By Kyoko Saito
I walk into an ICU located in the heart of Uganda’s capital city of Kampala. I am shocked to see hundreds of hospital beds, all full, shoved together in a single room the size of a small lecture hall. Family members stand squeezed between the beds, and physicians and nurses run around, apologizing for bumping into patients’ legs. I turn to the doctor that I am interviewing in bewilderment, but he proudly boasts, “This is one of the most spacious ICUs in all of Uganda, and many wealthy patients pay extra to come here.”
Over winter break, I had the opportunity to assist on a research trip to Uganda with a team of researchers, leaders of non-profit organizations, and students, all with a diverse array of expertise and interests. In my role as a public health student, I researched Uganda’s health systems and the issues with it, interviewing healthcare workers and visiting hospitals and public health organizations. Uganda faces major challenges due to a shortage of healthcare workers and a lack of affordable healthcare services, but the country is making remarkable progress in infectious disease and community health.
Located in East Africa, Uganda is one of the poorest countries in the world with a young and rapidly growing population.1 Uganda has been heavily impacted by infectious diseases, and the leading causes of death are malaria, tuberculosis, human immunodeficiency virus (HIV), and neonatal conditions.2 Major social determinants of health for Uganda include poverty, with 30 percent of the population living below the poverty line, as well as poor air and water quality brought about by rapid population growth and urbanization.3,4,5
The first major issue I saw with Uganda’s healthcare system was the lack of healthcare workers and medical education. Uganda has one of the lowest doctor-to-patient ratios in the world with only one doctor available for every 25,000 people.6 This ratio is below the World Health Organization (WHO) recommendation of 1 doctor per 1,000 people. An emergency physician I interviewed mentioned that he is one of only 15 emergency physicians in all of Uganda, a country with a population of 45 million. The lack of medical education is also an issue as a majority of physicians and nurses do not receive sufficient training. I had the opportunity to speak with an intern doctor who stressed that improving the medical education system is the most important factor to improve Ugandan healthcare. He is planning to complete his training in South Africa so that he can learn diagnosis and treatment methods that Ugandan healthcare workers have no exposure to. After training in South Africa, he has no plans to return to Uganda to practice. Growing up in poverty, he always dreamed of providing a better life for himself and his family, and he believes it necessary to permanently emigrate out of Uganda to do so. This sentiment exemplifies a larger societal trend within Uganda of educated and skilled individuals leaving the country in search of better opportunities. Efforts must be made to provide a more comprehensive medical education to healthcare providers while simultaneously creating incentives to retain them.
The second major issue I saw was the lack of affordable healthcare. At a hospital I visited, an inpatient stay costs about $20 a night with additional fees for any procedures or medications provided. This is not affordable for most people in Uganda, considering that the average monthly income is around $78.7 Additionally, if medical equipment breaks down or medications run out of stock, patients are responsible for locating and purchasing the replacement equipment or medications themselves. Similarly, if an ambulance breaks down or runs out of gas while transporting a patient, which occurs frequently, the patient is responsible for paying for the repairs. If they are unable, these services are denied. In Uganda, patients’ financial status is the biggest determinant of what, if any, care they can receive. When patients walk into the emergency room, they are immediately interviewed about their financial means and asked to pay a consultation fee as a deposit. According to a physician, many of the assumptions made about a patient’s ability to pay is based on their clothing and race. If they are unable to pay the consultation fee or are deemed unfit to pay for the cost of care, patients are turned away from the hospital. Although health insurance exists, only well-educated individuals who have been taught the benefits of insurance are able to purchase it. Thus, most of the population lacks any financial protection against medical fees, and as many as 20 percent of Ugandan households incur catastrophic health expenditures each year.8 When I asked about the prospect of universal health coverage, the physician cited corruption within the government and a lack of understanding about insurance as major barriers.
On the other hand, an area in which Uganda’s healthcare system excels is in communicable diseases. In recent years, Uganda has experienced remarkable progress in the prevention of infectious diseases like HIV and tuberculosis. The reduction in infectious diseases is partly due to various initiatives by the government, including free condoms being distributed to combat HIV. Moreover, countries in Africa have a long history of dealing with deadly viruses such as Ebola, Middle East respiratory syndrome (MERS), severe acute respiratory syndrome (SARS), and HIV. As a result, they are among the most advanced nations in the field of infectious diseases and are highly equipped to deal with them. Despite the highly contagious nature of Ebola, a 2022 Ebola outbreak in Uganda was contained in just two months with only 164 individuals affected.9 Similarly, during the COVID-19 pandemic, Uganda imposed very strict guidelines, faring much better than countries like the US.6 As the prevalence of infectious diseases decreases, illnesses seen at hospitals are now predominantly non-communicable conditions like diabetes, hypertension, and stroke. As Uganda becomes wealthier and the middle class grows, more people gain the ability to indulge in processed foods, making obesity and diabetes more pressing issues.
Despite an insufficient healthcare system, many passionate individuals have come up with creative solutions to meet their community’s needs. For example, I visited a nonprofit organization that teaches web design and video editing to students who cannot afford secondary school. After noticing that many students were dropping out due to STIs, pregnancies, mental health issues, and alcoholism, the organization started implementing health education into their curriculum, inviting local physicians to teach students about safe sex practices and mental health. I also met a mural artist who uses his art to inspire positive change in his community. There is a strong stigma against autism in Uganda, so he paints murals of autistic children on their houses for free. In Uganda, having your face painted on a wall is associated with wealth and fame, causing the community to respect and engage with the autistic kids and their families. Lastly, the intern doctor that I interviewed taught himself how to conduct research to assess and meet refugees’ healthcare needs. There is very limited focus on academic research in Uganda, with not a single physician having a PhD, but he still found a way to contribute to research that would improve his community.
In Uganda, I saw and heard heartbreaking stories about patients who could not afford basic healthcare services.Exacerbating the issue, healthcare workers are prevented by systemic inequities from meeting their community’s health needs. Despite this, I met incredibly inspiring healthcare professionals and community leaders who are passionate and relentless in their pursuit to improve Uganda’s public health. As a student passionate about health equity, I hope to apply what I have learned and experienced to continue thinking about how I can work collaboratively with healthcare workers and public health leaders around the world to create more sustainable and equitable healthcare systems.
References
- Population Reference Bureau. (2011, July 15). Uganda: At the beginning of a transition. PRB. https://www.prb.org/resources/uganda-at-the-beginning-of-a-transition/
- World Health Organization. (2024). Uganda [Country overview]. Data. https://data.who.int/countries/800
- World Bank Group. (n.d.). Uganda. Poverty & Equity Group. https://databankfiles.worldbank.org/public/ddpext_download/poverty/987B9C90-CB9F-4D93-AE8C-750588BF00QA/current/Global_POVEQ_UGA.pdf
- Okure D, Ssematimba J, Sserunjogi R, Gracia NL, Soppelsa ME, Bainomugisha E. Characterization of Ambient Air Quality in Selected Urban Areas in Uganda Using Low-Cost Sensing and Measurement Technologies. Environ Sci Technol. 2022 Mar 15;56(6):3324-3339. doi: 10.1021/acs.est.1c01443. Epub 2022 Feb 11. PMID: 35147038.
- Water.org. (n.d.). Uganda’s water crisis – water in Uganda. Water.org. https://water.org/our-impact/where-we-work/uganda/
- Ajari EE, Ojilong D. Assessment of the preparedness of the Ugandan health care system to tackle more COVID-19 cases. J Glob Health. 2020 Dec;10(2):020305. doi: 10.7189/jogh.10.020305. PMID: 33110509; PMCID: PMC7533609.
- World Data. (2024, March). Indicators of economy in Uganda. https://www.worlddata.info/africa/uganda/economy.php
- African Strategies for Health. (n.d.). Health Financing Profile: Uganda. United States Agency International Development. http://www.africanstrategies4health.org/uploads/1/3/5/3/13538666/country_profile_uganda_-_us_letter.pdf
- Branda F, Mahal A, Maruotti A, Pierini M, Mazzoli S. The challenges of open data for future epidemic preparedness: The experience of the 2022 Ebolavirus outbreak in Uganda. Front Pharmacol. 2023 Feb 10;14:1101894. doi: 10.3389/fphar.2023.1101894. PMID: 36843943; PMCID: PMC9950500.