Wednesday, August 10, 2011

When Free Access is not Free

Half of the 340,000 deaths of women from pregnancy-related causes each year occur in Africa. 80 percent of the world’s maternal deaths occur in just 21 nations, 15 of which are in Linksub-Saharan Africa, according to the University of Washington study. Uganda was among them. About 5,200 women died from pregnancy-related causes in the country in 2008, the researchers estimated.

Dr. Rafael Lozano, a professor at the university, said that except for recent gains in saving the lives of H.I.V.-positive pregnant women with antiretroviral treatments largely financed by donors, “you see basically almost no progress in maternal deaths in Uganda.” As the United States and other donors have given African nations billions of dollars to fight AIDS and other infectious diseases, helping millions of people survive, most of the African governments have reduced their own share of domestic spending devoted to health, shifting to other priorities. For every dollar of foreign aid given to the governments of developing nations for health, the governments decreased their own health spending by 43 cents to $1.14, the University of Washington’s Institute for Health Metrics and Evaluation found in a 2010 study.

According to the institute’s updated estimates, Uganda put 57 cents less of its own money toward health for each foreign aid dollar it collected. Rogers Enyaku, a finance expert in Uganda’s Health Ministry, disputed the assertion, saying the country’s own health spending had increased, “but not that substantially.” Still, the government had paid more than half a billion dollars for fighter jets and other military hardware — almost triple the amount of its own money dedicated to the entire public health system in the last fiscal year.

Poor people surged into Uganda’s public health system when the government abolished patient fees a decade ago. Increasingly, African countries are adopting similar policies, and experts say that many more people are getting care as a result. But Uganda’s experience illustrates the limits of that care when a system is poorly managed and lacks the resources to deliver decent services, experts say. At regional hospitals like the one here in Arua, more than half the positions for doctors are vacant, part of a broader shortage that includes midwives and other health workers. A majority of clinics and hospitals reported regularly running out of essential medicines, while only a third of facilities delivering babies are equipped with basics like scissors, cord clamps and disinfectant, according to a 2010 Health Ministry report. Dr. Emmanuel Odar, the hospital’s sole obstetrician, said that even in childbirth emergencies, families must buy missing supplies themselves, typically at nearby pharmacies. Patients without money must beg or borrow it, Dr. Odar said. “We are overwhelmed with cases of people looking for free services, and they expect a lot despite supplies not there, human resources lacking and the beds not enough,” he said.

When Ms. Nalubowa, 40, a peasant farmer and a mother of seven, arrived at the decrepit hospital in Mityana, said her mother-in-law, Rhoda Kukkiriza, nurses demanded a bribe of about $24 and more money to buy airtime for a cellphone call to the doctor, accusations the nurses have denied. Ms. Kukkiriza said she had less than a dollar left after spending $2.40 to buy a razor blade, gloves and other items the hospital lacked. Unable to pay the bribe, Ms. Nalubowa was taken to the maternity ward and left unattended, her mother-in-law said. “As she pushed with the labor pains, all that came out was blood,” Ms. Kukkiriza said. “Sylvia called out, ‘I’ll sell all my pigs, I’ll sell my chickens, my goats — please, nurses, come help me.’ ” Even if a doctor had arrived promptly, the hospital staff would have struggled to save Ms. Nalubowa, who bled to death. Dr. Vincent Kawooya, the hospital’s medical superintendent, said there was only one small unit of blood for a child in stock that night. The health minister himself toured the hospital after Ms. Nalubowa’s death incited demonstrations, but Dr. Kawooya said the minister refused to set foot in the operating room, with its moldy walls and leaky ceiling, saying it should be condemned. The roof of the maternity ward was a home to bats, and droppings come down its inner walls.

“We are in a state of emergency as far as maternal services are concerned,” Dr. Sentumbwe-Mugisa said.

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