For four years, John Kamulegeya was the only doctor in Nakasongola, a district in Uganda big enough to cover Greater Sudbury. His health centre recently hired a second doctor, but they still struggle to meet the needs of the 100 patients who come every day. There are no specialists here — not a single psychiatrist, gynecologist or anesthetist.
Last year, 13 Ugandan doctors with these specialties were chosen by the government for relocation, along with another 270 physicians, nurses and midwives — but not to needy districts like Nakasongola.
Rather, the government plans on “exporting” these health workers for three-year contracts in Trinidad and Tobago, a Caribbean country more than 10,000 kilometres away. The deal has prompted outcry from some in Uganda’s medical community, as well as an unprecedented “brain drain” lawsuit to stop the exodus.
The whole affair exposes the deep dysfunction of Uganda’s health-care system, where medical graduates are languishing in unemployment even as the government struggles to staff its hospitals and health facilities.
Medical workers in the public sector get paid so little that even Kamulegeya, whose district is starved for even a single extra health worker, supports his colleagues who would rather go abroad.
“The reasons for shortages of health workers in public health services in Uganda is not because they are not available,” he wrote in an email. “It is because of the unfavorable conditions.
“Ugandan health professionals have a right to work anywhere in the world if opportunities are available.”
In 2006, the Global Health Workforce Alliance identified Uganda as one of 57 countries facing a crisis in its human resources for health. The country has been aggressively recruiting workers in recent years, but according to a 2013 government report, 42 per cent of Uganda’s health positions were still vacant, with only one doctor for every 24,725 people.
This shortage is being fuelled by a medical brain drain, both within Uganda, where health workers are heavily concentrated in the capital city Kampala, and to greener pastures abroad.
While many Ugandan health workers are migrating overseas to places like Canada and the United Kingdom, they are increasingly flocking to neighbouring countries like Kenya, where salaries can be up to seven times higher, says Dr. Margaret Mungherera, a psychiatrist with the Mulago National Referral Hospital in Kampala.
“The Ugandan health worker is the least paid among the East African countries,” says Mungherera, who is also an executive with the World Medical Association, an international organization representing physicians.
The Ebola outbreak in West Africa has opened the world’s eyes to the dangers of a weak health system, making the prospect of losing more than 260 health workers all the more alarming for the Institute of Public Policy Research, the Ugandan think-tank now suing the government.
In Uganda, where 7.2 per cent of adults are living with HIV and 16 women die every day in childbirth, politicians should focus on keeping workers in the country, the IPPR argues, not brokering deals to help them leave.
“The issue in dispute is not the right of health workers to seek gainful employment,” the IPPR wrote in an affidavit filed with Uganda’s High Court. “(It is) the legality and procedural propriety of government-facilitated brain drain ... for the benefit of a foreign government yet with fatal consequences to her own citizens.”
The IPPR argues that the Trinidad deal is “unconstitutional, unethical and irrational” because it deprives Ugandans of their right to access basic medical services. Included on the government’s shortlist of health workers bound for Trinidad are a neurologist (there are only five or six in Uganda) and 185 midwives, who are sorely needed in a country with one of the world’s worst maternal mortality rates.
Trinidad, while grappling with its own health worker shortages, has a doctor-to-patient ratio that is still 10 times better than in Uganda, the IPPR contends. And while Uganda is a developing country, the United Nations considers Trinidad a nation with high human development; its oil reserves have also made it one of the wealthiest nations in the Caribbean.
“It would be irrational to strengthen a better resourced foreign health service at the expense of Ugandan public health,” the IPPR wrote in its affidavit.
Fred Opolot, a spokesperson for Uganda’s Ministry of Foreign Affairs, declined to comment on the lawsuit because it is currently before the courts.
But he explained that the Ugandan government has a bilateral agreement with Trinidad and Tobago, which has been helping the sub-Saharan country develop its emerging oil industry.
In 2006, Uganda found vast oil reserves in its western Albertine Graben region; it is now estimated the country has reserves of 6.5 billion barrels. But Ugandans lack the skills to develop its nascent energy sector and Trinidad has been offering training programs, Opolot said.
In return, the Caribbean country has made its own requests of Uganda, which have included health workers.
“We said yes, absolutely,” Opolot said. “There is a high rate of unemployment, especially with the youth, so it was felt that this is an opportunity for some of these health workers to go abroad (and) learn more skills.”
Opolot said Trinidad is offering salaries that easily quadruple what these health workers are currently making in Uganda. The contracts also come with attractive benefits and a 20 per cent gratuity.
Opolot insists the Ministry of Health will have no problem filling the vacated positions because of the “many, many young people” currently unemployed in the health sector. He acknowledged this “contradiction,” given the country’s health worker shortages, but directed questions on that matter to the Ugandan Ministry of Health, which did not respond to emailed questions from the Star.
According to Edward Mills, a University of Ottawa professor who has worked in Uganda and researched brain drain, the country’s biggest problem isn’t necessarily that it lacks health workers, but that it mismanages them.
“The health system is the bigger issue,” said Mills, who is now in Seattle working with the Institute for Health Evaluation and Metrics. “There’s gross mismanagement of resources over there and total inefficiencies.”
For Orijabo Geofrey, a 34-year-old nurse living in a Kampala slum, the health system’s dysfunction is what motivated him to apply to go to Trinidad.
His parents are impoverished tobacco farmers who struggled to fund his nursing degree. But since graduating in 2007, Geofrey has been unable to find a job, bouncing from contract to contract and earning $184 (U.S.) a month, barely enough to feed his wife and two children.
In the public health-care sector, the government has yet to create any jobs for nurses with degrees, he said. There are only positions for nurses with certificates and diplomas, lower qualifications that earn lower salaries.
“Being uneducated, my parents thought the deep-rooted poverty at our home was just because they had not studied, so education for us was their priority,” Geofrey said. “As I speak now, I don’t relate very well with my parents because they feel I have actually failed them.”
Geofrey said he wanted to become a nurse because of the desperate need in his village, where “innocent children and women are dying helplessly.” He would much rather stay in Uganda but needs to repay his debt to his parents.
“It would be a terrible thing if the petitioners succeed in stopping us from going,” Geofrey said, adding he will try to go to Trinidad even if the lawsuit to block the health worker exportation succeeds.
Mungherera, a past president with the Ugandan Medical Association, believes health workers have a right to pursue employment wherever they can. But she also thinks the Ugandan government should be creating career opportunities for people like Geofrey, not paving their path out of the country.
“This is not the time for the government to be giving away the few human resources we have,” she said. “This government needs support from a country like Trinidad and Tobago, not the other way around.”