Uganda put to the test on maternal healthcare

Half of the 3.4 lakh deaths of women from pregnancy-related causes each year occur in Africa

An obstetrician who investigated the case said Mrs. Anguko, the mother of three young children, had arrived in time to be saved.

Her husband, Valente Inziku, a teacher, frantically changed her blood-soaked bedclothes as her life seeped away. “I’m going to leave you,” she told him as he cradled her. He said she pleaded, “Look after our children.”

Half of the 3,40,000 deaths of women from pregnancy-related causes each year occur in Africa, almost all in anonymity. But Anguko was a popular elected official seeking treatment in a 400-bed hospital, and the lawsuit over her death may be the first legal test of an African government’s obligation to provide basic maternal care.

It also raises broader questions about the unintended impact of foreign aid on Africa's struggling public health systems. As the US 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 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.

Ugandan officials dispute the idea, with one saying the country's own health spending had increased, ‘but not that substantially.’ Still, the government set off a bitter domestic debate this spring when it confirmed that it 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. A growing number of African countries adopted similar policies, and experts say that many more people are getting care because of them. 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 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 running out of essential medicines on a monthly basis, while only a third of facilities delivering babies are equipped with basic supplies like scissors, cord clamps and disinfectant, according to a 2010 Health Ministry report.

The hospital where Mrs Anguko died handles obstetric emergencies for a region of almost three million people, but it recently had no sutures in stock to sew up women's bellies after Caesarean sections. 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, he 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.

Dr. Olive Sentumbwe-Mugisa, a Ugandan obstetrician and adviser with the WHO, participated in the ministry's investigations of the deaths of both Mrs Anguko and Sylvia Nalubowa, a second woman named in the lawsuit against the government, and concluded that both women arrived in time to be saved.

In its lawsuit filed in March, the Centre for Health, Human Rights and Development; a Ugandan nonprofit group, contended that the government violated the two women's right to life by failing to provide them with basic maternal care. The attorney general’s office replied that the ‘isolated acts’ alleged in the case ‘cannot be used to dim the untiring efforts in the health sector.’

But the government has come under tough questioning since April, when its spending on the Russian-made fighter jets became public. Officials in president Yoweri Museveni’s government say the jets are critical to protecting Uganda in a region with a history of conflict, especially as it develops oil fields. “The enemies of Uganda don’t want us to have those jet fighters,” said Tamale Mirundi, a spokesman for Museveni.

Matter of conscience
But opposition leaders decried the spending in a nation at peace, with huge social needs. “You are talking about investing in jets? Come on!” Christine Bako, a member of parliament who represented Mrs. Anguko, said in a debate in parliament. “This is now a matter of conscience.”

As Africa's population swells, so will demand for emergency obstetric care. The United Nations recently estimated that Uganda's population was likely to almost triple to 94 million by 2050, meaning tens of millions of babies to be delivered.

Dr Rafael Lozano, aglobalhealth professor at the university, said that except for recent gains in saving the lives of HIV-positive pregnant women with treatments largely financed by donors, “you see basically almost no progress in maternal deaths in Uganda.”

When Mrs Nalubowa, 40, a poor peasant farmer and mother of seven, arrived at the district hospital in Mityana, her mother-in-law, Rhoda Kukkiriza, said 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. Mrs Kukkiriza said she had less than a dollar after buying a razor blade, gloves and other items the hospital lacked. Mrs Nalubowa was taken to the maternity ward and left unattended, her mother-in-law said.

Even if a doctor had arrived promptly, the hospital would have struggled to save Mrs Nalubowa, who bled to death. Dr Vincent Kawooya, the hospital's medical superintendent, said there was only one small unit of blood in stock that night.

The health minister himself came to tour the hospital after Mrs Nalubowa's death incited public demonstrations, but Dr Kawooya said the minister refused to set foot in the operating theatre, with its moldy walls and leaky ceiling, saying it should be condemned.

The roof of the maternity ward was home to bats, and droppings come down its inner walls. Vincent Nyanzi, a member of parliament from the area from the governing party, said he introduced Mrs Nalubowa's mother-in-law and husband to Museveni when he made a public appearance in a nearby district.

The president's private secretary gave them an envelope containing about $190, the family said. In their brief audience with the president, Mrs Kukkiriza said he told them, “I’m sorry. It’s really a pity.”