Vol. 2, No. 1
ugandahealthcom@yahoo.com
28 January, 2008
Back to the Basics: Is Primary Health Care in Uganda Sick? While we devote much of our attention – and most of donors’ money – to “big” epidemics such as HIV, journalists periodically remind us that a lot of people suffer quietly from “neglected diseases” like lymphatic filariasis, leprosy, schistosomiasis, soil-transmitted helminthes, sleeping sickness, and jiggers. But what if the most seriously neglected health issue in Uganda isn’t a specific disease at all, but rather the most basic, general level of care – the system that gives us routine check-ups, vaccinates our children, teaches us how to stay healthy, treats relatively minor problems before they major ones, and helps us cope with a wide range of concerns that may not attract big programs and massive research but determine the quality of our daily lives? This is the Primary Health Care system, and it is attracting renewed concern. This issue of Uganda Health Reporter focuses on it. In addition, UHCA asked four experts to explore the state of primary care in Uganda at a workshop 28 January 2009 at the Speke Hotel on Speke Road. We will report on their remarks in a subsequent issue. Our experts include: •
Dr. Emmanuel Otaala, Minister of State for Primary Health Care: Overview – Uganda’s strategy for providing primary health care.
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Dr. Sarah Kiguli, head of the Department of Pediatrics and Child Health, Makerere University Faculty of Medicine: Are Uganda and its donors making enough of a commitment to primary health care to make the Millennium Development Goals achievable?
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Dr. Nathan Kenya Mugisha, Director for Clinical Services, Ministry of Health: Village Health Teams – Can they close the primary health care gap?
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Dr. Peter Okwero, Senior Health Specialist, The World Bank: What approaches to primary health care are affordable and sustainable?
Also in this issue, we: •
Assess primary health care coverage in three major Ugandan newspapers…….Page 2
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Offer some select resources on primary health care……………….……………...…Page 4
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Describe a successful primary care effort in Katakwi District………………………Page 5
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Provide background on sanitation, an important aspect of primary care………...Page 5
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Report on some health-communication fellowship opportunities…………….…...Page 6
Seeking a Health Content Manager UHCA is looking for a full-time “content manager” to help us amass reliable information on health issues and run our planned web site day-to-day. Applicants must have basic Internet skills. A background in library sciences, journalism or another communications field, or both is preferred. If interested, please send your CV and salary requirements to Hugandahealthcom@yahoo.comH by 11 February
Primary Health Care in Ugandan Newspapers: Coverage is Broad But Not Deep Primary health care is obviously a serious concern for Ugandans, judging from the substantial amount of media coverage it garners. In a content-analysis of last year’s newspapers, UHCA found that 62% of all health stories that ran in the country’s three major newspapers addressed primary health care. At a time when public health advocates are saying that policy-makers – especially international donors – are short-changing primary care, the findings suggest that the Uganda media are focusing where such experts say they should: on this most basic level of care. But our journalists have plenty of room to improve. The analysis showed that primary care issues largely get second-class treatment: such stories almost never find their way onto the front pages of major newspapers. And while primary-care advocates say community involvement should be a key ingredient of primary care, media coverage of these issues focuses almost exclusively on leaders and opinion-makers. The voices of everyday people are rarely heard. For its analysis, UHCA looked at a total of 430 issues of the Monitor, New Vision and the Observer. Stories were coded according to whether the dealt with primary care – basic and preventive treatment – or specialized, disease-specific programs. Our finding: nearly 70% of the coverage in the health pullouts in both the Monitor and New Vision focused on primary care.
Of more than 430 issues of the Monitor, New Vision and Weekly Observer sampled, a health story reached the front page only three times, and of those three, only one involved primary health care. The daily papers’ pullouts featured many stories on maternal and child health, nutrition, personal hygiene and exercise. The Observer’s reporting on the Katine project (a three-year program by the African Medical and Research Foundation and Farm-Africa in a sub-county in Teso) highlighted primary health care issues faced by rural grassroots people. http://www.guardian.co.uk/katine Generally, maternal and child health was the single most frequently featured primary health care issue. The government pilot projects in indoor spraying of houses in rural areas and the accompanying controversy inspired more than a few stories in the hard news sections of the newspapers in 2008, as did community sanitation improvement efforts by government, NGOs and corporate bodies. Hard News, Lightweight Approach Hard-news sections carried the highest number of health stories compared to other sections, but on a percentage basis, their coverage of primary health care was low compared to others sections. Some 57% of hard-news health stories involved PHC, compared to 70% of stories in the health pullouts, 63% of other health features and 62% of the health op-ed pieces. PHC issues may be covered frequently by the papers but editors apparently still do not see them as ‘heavyweight‘ stories. More than half (57%) of all PHC stories were either inside-page, non- lead stories or briefs. 62% of the lead stories on the inside pages did not exceed half a page in length (approximately 450 words). Of the more 430 copies of the Monitor, New Vision and Observer that we sampled, a health story reached the front page only three times, and of those three, only one involved primary health care.
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Sourcing of stories on primary health care also raises concern. Frequently, health stories – especially those involving rural communities – did not carry voices from the affected communities. One such story, which described how mothers in Masaka district shun hospitals to give birth at home with the aid of Traditional Birth Attendants, gave the doctors’ perspective and highlighted the congestion and lack of equipment in hospitals but it had no mother describing her views or explaining her choice of a birth attendant over a hospital. Similarly, there was little enterprise journalism on primary health care in rural communities. The papers did well publicising projects by NGOs and other stakeholders to improve health in those communities, but they failed to explore which community primary health care needs were being met or neglected. There typically were brief stories reporting such news as a “water purifier [was] launched” or that an “LC chief warns on lack of toilets,” but stories examining such questions as why many rural infants still die of diarrhoea were hard to find.
Our conclusion: While we set out with fear that the media, perhaps like other stakeholders, were following donor money and focusing on specialized concerns, we were pleasantly surprised. But we aren’t ready to say the battle has been won. Getting close to communities, where the real challenge of primary health care is most acute, remains a challenge for the media as much as for health providers.
Tuberculosis Journalism Award: The Stop TB Partnership and the Lilly MDR-TB Partnership Journalists are offering prizes to journalists from developing countries for articles that raise awareness of tuberculosis and multidrug-resistant tuberculosis. Articles must be published between 1 March 2008 and 31 March 2009. Prizes of US$3,000, $2,000 and $1,000 will be given. For information, visit http://www.stoptb.org/bi/journalismaward.asp or contact Judith Mandelbaum-Schmid at schmidj@who.int.
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Primary Health Care Resources Defining Primary Care: Primary health care rests on five principles: accessibility, use of appropriate technology, individual and community participation, disease prevention and cooperation among sectors. According to the World Health Organization (WHO), primary care should be evidence-based, use appropriate technology, promote community participation in decisions about health services, be affordable, encourage self-care and empowerment of community members, and bring health care as close as possible to where people work and live. A good summary of these concepts can be found at: http://www.nurses.ab.ca/pdf/Primary%20Health%20Care.pdf The Alma Ata Declaration: This widely cited statement issued by health professionals who attended a 1978 conference (in what is now Khazakstan) calls on governments and health-care providers to commit themselves to comprehensive programs that ensure primary care “based on practical, scientifically sound and socially acceptable methods and technology made universally accessible through people’s full participation and at a cost that the community and country can afford.” http://www.who.int/hpr/NPH/docs/declaration_almaata.pdf Why invest in Primary Health Care? “Health systems in low-income countries with a strong primary care orientation tend to be more pro-poor, equitable and accessible,” according to this study prepared for the WHO in 2004. The research report notes further that “using primary care physicians reduces costs, and increases patient satisfaction with no adverse effects on quality of care or patient outcomes.” http://www.euro.who.int/document/e82997.pdf The Financial Challenges: The U.K’s Institute for Development Studies discusses approaches to paying for improved primary health care: http://www.id21.org/insights/insights-h12/index.html
Even the rich need primary care The United States has one of the world’s most highly specialized systems for delivering health care. Yet some people say it, too, needs to pay more attention to primary care. Last year, 75% of the $2.1 trillion Americans spent on medical care went to treat chronic diseases like heart disease, diabetes, prostate cancer, breast cancer and obesity that “are largely preventable and even reversible by changing diet and lifestyle,” according to this article in the online Wall Street Journal. Hhttp://online.wsj.com/article/SB123146318996466585.htmlH
Donor Support: Some donors, including the United Nations Children’s Fund (UNICEF), have devoted considerable attention to building primary health care capacity. UNCEF’s program (http://www.unicef.org/saotome/health.htm) is based, in part, on the Bamako Initiative, a program adopted in varying degrees in half of the countries of sub-Saharan Africa that successfully put into effect some of the Alma-Ata principles of community involvement in health.http://wwwwds.worldbank.org/external/default/WDSContentServer/IW3P/IB/2003/10/24/000160016_200310241 14304/Rendered/PDF/269540Bamako0Increasing0clients0power.pdf The Critique of Donor Strategies: “15 by 2015,” a coalition of primary care advocates, is pressing donors to start spending 15% of their resources on primary care by 2015. http://www.15by2015.org See especially this article, which lays out the argument that donors, in their emphasis on “diseasespecific programs,” have failed to achieve broad-based improvements in health: http://www.15by2015.org/wp-content/uploads/2008/01/editorial.pdf The Spirit Lives On: In its World Health Report 2008, the World Health Organization declared: “Globalization is putting the social cohesion of many countries under stress, and health systems are clearly not performing as well as they could and should. People are increasingly impatient with the inability of health services to deliver…Health systems need to respond better – and faster – to the challenges of a changing world. PHC can do that.” http://www.who.int/whr/2008/en/ More web links and articles: The Institute for Development Studies (IDS) has compiled a useful list of other web sites, as well as a number of pertinent articles: http://www.id21.org/insights/insightsh12/weblinks.html . See especially the articles, “Is the Declaration of Alma Ata Still Relevant to Primary Health Care?” British Medical Journal http://www.bmj.com/cgi/content/extract/336/7643/536 and “Three Decades of Primary Health Care: Reviewing the Past; Defining the Future,” Bulletin of the WHO, http://www.scielosp.org/scielo.php?script=sci_arttext&pid=S004296862008000100003&lng=en&nrm=iso&tlng=en
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Primary Care in Practice Would it pay to provide universal primary health care? Stephen Otage, who responded to our previous issue of this newsletter tells us a story that that might help answer that question. After the floods early last year, public health service providers worried there would disease outbreaks that would overwhelm the capacity of Katakwi district, which has only one health centre IV, one full time doctor and a few nurses and clinical officers to serve its 170,000 people. So, Pilgrim, a NGO, and the Ministry of Health joined forces to provide basic and preventive care to all those who responded to their call by going to the treatment centres. In a campaign that ran from 13 October to 20 November, 48,000 of the children were dewormed, 24,800 given Vitamin A supplements and 24,400 people were tested for malaria. All the 3,450 found positive for malaria were treated. Some 650 expectant mothers were given preemptive malaria treatment while 6,455 children were immunized against tuberculosis, diphtheria, polio, measles, hepatitis B and hepatitis II. Within three weeks after the campaign, attendance in the out- patient department (OPD) had dropped by 40% while admissions in the children's ward of Katakwi Health Centre IV, which had averaged 60-70 at one time, had dropped below five. During a field visit to the district in December, Dr. Myers Lugemwa of the health ministry found just one patient admitted to the children’s ward for malaria: a child who didn’t even come from Katakwi, but rather was from Abarilela in the neighboring Amuria district.
Training Opportunities….
Sanitation: A Backgrounder At a UHCA workshop in April, it was observed that three-quarters of all epidemics in Uganda arise from poor sanitation and hygiene. The problem isn’t confined to Uganda: Around the world, as many as 2.6 billion people do not have a clean and safe place to defecate; as untreated waste contaminates food and pollutes rivers, more than 80% of people in developing countries become ill because they lack clean water and proper facilities for the disposal of their waste. One example is the Hepatitis E outbreak that is still raging in northern Uganda. The United Kingdom’s Department for International Development (DFID) has compiled a series of informative articles and reports on the global sanitation crisis. It includes: •
“The Last Taboo: Opening the Door on the Global Sanitation Crisis,” a fascinating book issued by Earthscan, a British publisher on climate change, sustainable development and environmental technology.
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A report on how many countries – including Malawi, Tanzania, Ghana and Nigeria – are using Global Positioning System (GPS) technology to identify water resources and help local officials determine where improvements are needed.
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A study on efforts to improve sanitation in Asia; it shows that building good facilities is not enough to solve waste-disposal problems and that it also is necessary to work with communities to ensure that the facilities are sustained and used hygienically.
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A report that examines efforts to increase the number of home latrines in Ghana, where three-quarters of the population rely on public toilet facilities.
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An analysis of the challenges the government of Ethiopia must face as it presses ahead with an aggressive latrine-building program.
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A manual with practical advice on how to improve school sanitation in African countries.
There is plenty of information relevant to Ugandans, where the media haven’t paid much attention lately to this issue: http://www.id21.org/urban/sanitation.html .
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Training Opportunities….. Knight Science Journalism Fellowships Individuals with at least three years full-time experience as freelance or staff journalists for general interest print, web or broadcast organisations are being offered one year fellowships at Harvard University and Massachusetts Institute of Technology. Fellows take field trips to various science research centres, participate twice-a-week in seminars with leading science journalists and take courses of their choice at Harvard and MIT. Tuition and field trip costs are covered, stipends are paid to cover their costs of upkeep. The deadline for application is 2 March. To download the application form, visit http://web.mit.edu/knight-science. For a personal perspective on the fellowship, contact Esther Nakkazi a Ugandan journalist active in UHCA who was a fellow last year, at nakkazie@yahoo.com.
Public Health Fellowships Applications are now being accepted for the public health fellowships we announced in the last issue. The following categories of fellowships are being offered by the Makerere University School of Public Health in collaboration with the Centres for Disease Control: •
Long-term apprenticeships. Ten full-time, two-year placements will be available for people with post graduate degrees in public health or health-related fields such as medicine, social sciences, statistics, journalism and information technology. Fellows spend 75% of their time at host institutions and 25% attending short courses and seminars at the School of Public Health.
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Medium-term fellowships. A total of 24 eight-month placements are available in organizations that deal with HIV/AIDS. Fellows take a one-month course in program leadership and management, as well as courses in monitoring and evaluation of HIV/AIDS program. They implement hands-on projects related to the courses. Applicants should be in full-time employment in the HIV/AIDS field.
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Technical placements. Participants work for up to one month at Rakai Health Sciences Program (formerly the Rakai Project) in the following departments: male circumcision (8), laboratory (2) and community-based anti-retroviral treatment (2). Theatre assistants, clinical officers and medical doctors working in Health Centre IVs and District Hospitals are particular encouraged to apply for male circumcision placements. Individuals involved in laboratory and ART work at different levels are sought for the other placements.
Requirements: • • • •
Application letter, updated curriculum vitae and reference letters from two professional referees with their telephone and email contacts Copies of academic transcripts and certificates of degree programs undertaken Personal statement not exceeding 300 words outlining past/current programmatic involvement in HIV/AIDS activities and the personal goals you hope to achieve from the program. For the apprenticeship, spell out your area of specialized interest. For the technical placement applications, include a letter of endorsement from your employer indicating support for the placement as well as willingness to release you for one month.
Deadline: 13 February. Send or Deliver your application to: Office of the Dean Makerere University School of Public Health P.O. Box 7072 Kampala, Uganda dean@musph.ac.ug 256-414-543872/031 2263 158 Fax: 256-414-531807
Here’s to your health…and to the health of all Ugandans! --6--