The shortage of health workers in Uganda is a "crisis", says the Minister of Health, and activists say expectant mothers are bearing the brunt of the country's staffing deficiency.
Just 56 percent of Uganda's available health positions are filled. Parliament's recent refusal to reallocate part of the country's budget to hire more doctors, nurses and midwives has now become a rallying point for Uganda's maternal health advocates.
A parliamentary committee's recent attempt to redirect 75 billion Ugandan shillings – about US$27.5 million - out of a national budget of more than 10 trillion shillings ($3.6 billion) towards hiring enough health workers was rebuffed in September, a rejection that became official when President Yoweri Museveni agreed parliament's final budget.
The reallocation failure has angered health advocates, especially maternal health activists, who point to the lack of trained nurses and midwives as a key reason an estimated 16 women die daily giving birth in Uganda. According to the International Monetary Fund, Zambia and Uganda have similar GDPs, but World Health Organisation figures show very different death rates for mothers in the two countries: 7.8 percent of all deaths of women of reproductive age in Zambia are related to childbirth, against 11.3 percent in Uganda.
Government "should prioritize", said Dorcas Amoding, advocacy manager for a local NGO, Community Health & Information Network. "There are these non-essential areas [in the budget]: the allowances; the cars; the international travel. Those are things they can wait for... What are the priorities? Women are going to hospitals, but they don't have someone to attend to them."
The health ministry, which was criticized for not including new recruitment in its initial draft budget to parliament, has responded by shifting some of its funding towards hiring and has been talking to donors about accessing more money for staffing, but health advocates say it is not enough. They are calling on government to pass a supplementary budget this year or risk losing thousands of mothers.
Asuman Lukwago, the ministry's permanent secretary, acknowledged a supplementary budget was a possibility but made no guarantees. Ministry officials did not respond to queries about why money was not targeted for recruitment in the initial ministerial policy statement submitted to parliament.
Finding the money
During September's parliamentary budget debate, the social services committee – which has oversight of health spending – called for the government to reallocate money towards recruiting 5,000 additional health workers and retaining those who might look for a pay rise by moving to the private sector.
The money would have beefed up staffing levels from 56 percent to 65 percent – the minimum rate necessary, according to Ministry of Health estimates, to meet the country's health needs.
As Sam Lyomoki, chairman of the social services committee, finished presenting the report to parliament, he reminded his fellow MPs: "Since we have been here this morning, four mothers have died. I think as parliament we must stand in the eyes of God and save those lives."
But when the final budget was presented, only 5.57 billion shillings, about $2 million - all from the health ministry's own budget - was reallocated for hiring health workers. "Each sector started fighting for its own resources. Our case had been clearly explained and understood... I know we shall access this money over time. Of course, as we wait, we lose more mothers," he said.
The reallocated funds are already being used to recruit new doctors, nurses and midwives, according to health ministry permanent secretary Lukwago.
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He said the health ministry was in discussions with the US President's Emergency Plan for AIDS Relief, which had pledged funding for 800 new medical salaries. He also emphasized the government's decision to give away free “mama kits” – packages with critical delivery items, such as gloves and a plastic sheet for the delivery bed – to improve maternal health.
Keeping up the pressure
Community Health & Information Network's Amoding said the continued shortage of funding for health workers meant Uganda's appalling maternal health record would continue. "It is not going to create a reduction in maternal mortality," she said.
But the activists say they will continue to lobby for Parliament to pass a supplementary health budget.
"You don't just do it in one moment in one day. We're going to be very active," Amoding said.
And Lyomoki said his committee would continue to keep the failings of the health system in the parliamentary spotlight. His committee had already commissioned what he described as a "fully fledged investigation of the health sector", which would incorporate maternal health issues and hopefully "again energize allocation to health in terms of a supplementary [budget] for this area. Or make it not negotiable for next financial year."