Why is Uganda exporting doctors it doesn’t have?

By Flavia Nassaka and Haggai Matsiko

Government criticised over decision to export 300 Uganda doctors to Trinidad and Tobago

For a country where less than 3,000 practicing doctors have to treat 34.9 million people, Uganda’s decision to export about 300 doctors to Trinidad and Tobago, a small country of about 1.3 million people, is attracting attention.  Patients like Zainabu Aligaweesa, have difficulty accepting it. She had been suffering acute abdominal pains for six months when she was referred to Mulago National Referral Hospital from Mubende District.

But when she spoke to The Independent in November, she had been reporting to the hospital every day for about two weeks but finding no doctor to see her.

In other cases where the doctors are available, they are too harried and sometimes offer wrong diagnosis.

That is what happened to Babra Nakityo. The 31-year old nearly died on Aug.17 at Mulago National Referral Hospital, where she had been admitted to deliver. During checkups, Nakityo had been told she could not deliver normally and needed to be operated. But on the fateful night, the doctor on duty insisted she would deliver normally.

“I could feel the baby suffocating me,” Nakityo told The Independent.

After eight hours of non-stop agony, at exactly 4:00 am—Nakityo remembers because her eyes were glued on the wall clock—a senior doctor entered the ward, where over 20 women due to deliver were all wailing.

“How come they haven’t operated you?” Nakityo remembers the doctor asking after checking her before quickly asking her juniors to rush her to the operating theater.

“You are lucky,” the doctor told Nakityo after the operation, “you and your baby have survived by a whisker.”

The situation is worse in the over 70 hospitals scattered across the country—some do not even have a single doctor.

Interestingly, Trinidad and Tobago’s doctor to patient ratio is not only 12 times better than Uganda’s, the country’s health system ranks much better than Uganda according to the World Health Organisation (WHO).

Health ministry denies role

But Uganda has made a decision to export the doctors to the country to strengthen the two countries’ relations, at least according to Henry Oryem, the state minister for foreign affairs.

The ministry even issued an advert seeking over 260 medical specialists including psychiatrists, ophthalmologists, gynecologists and anesthetists to work in Trinidad and Tobago. A total of over 260 candidates have already been shortlisted to travel including 185 midwives and several other highly specialized health professionals.

The specialists include; 15 of Uganda’s 91 the registered Internal medicine specialists, 4 of the 11 registered psychiatrists, 20 of the 28 radiologists, 15 of the 92 pediatrics, 15 of the 126 gynecologists, 15 of the 28 orthopedics, 4 of the 15 pathologists, 4 of the 6 urologists, and 4 of the 25 ophthalmologists among others. The Independent has also learnt that Uganda has 3 neurosurgeons and one of them is among those leaving.

Mulago National Referral Hospital alone is set to lose 93 doctors according to the final shortlist. Yet just two years ago, the Health Service Commission (HSC) had failed to fill 36 vacancies of highly qualified staff at the same hospital as they could not get takers for two years. The vacant positions included; consultant paediatricians, neurologists, orthopaedics and ophthalmology, senior oncologists, consultant nuclear medicine among others.

Dr. Michael Bayigga Lulume, who sits on the Parliamentary Committee on Health, says it is unfortunate that Uganda is exporting medical workers yet it does not have enough of them. He blames the Ministry of Health.

“It’s sad that the institution which is supposed to train and make sure that medical workers are retained is now supporting them to flee just to satisfy selfish interests for a few individuals,” he says.

But Asuman Lukwago, the Permanent Secretary of the ministry of Health told The Independent that his ministry was not involved in any of the processes.

“I was approached to sign the contract with the Trinidad government but I referred them back to foreign affairs,” he told The Independent, “We were not involved in this. The health ministry only gives them technical advice whenever they need it”.

Oryem told The Independent exporting doctors was not a new arrangement. Russia and Cuba, he said, are examples of countries that have been sending medical workers to Uganda and vice versa.

He refuted allegations that some officials stood to gain financially out of this arrangement. The Foreign Affairs Ministry, he said, is coordinating the process with the ministry of Health, Gender and Labour together with the office of the president.

The medics are just going to be away for two years and another set will be sent, he added, and returnees will bring in more experience for the benefit of Ugandans.

But Dr Lulume says, instead of exporting them, the government should be finding ways of increasing remuneration and putting in place facilities that can enable medical workers deliver their best at home.

When asked what parliament would do about the move, Lulume said the committee plans to ask the government to explain the policy under which they are exporting the medical workers.

“As far as I know there’s no legislative framework that allows them to do this,” he said.

Oryem had implied that the move would not affect Uganda because during the recruitment process, first priority was being given to those that have not yet been posted by government.

However, for one to make it to Trinidad, the physicians are required to have been registered by the Medical Council and also to have copies of appointment and confirmation letters from the ministry of Health.

Against official policy

The move has been criticized by members of parliament, health practitioners and activists. Some like, Dr. Margret Mungherera, the president of the Uganda Medical Association, have for long decried the uncontrolled migration of health workers to other places saying it is at its worst and growing very rapidly.

A think tank, the Institute of Public Policy Research (IPPR) is already challenging the decision in court.  In a first ever public interest litigation claim on medical brain drain, IPPR is seeking a judicial review to restrain the government from recruiting the health professionals for Trinidad and Tobago, pending determination of the main suit.

“Their recruitment and deployment out of the country will result in irreparable damage to the public health sector and the public interest and severely affect the constitutional right   of accessto basic medical services,” the petition reads in part.

Speaking to The Independent, the think tank’s Executive Director, Justinian Muhwezi Kateera said the private right to migrate in search of better prospects is not what IPPR is disputing.

“What is in dispute is  that the Inter-ministerial committee is acting as a recruitment agency at the expense of its citizens and  further acting beyond their mandate as they are only authorized to strengthen Uganda, and not Trinidad…” Kateera said, “But even if Trinidad and Tobago had hired a private agency to recruit, government would have exercised its ethical and legal obligation to regulate the brain drain.”

Kateera added that the exporting the doctors is contrary to existing public health policy.

“The move is clearly a regressive denial of the Ugandan people’s right to health,” Kateera said, “We hope to advance jurisprudence on the relationship between health and human rights, specifically with respect to the impact of medical brain drain on women and children.”

Uganda loses 100,000 children to malaria every year and 16 mothers die in labour everyday.

Kateera bases his concern on that state of affairs the understaffing in Uganda’s health sector.

WHO recommends a ratio of 1 doctor per 1,000 people but in Uganda, as of 2010, the doctor to patient ratio was 1:24,725 and a nurse to patient ratio of 1:11,000. Trinidad and Tobago is 12 times better off. The tiny country is not only good here, WHO ranks its health system 67th in as far as providing medical services and health facilities. Uganda is the 149th.

Only a fraction of Uganda’s 4,672 registered doctors are involved in active practice. That is why the move to export doctors is likely to make a bad situation worse as Uganda loses over 200 registered doctors to other countries every year.

The number could even be higher given that some doctors go to countries like South Sudan, South Africa, and Somalia, which do not require approval from the responsible body, the Uganda Medical and Dental practitioners Council (UMDPC), says the Registrar, Dr Katumba Sentongo.

“It’s not a good gesture when the government which would be controlling brain drain is now fuelling it,” Dr Sentongo says.

High costs involved

Medical education is not only too costly and Uganda is estimated to lose US$ 13million (Shs 36 billion) to medical brain drain and Africa $ 2 billion (Shs 5.6 trillion).

Uganda trains very few doctors because medical school is costly and the education system is too poor to support more. A University of Ottawa study has showed that Uganda spends upward Shs 50 million (Approx. US$20,000) to train a single doctor.

Yet retaining doctors has for long been a problem mainly because, for such a specialised field, the government salaries offered to them on graduation are not competitive.  The starting salary of a freshly recruited doctor is about Shs 800,000 after taxes (Approx. US$300). In neighboring Kenya and Rwanda, it is not rare for counterparts to earn triple that and have other packages like housing.  The health facilities there are also better compared to Uganda.

Ministry of Health PS, Lukwago, says the problem in the sector goes beyond salaries. He says the government has set up infrastructure but some of this is in remote areas where medical staff do not want to work.

In other areas, the health facilities are in a bad state and in some hospitals doctors lack nurses to help them during operations.

Because of this, Lukwago says, some medical workers resort to other businesses that are less tasking yet lucrative creating internal brain drain.

Interestingly, in 2007, the same government had instituted regulations to prevent Ugandan doctors from obtaining employment outside Uganda before serving at least five years in Uganda.

Then-minister of State for Primary Health Care, Emmanuel Otala, even announced a 30 percent salary increment for medical workers in rural areas as one of the new measures.

Under the auspices of WHO, Uganda the following year even hosted a global conference aimed at combating medical brain drain.

According to Prof. Posiano Kaleebu, the director of the Medical Research Council under the Uganda Virus Research Institute, the government has been trying to staunch the brain drain by awarding local scholarships among others.

The problem is fuelled mainly because the Uganda government does not invest adequately in the health sector. Uganda is a signatory to the Abuja Declaration which requires African countries to spend 15 per cent of their annual budgets. Instead, in the 2013/14 Financial Year, Uganda spent just 6.2 per cent on Health.