Donors contribute almost triple the 18% which the government contributes to Uganda’s health financing matrix, leaving 40% of the pie to Ugandans. It is a healthcare system badly in need of repair, a point that the medical workers made powerfully when they went on strike at the close of 2021.
Uganda’s health workers – doctors, intern medics and laboratory technologists – grabbed headlines as the year 2021 drew to a close by taking to industrial action to press the government to improve their pay and working conditions.
The heroes of the fight against the Covid-19 pandemic, who have over the years felt ignored by the government, issued a rude reminder of the power they wield and acted like they sought to reassert their position in society when they went on strike.
The issues run deep. Apart from pay enhancement, the doctors under their umbrella body the Uganda Medical Association (UMA), declared a strike late November demanding that the government compensates the families of the medical workers who contracted covid-19 in line of duty and died; employs all medical officers who work in government hospitals but are not yet on the payroll; boosts medical supplies and technologies in health centres; and improves the general welfare of medical workers.
In going on strike, the doctors were building on a job they had started four years earlier. In 2017, they felt they had had enough and went on strike after about 20 years without the country experiencing a nationwide medics’ strike. At the time, the government was paying a medical officer Shs1.1m, a consultant Shs2.6m and a senior consultant Shs3.4m a month.
The medics demanded huge increases, so that medical officers would be paid Shs8.5m, a consultant Shs15m, and a senior consultant Shs48m, in addition to accommodation and transport.
When the doctors called the countrywide industrial action on November 6, 2017, the government stated that it was preparing to increase their pay, but that the doctors needed to wait for a salary review commission – which they said President Museveni would set up – to first finish its work. The salary review commission, the government said, would need two weeks to review pay for all civil servants and address discrepancies.
Rationalising pay for civil servants is back on the table these days, so that similar and similarly placed workers are treated in a similar way regarding compensation. As it stands now, many civil servants are paid dismally low salaries, and there are huge disparities between some classes of civil servants who do similar work and have comparable qualifications and experience. Time will tell whether this process will be pushed through.
But until the medics went on strike towards the end of last year, no such salary review commission as had been promised in 2017 had done any such work. To calm the medics in 2017, Museveni met up with the leaders of the medics and made promises to enhance their pay, so that the lowest paid medical officer would earn Shs5m a month.
The increment would happen in a phased manner, it was agreed, starting with financial year 2018/19. The first increment indeed came through in the financial year that followed, but the subsequent financial years did not see any increments as promised. The doctors have now been made a fresh promise, that their enhanced salaries – so that the lowest paid medical officer earns Shs5m a month – will take effect on July 1, 2022, when the budget that is currently being written comes into force.
So the medics called off their strike just as the year came to a close, but with a standing warning that they will resume the strike if the issues for which they had laid down tools won’t have been addressed around mid-2022. What they have therefore declared is technically a ceasefire and not an end to the industrial action.
Enter the interns
The doctors carry a big burden. The Uganda Medical Association (UMA) estimates that each doctor in Ugandan is supposed to serve an average of 21,000 people, as opposed to the ratio of 1:1000 which the World Health Organisation (NGO) recommends.
It is a common practice for doctors who work in government hospitals to also run private clinics of their own or to moonlight in other private clinics. The government has in the past – like in 2006 – tried to stop doctors in its employment from running private clinics but to no avail. This is mainly because the doctors get paid less than they deserve and augment their pay by moonlighting in private clinics. Perhaps the government abandoned the move having realised that many doctors would rather give up their work in government hospitals than abandon their private practice.
The outrageous doctor-to-patient ratio, coupled with the fact that the doctors are not always available in hospitals since they also spend time in private clinics, means the role of medical interns takes on a whole new importance. The interns are always available to attend to patients, often only referring to their superiors the complicated cases.
But the interns have not been happy either, and they too went on strike on November 8 last year. Before the strike, the government paid each intern an allowance of Shs750,000 a month. That is about the monthly rent for a two-bedroom house for a middle class family in places like Najjeera or Ntinda in Kampala. Some of the interns, particularly those that work in some of the government hospitals, had to use that money to pay rent, food and cater for transport.
Their luckier colleagues work in government hospitals that have staff quarters, hence saving on rent. Even luckier are those who work for private not-for-profit hospitals like Nsambya, Rubaga and Mengo, who are afforded food, housing and a top-up allowance to augment the token that the government offers.
The interns serve for one year between graduating after their five-year university courses and being registered as medical officers.
The interns intensified their agitation for enhanced pay in 2019, when they carried out what they called the ‘march to Parliament’, where they met with then Speaker Rebecca Kadaga and delivered a petition demanding for better pay and improved working conditions.
Parliament discussed the matter and recommended to Cabinet that the pay for interns be increased from Shs750,000 to Shs3m per month. President Museveni took up the matter and directed that the interns be paid Shs2.5m a month, but his directive had not been actualised by November last year – two years later – when the current interns went on strike.
The government, in explaining why there had been a delay in fulfilling the president’s pledge, invoked the covid-9 pandemic, which turned things on the head and led to tightening of budgets. But the interns and their senior colleagues argue that the covid-19 pandemic a key reason for them to be looked after better. They complain that they were made to treat covid-19 patients without sufficient protection due to limited supplies, and some of their colleagues lost their lives as a result. The UMA says over 80 medics lost their lives to covid-19, which they contracted while on duty. They want the government to compensate their families.
Whereas the interns were not specifically deployed in wards that handled covid-19 and continued working on the general wards, they say that made them even more exposed since the vigilance on the general wards was lower and the exposure for the health workers even greater than it was in the wards that handled covid-19 patients.
The present cohort of interns that went on strike, according to Ministry of Health Senior PRO Emmanuel Ainebyoona, numbers 1,003, with another 450 having finalised their internship in October. Also counted as interns are the Senior House Officers (SHOs), those who are pursuing masters’ degrees at the medical schools and are looking to specialize in different fields. These number 450 in government hospitals and 61 in the private not-for-profit hospitals, according to Ainebyoona. They are also supposed to be paid Shs2.5m per month.
The interns had expected that their enhanced pay of Shs2.5m per month would take effect in July 2021 but when that did not happen, their agitation increased and finally resulted in the strike. The government, having not budgeted for their pay rise for this financial year, processed a supplementary budget expenditure of Shs35.2 billion to cater for it. The strike went on even after the supplementary financing had been approved by Parliament until the Ministry of Health effected the pay to the interns, with top-up arrears since July last year.
Government riding on donors’ back
Pay enhancements for medical workers and affording them the requisite technologies and pharmaceuticals so that they can work more effectively are the key issues that the medical workers fronted for their industrial action.
Because of these issues, many medical practitioners trained in Uganda – many of them on public money – routinely migrate to other countries, including Rwanda, Kenya and Botswana, where they are paid better and have better working conditions. Ugandan doctors routinely complain that in many circumstances they know what to do to save lives but they don’t have what to use, be it diagnostic equipment or medication. It is common for patients who visit Mulago, the national referral hospital, to be referred to a private facility in Kampala to have a certain scan or other procedure carried out.
Away from that, one other area that requires heavy investment is physical infrastructure, in particular building hospitals and health centres. Considerable progress has been made in this area in different parts of the country, with a number of health centres IV and hospitals built or upgraded.
But the bulk of the money that has gone into financing the health sector in the recent years did not come from the public purse. The government has over the recent years prioritised investment in infrastructure – mainly energy and road construction – and sectors like health have suffered as a result.
According to Uganda’s Health Financing Strategy 2015/16 – 2024/25, released by the Ministry of Health in February 2016, the government contributes only 16% of the total health expenditure, leaving an “unacceptably high” out-of-pocket expenditure of 50% for citizens to deal with. This means that 34% of Uganda’s total health expenditure is contributed by donors.
Other accounts have it that the figures have since changed, with donor contribution to the health financing matrix climbing to 42%, out-of-pocket dropping to 40% and the government still contributing a miserly 18%.
One of the areas where donors weigh in heavily is with regard to paying critical staff in different fields of the health service sector. There is an example in the Ministry of Health’s Ministerial Policy Statement for the financial year 2021/22. Among the ‘unfunded priorities’ is Shs12.9b that is required to cater for the absorption of previously donor-supported contract staff at the Ministry of Health headquarters, the Uganda Virus Research Institute, Mulago hospital, regional referral hospitals, district local governments, the Joint Clinical Research Centre, and Central Public Health Laboratories.
The Ministry of Health noted thus in the Health Financing Strategy of 2016 that we referenced above: “While the proportion of the budget allocated to the health sector has stagnated at around 8% of the total budget, the proportion of the budget allocated to roads and works and energy and minerals increased from 18.7% (2009/10) to 23% (2013/14) of total budget.” The proportion of the budget the government commits to the health sector each year has since dropped to below 7%.
This chronic underfunding of the health sector by the government has only been made to appear less severe by donor financing. The health financing strategy we have cited shows that while the proportion of donor financing for the whole budget has been declining in the recent years, the reverse has happened with regard to donor financing as a proportion of total health expenditure.
The health financing strategy cited further indicates that while the contribution of donors to the government’s total budget declined from 25% in financial year 2010/11 to 18% in financial year 2014/15, the proportion of donor financing to the total health budget increased from 14% to 42% within the same period.
Where is the solution?
In most public discourse, many commentators say the government just needs to implement what it committed to do in the Abuja Declaration of 2001 and commit 15% of the budget to the health sector. That’s an almost three-fold jump from the current financing levels, which would raise the government’s contribution in the health financing matrix to at least over 30%.
Easier said than done, those in government keep saying to that proposal. Museveni, for instance, argues that the economy needs its basic infrastructure – roads, railways, power etc – set up first in order to support future prosperity that will enable heavy investment in health and other sectors. In addition, the government has continued to invest heavily in security, not just to secure Uganda within the turbulent Great Lakes region, but also for Museveni to keep in power. In the same vein, the price of managing the politics keeps rising, explaining the routinely high expenditure on patronage and ‘classified budget’.
Ugandans can only count themselves lucky that bilateral and multilateral donors have prioritised health and kept propping up the sector as illustrated above.
The optimistic view is that when oil starts flowing in four or so years, there will be more resources in the government’s purse to commit to the health sector. The other side to this is that when that anticipated rise in revenues eventually happens, Uganda will be classified as a middle income country and many donors will withdraw their aid, meaning that much of the oil money may just replace current donor financing.
The projections may pan out as they may. But it appears that Uganda’s health sector cannot improve in isolation of other sectors.
Dr Nicholas Kamara, a member of the opposition Forum for Democratic Change (FDC) party who is the MP for Kabale Municipality, practiced medicine in Uganda for about 15 years and rose to become a consultant. Regarding the medics’ strike, he says the issue has to be looked at holistically.
In the years gone by, Dr Kamara says, Ugandan medics could do with relatively low pay because the other social services were functional. A doctor could educate their children in good public schools, paying small amounts in fees, and they had good housing facilities provided by the government. This is a far cry from what is obtaining today, where the standards of most public schools collapsed and the medical workers have to pay astronomical fees in private schools for their children. They therefore demand that the government increases their pay to enable them meet the costs.
Now the medics have asked for enhanced pay, and have in addition demanded that that the government makes some other opportunities available to them, like importing personal vehicles tax-free. The government appears to have made multiple concessions, by way of promises, before the medics called off their recent strike. If – and is a big IF – the promises are fulfilled and the medical workers are happy, that will be the beginning of a very long journey in the direction of improving Uganda’s health care system.