This in not an official U.S. Department of State (DOS) blog and the views and information presented are my own and do not represent the Fulbright Program or the DOS.
In Uganda, the government provides basic healthcare at no cost to all of its citizens. This consists of a series of levels of care that start with the Village Healthcare Teams (VHT). These are people who are trained to provide simple health education to members of their own villages and act as a liaison to the next level of care, which is the Healthcare Center 2 (HC2) staffed by nurses. The VHT notify villagers when well-baby immunization clinics are occurring and remind women to attend their regular pre-natal visits when pregnant. They also are often the first point of contact when their are disease outbreaks like cholera and can notify both the healthcare centers as well as spread the word among the villagers. This program is a way to bring healthcare to the people. The next level HC3, which is staffed by a nurse and Clinical Officer (like a Physicians Assistant in the USA). The HC4 are are local district hospitals with Regional Referral Hospitals the highest level of care. Basic care includes a Clinician to give exams and prescribe drugs. The Ministry of Health has an Essential Drugs List that identifies the free medications that are approved as the standard of care in the country and should be available at government run health centers for doctors to prescribe. Unfortunately, the distribution of supplies and medications is not always based on need and what was ordered but rather on a standard set of supplies that are to be delivered to all healthcare centers of a certain level on a routine schedule. What this means is that although a healthcare center of a certain level may serve a much larger population than others at that same level, they receive the same amount of supplies. This practice contributes to the lack of adequate resources where they are needed. There are many other factors that also contribute to this such as out-of-stock medications at the National Drug Stores so that what should be delivered isn’t available. In addition to physical examinations and drugs, basic lab tests are also provided for free, when they are available. One of the things that distinguish a HC2 from a HC3 is the availability of a laboratory on site. For example, a HC2 should be able to perform a rapid diagnostic test (RDT) for malaria, which is a finger prick of blood applied to a test strip and then read by a color change when the developer reagent is applied. This tests for the Malaria antigen indicating the presence of the parasite. They can’t do an actual blood smear in which a lab technician is able to actually see the parasite on a slide under the microscope- these are done at HC3 and above. The interesting thing is that recently there have been studies showing RDT’s may be more sensitive and accurate than blood smears which are only as good as the technique and experience of the technician. But, the clinics often run out of test kits and since the blood smear is cheaper, the hospitals continue to use that as the primary diagnostic test for malaria rather than use the more sensitive RDT’s.
Another challenge to quality healthcare in Uganda is the inability to rely on having basic clinical tools available in every setting. For example, it is not uncommon for the ward’s Blood Pressure Cuff, Stethoscope, and Thermometer to go missing for days at a time. One time I was rounding in a smaller government hospital and noticed that in every patient chart the BP reading was missing as well as the temperature. I was told that the tools were missing and they couldn’t get another set of supplies because either the hospital had run out of budgetary allowances for the month or the National Drug Stores was out-of-stock. In a large hospital where I work, there are very few scales for weighing adult patients but weight is often critical for making sure the drug doses are appropriate for each individual patient. If a patient doesn’t know his or her weight, we usually have to estimate based on the patient’s appearance. For most drugs, this is adequate but knowing the actual weight for very ill patients can be critical as a monitoring parameter for drug therapy, such as in treating patients with Congestive Heart Failure.
So, despite the availability of government-sponsored healthcare, most people who have some money tend to seek the services of private doctors and pharmacies for supplemental services, if not for their entire healthcare. The availability of pharmacies is especially important because the Essential Drug List is very narrow in scope and just because a drug is on the list, doesn’t mean it will be available for patients when needed. This week, Joe, another American Pharmacist volunteer, and I had the opportunity to visit a very nice private pharmacy outside of Kampala. I have gotten to know Gonsha, the Pharmacist and Owner, over the past couple of years. On a volunteer basis, she coordinates the education program for the Pharmacy Interns at Mulago Hospital, and she has arranged for me to help precept the Interns for their weekly Case Presentations. She is deeply committed to providing high quality care to the patients who use her pharmacy, as well as ensuring the Pharmacy Interns are capable of doing the same upon completion of their training year, which is the year after Pharmacy School graduation before they can take the licensure exam. She is very active in the movement to advance pharmacy practice in Uganda and increase the ability of Pharmacists to provide Pharmaceutical Care to help improve patient health outcomes. I was impressed with how organized and clean Extra Care Pharmacy was and the level of staff she has hired. Although every Pharmacy must have a licensed pharmacist supervising the pharmacy activities, the Pharmacist is not required to be on duty to open the store and dispense medications. And Pharmacists are allowed to supervise 2 Community Pharmacies at a time because the number of pharmacists in the country can’t meet the demand.
Most pharmacies hire untrained staff or maybe a nurse for dispensers but Gonsha has hired a Clinical Officer whom is much more qualified to advise patients and fill prescriptions in her absence. Gonsha also offers some services to her patients that are not very common in most pharmacies. For example, when a patient who has high blood pressure comes to get a medication refill, she is able to take their blood pressure to be sure the medication dose is still adequate.