower in terms of diagnostic accuracy. Overall diagnostic accuracy was significantly higher in Kampala.

The survey also took into account the availability of minimum equipment and drugs expected at a facility (weighing scale for adults, children or infants, a stethoscope, a blood pressure machine and a thermometer).

In terms of health facility infrastructure, 90% of facilities had access to sanitation, more than 90% had access to clean water, and close to three quarters (74%) had a source of electricity. This according to the World Bank report translates into an indicator of “infrastructure availability” of 64%.

In terms of drug availability, defined as the number of drugs of which a facility has one or more available, as a proportion of all the drugs on a list of 26 tracer medicines for children and mothers identified by WHO. On average only 47% of this long list were available.

However, when the six major tracer drugs on Uganda’s essential medicines and health supplies (EMHS) list were put into consideration, ‘the picture looked brighter,’ the report notes.

On average, 79 % of the six tracer drugs were available at the facilities. However, less than half (49%) of the priority drugs for children and close to one out of  three (35%) priority drugs for mothers were available.

Government facilities worst

In government health facilities, the rural had poorer equipment and infrastructure. However, the availability of drugs was higher in rural facilities. The northern and eastern regions were worse off in almost all dimensions except for drugs, which were available in more than 90% of northern health facilities.

Another indicator for health provider’s level of effort is patient caseload (the average number of outpatient visits a health provider attends to per working day).

According to the report, the average health provider consulted with 6.1 outpatients per day, a surprisingly low number.

But smaller facilities staffed with one or two health providers had the largest caseload with 11 outpatients per provider per day, which is more than twice the load for facilities with 3 to 5 providers [5.3 outpatients].

Very large facilities with more than 20 health providers recorded a caseload of only 2.1 outpatients.

High level of absenteeism

To gauge the poor utilization of the few health providers available in Uganda’s health system, the survey also discovered high levels of absenteeism in many facilities across the country.

According to the report, more than half (52%) of public health providers were not present in the facility with 60% of this absence approved, and hence potentially within management’s power to influence.

The western and central regions had the highest absenteeism with roughly 6 out of 10 health providers absent.

In the majority of cases, respondents gave a legitimate reason for the absence of health workers—such as attending training or a seminar (15%), on official mission (10%), or other approved absence (25%).

“A typical expected absence rate is about 5 to 10% authorized leave. The rates in Uganda are substantially higher,” the report says.

“From the citizen’s perspective, if almost half of staff is not attending to patients, there is a legitimate reason for concern even if every single absence was sanctioned.”

It recommends better management at the facility or higher administrative level could probably curb sanctioned absence by implementing tighter leave rules.

Regional inequalities

There is a lot of regional and public-private variation in providers’ level of effort.  Starting with the caseload, public health providers’ caseload (10 outpatients per provider per day) was almost five times that of private providers (2.2 outpatients).

Within the public sector, rural providers’ caseload was more than twice that of urban providers. Public health facilities with only 1 or 2 health providers were the busiest and received 18.6 outpatients on a daily basis.

Although basic inputs and infrastructure—with the notable exception of drugs—are largely available at health facilities across Uganda, attention needs to be paid to the level of knowledge and effort among providers.

The big picture

According to the report, Uganda’s health sector has made steady progress over the last two decades, especially with regard to under-five mortality, which fell from 180 to 137 deaths per 1,000 live births between 1989 and 2006. This improvement, the report says, has largely been credited to vertical programmes yet system-related indicators such as maternal mortality rate have stagnated or slightly deteriorated.

The World Bank says, it is possible, the disappointing results are most likely related to the quality of service delivery. This, the World Bank says must change if Uganda is to achieve its ambitious but attainable Vision 2040.