Research Articles

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Endomyocardial fibrosis in Uganda (Davies' disease). Part II: An epidemiologic, clinical, and pathologic study
(Elsevier - American Heart Journal, 1968) Connor, Daniel H.; Somers, Krishna; Hutt, Michael S.R.; Manion, William C.; D'Arbela, Paul G.
Endomyocardial fibrosis in Uganda (Davies' disease) is a common type of fatal heart disease in the autopsy population at Mulago Hospital. During this study, endomyocardial fibrosis caused 25 per cent (1665) of deaths from intrinsic heart disease; it showed a striking and unexplained predilection for the immigrant Rwandans, but spared the large local indigenous tribe, the Ganda. Clinically the patients had a sudden or insidious onset of failure of one or both ventricles, which proved fatal over a period of days, weeks, months, or years. At necropsy there were mural endocardial lesions at one or more of three sites—the apex of the right ventricle, the posterior wall of the left ventricle, and the apex of the left ventricle. In the early stage the cardiac connective tissues, especially those of the endocardium, were swollen with acid mucopolysaccharide (AMP) and covered by a layer of fibrin. In later lesions, the involved areas had resolved as hard, white scard composed of collagen and elastica. There were peculiar, and we believe characteristic, foci of collagen necrosis in the scar tissue at the endomyocardial junction. The cause of endomyocardial fibrosis remains unknown, but the consistent mucinous swelling of the cardiac “ground substance” and vessels plus the focal nonsuppurative disintegration of collagen suggest to us that hypersensitivity is the underlying mechanism. Although rheumatic heart disease and endomyocardial fibrosis have a number of common features, including diffuse and focal disruption of the cardiac connective tissues, the consistent differences in RHD and EMF have convinced us that the two are different diseases. At the present time there is no microscopic evidence to support the view that endomyocardial fibrosis in Uganda (Davies' disease) has a similar histogenesis to cardiopathies in other parts of the world.
Familial Cases of Endomyocardial Fibrosis in Uganda
(Br Med J - The BMJ, 1971) Patel, Ashvin K.; Ziegler, John L.; D'Arbela, Paul G.; Somers, Krishna
This report describes nine cases of endomyocardial fibrosis occurring in four families. All patients came from Rwanda or South-western Uganda, and five had tropical splenomegaly syndrome as well. It seems likely that genetic as well as environmental factors are operative in the aetiology of endomyocardial fibrosis.
Survival after first presentation with endomyocardial fibrosis
(British Heart Journal, 1972) D'Arbela, Paul G.; Mutazindwa, T.; Patel, Ashvin K.; Somers, Krishna
Forty-six cases of necropsy endomyocardial fibrosis are analysed and presented with the objective of determining their prognosis after first symptoms of the disease. Survival from first symptoms ranged from 12 days to 12 years and 2 weeks, the mean survival being 24 months. The commonest mode of termination was by progressive myocardial failure, very frequently associated with acute respiratory events - either pulmonary oedema, bronchopneumonia, or pulmonary infarction. Un-explained sudden deterioration and collapse probably due to a terminal acute dysrhythmia was the second most important immediate cause of death. Patients with sole left-sided endomyocardial fibrosis run a higher risk of succumbing to acute pulmonary oedema. Protection by development of severe right-sided endomyocardial fibrosis, organic tricuspid regurgitation, or pulmonary hypertension was therefore a relative advantage, and if other un-expected complications were excluded, survival time was increased. The role of the continuing myocardial destructive process in determining survival rate is discussed.
Endomyocardial fibrosis and eosinophilia
(British Heart Journal, 1977) Patel, Ashvin K.; D'Arbela, Paul G.; Somers, Krishna
Absolute eosinophil counts were assessed in 15 African patients with proven endomyocardial fibrosis. Though the mean eosinophil count in patients with endomyocardial fibrosis was higher compared with the normals reported from Kampala (1-13 vs 0.72X10(9)/1), the absolute range was comparable. A high percentage of patients with endomyocardial fibrosis had malarial parasites, high malarial antibody titres, hookworms, or strongyloides, but the correlation of eosinophilia to various parasitic infections was poor. Both eosinophilia and parasitic infections are common in the tropics and they effect patients with endomyocardial fibrosis no more than the population at large. Other aetiological factors, genetic, environmental, and immunological, are felt to be important in the causation of endomyocardial fibrosis in Uganda and evidence for this is reviewed. Though there is a similarity in pathological features, African endomyocardial fibrosis is a distinct entity from Löffler's endocarditis and cardiac lesions seen in eosinophilic leukaemia or reactive eosinophilia. There is no hard evidence to suggest that African endomyocardial fibrosis is a variant of Löffler's endocarditis caused by parasitic infections via eosinophilia.
Monumental through Design, Identity by Definition: The Architecture of Uganda prior to Independence
(The University of Adelaide, 1998) Olweny, Mark R. O.
“Throughout history monumental architecture has been employed to embody the values of dominant ideologies and groups, and as an instrument of state propaganda.”1 To an extent however, the presentation or representation of national identity through architecture has been an invention of sorts, particularly in the former European colonies of Africa, where unified national identities has never existed. The function of this representation was twofold; firstly to provide a visible symbol of economic and political development, and secondly to provide a recognisable symbol to which people could eventually identify. This paper will explore the issues of ‘identity’ and ‘monumentality’ in relation to state architecture in Uganda particularly during the decade prior to its independence from Britain in 1962. The issue of identity arising from the notion that architecture can be used to communicate values, aspirations and ideologies, thus expressing a particular identity, with monumentality and monumental architecture defining architecture of high significance, and in most cases manifested through state buildings. These issues will explore in relation to three questions in particular; i) Why were these buildings constructed? ii) For whom were they built? iii) Who do they represent?
Africa: A Continent Exiting and Entering a Century in a ‘Sick-Bay’
(Uganda Martyrs University, 1999) Mataze, Owa Nduhukhire
The paper appears in three parts, which must be read as one. Part One situates the current development crisis in Africa in the relevant theoretical and historical context. It also highlights the global context of the crisis and the extent it has hindered genuine human-centred development in the continent to date. Part Two examines the ideological assumptions that underlie and sustain the development crisis. These are the myths and deceptions on and about Africa, its natural and human resources and the reproduction of these distorted images. The relationship between the ideologies and the anti-social and anti-environmental growth patterns is examined. Part Three examines current philosophies and practices that are increasingly pushing Africa into the fangs of global capitalism on the basis of an intensified `sponsored-peripheral capitalism'. Finally, suggestions as to how the continent can enjoy the twenty-first century outside the `sick-bay' of `mal-development' are made. A select bibliography is included at the end of each part.
The Pattern of Cancer in Kampala, Uganda
(The College of Surgeons of East, Central and Southern Africa (COSECSA), 2001) Kakande, Ignatius; Ekwaro, Lawrence; Obote, W. Wiam; NassaLi, Gorreti; Kakande, Irene Rarban; Kabuye, S.
This study on the pattern of cancer in Kampala is based on data collected from 2246 patients at Mulago Hospital and 355 patients at St. Francis Hospital Nsambya, between January 1995 and December 1998. All diagnoses were histologically confirmed. Of these 2601 patients, 1225 were males and 1376 were females. Kaposi's Sarcoma was the commonest malignancy, accounting for 28.6% of all cancers. Among males, Kaposi's Sarcoma (KS) was the most common cancer (37.1°/o) followed by prostaticcancer(9.60/0), lymphomas (8.5%), oesophageal cancer (7.0°/o), eye malignancies (3.8%) and pharyngeal cancer (3.8%). In females, the order of frequency of malignancies was cervical cancer (22.200), Kaposi's Sarcoma (21.1°/0), breast cancer (10.9%), lymphoma (5.9%), oesophageal cancer (4.6%) and eye malignancies (3.60/0). The incidence of KS has dramatically increased from 6.3% in males and 0.4% in females among patients with cancer diagnosed in 1977-80, before HIV infection was recognized. This paper compares the cancer patterns of 1995-98 with those of 1977-80 and discusses the possible influence of HIV infection on the change of patterns of cancer in Uganda.
An Overview Cancer Management And Prevention In Africa
(The College of Surgeons of East, Central and Southern Africa (COSECSA), 2001) Kakande, Ignatius
Intestinal Volvulus at St Francis Hospital, Kampala
(The College of Surgeons of East, Central and Southern Africa (COSECSA), 2001) Kakande, I; Ekwaro, L.; Obote, W. W.; Nassali, G.; Kyamanywa, Patrick
A review of sixty patients with intestinal volvulus was undertaken at St Francis Hospital, Nsambya, Kampala. Forty three (71.7%) of the patients presented with sigmoid volvulus while 12 (20°0) had ileosigmoid knotting. There were 53 males and seven females. The ages of sigmoid volvulus patients ranged between 20- 87 years while for ileosigmoid knotting the range was 22-75 years with a mean of 41 years. The majority (53.5%) of the patients belonged to the Ganda tribe and were of low socialeconomic class. Resection and primary anastomosis was performed in 24 (560/0) of the 43 patients who presented with sigmoid volvulus. Two patients died following resection and primary anastomosis but both cases had presented with gangrenous bowel. Only one of the 12 patients with ileosigmoid knotting died. Resection and primary anastomosis is a generally safe procedure in the management of sigmoid volvulus. However, it should be avoided in cases of gangrenous sigmoid volvulus.
Assessment of a Pilot Antiretroviral Drug Therapy Programme in Uganda: Patients' Response, Survival, and Drug Resistance
(Elsevier, 2002-07-06) Weidle, J Paul; Malamba, Samuel; Mwebaze, Raymond; Sozi, Catherine; Rukundo, Gideon; Downing, Robert; Hanson, Debra; Ochola, Dorothy; Mugyenyi, Peter; Mermin, Jonathan; Samb, Badara; Lackritz, Eve
Background Little is known about how to implement antiretroviral treatment programmes in resource-limited countries. We assessed the UNAIDS/Uganda Ministry of Health HIV Drug Access Initiative—one of the first pilot antiretroviral programmes in Africa—in which patients paid for their medications at negotiated reduced prices. Methods We assessed patients' clinical and laboratory information from August, 1998, to July, 2000, from three of the five accredited treatment centres in Uganda, and tested a subset of specimens for phenotypic drug resistance. Findings 912 patients presented for care at five treatment centres. We assessed the care of 476 patients at three centres, of whom 399 started antiretroviral therapy. 204 (51%) received highly active antiretroviral therapy (HAART), 189 (47%) dual nucleoside reverse transcriptase inhibitors (2NRTI), and six (2%) NRTI monotherapy. Median baseline CD4 cell counts were 73 cells/μL (IQR 15–187); viral load was 193 817 copies/mL (37 013–651 716). The probability of remaining alive and in care was 0·63 (95% CI 0·58–0·67) at 6 months and 0·49 (0·43–0·55) at 1 year. Patients receiving HAART had greater virological responses than those receiving 2NRTI. Cox's proportional hazards models adjusted for viral load and regimen showed that a CD4 cell count of less than 50 cells/μL (vs 50 cells/μL or more) was strongly associated with death (hazard ratio 2·93 [1·51–5·68], p=0·001). Among 82 patients with a viral load of more than 1000 copies/mL more than 90 days into therapy, phenotypic resistance to NRTIs was found for 47 (57%): 29 of 37 (78%) who never received HAART versus 18 of 45 (40%) who received HAART (p=0·0005). Interpretation This pilot programme successfully expanded access to antiretroviral drugs in Uganda. Identification and treatment of patients earlier in the course of their illness and increased use of HAART could improve probability of survival and decrease drug resistance.
Grand narratives of the Great Lakes Region of Africa and their contribution to the current conflicts
(Mtafiti Mwafrika (African Researcher), 2003) Ngabirano, Maximiano
The strategy of this paper is to draw attention to the influence of narrative and group identities to the current conflicts of the Great Lakes Region. It argues that past memories, passed over to the present generation through community narratives, have contributed to the current crisis. Narratives have been a driving force in forming solidarity and at the same time in excluding and exterminating others. Narrative groups have further consolidated allies and distinguished enemies, in this way broadening the crisis in the region. The paper concludes by asserting that particular narratives remain dangerous in the Great Lakes Region, unless they are reconstructed in recognition of others narratives.
Competing Demands and Limited Resources in the Context of War, Poverty and Disease: the Case of Lacor Hospital
(Uganda Martyrs University, Department of Health Sciences, 2003) Accorsi, Sandro; Corrado, Bruno; Massimo, Fabiani; Iriso, Robert; Nattabi, Barbara; Ayella Odong, Emintone; Ogwang, Martin; Onek, Paul Awil; Pido, Bongomin; Declich, Silvia
Difficult choices have to be made among competing demands for health care in the context of severely limited resources and persistent humanitarian crisis prevailing in Northern Uganda. In particular, the challenge of a burden of disease from largely preventable and treatable conditions, the spread of emerging or re-emerging infections, the appearance of new, previously unknown, diseases (such as Ebola), and the heavy burden of poverty and war on health, make it imperative for getting information for identifying priorities and for decision making. However, major information gaps exist, and the little data available has been provided from scattered surveys and from incomplete reporting systems. In this context, readily available information collected using standardized procedures, such as data from hospital discharge records, becomes extremely important, in that these data can provide useful indications on the health situation at a low cost, in a long-term, sustainable way. This study is based on 155,205 medical records of inpatients admitted to the Lacor Hospital during the period 1992-2002, and its objective is to describe the health profile of the population of Northern Uganda, in order to estimate the impact of war, poverty, and social disruption in terms of morbidity and mortality. It analyses also the performance of Lacor Hospital in coping with this emergency situation, exploring pathways and mechanisms that link disease patterns, hospital performance, quality of care, and health outcomes, therefore providing an example of the thinking process leading from information to decision to action.
Development of Phenotypic and Genotypic Resistance to Antiretroviral Therapy in the UNAIDS HIV Drug Access Initiative – Uganda
(Wolters Kluwer Health, Inc., 2003-07) Weidlea, J. Paul; Downingb, Robert; Sozic, Catherine; Mwebaze, Raymond; Rukundo, Gideon; Malamba, Samuel; Respessa, Richard; Hertogsf, Kurt; Larderg, Brendan; Ochola, Dorothy; Mermin, Jonathan; Badara Sambk, Badara; Lackritz, Eve
Objective: We describe phenotypic drug resistance, response to therapy, and geno-typic mutations among HIV-infected patients in Uganda taking antiretroviral medica-tions for ≥ 90 days who had a viral load ≥ 1000 copies/ml. Methods: HIV-1 group and subtype, virologic and immunologic responses to anti-retroviral therapy, phenotypic resistance to antiretroviral drugs, and associated geno-typic mutations among patients at three treatment centers in Uganda between June 1999 and August 2000 were assessed. Therapy was two nucleoside reverse tran-scriptase inhibitors (NRTIs) or highly active antiretroviral therapy (HAART). Results: All HIV identified was HIV-1, group M, subtypes A, C, and D. Sixty-one (65%) of 94 patients with a phenotypic resistance result had evidence of phenotypic resistance including resistance to a NRTI for 51 of 92 (55%) taking NRTIs, to a non-nucleoside reverse transcriptase inhibitor (NNRTI) for nine of 16 (56%) taking NNRTIs, and to a protease inhibitor (PI) for eight of 37 (22%) taking PIs. At the time of the first specimen with resistance, the median change from baseline viral load was –0.56 log copies/ml [interquartile range (IQR), –1.47 to +0.29] and CD4+ cell count was +35 × 106 cells/l (IQR, –18 to +87). Genotypic resistance mutations, matched with phenotypic resistance assay results and drug history, were generally consistent with those seen for HIV-1, group M, subtype B infections in industrialized countries. Conclusion: Initial phenotypic resistance and corresponding genotypic mutations among patients treated in Uganda were similar to those with subtype B infections in North America and Europe. These data support policies that promote the use of HAART regimens against HIV-1, group M, non-B subtypes in a manner consistent with that used for subtype B infections.
Economic Impact of Lacor Hospital on the Surrounding Area
(Uganda Martyrs University, Department of Health Sciences, 2003-12) Maniple, Everd; Akello, Evelyn; Asio, Salome; Auma, Vento; Kazibwe, Francis; Lule, Haruna; Corrado, Bruno; Odaga, John
The health care industry is an important contributor to the economy, especially to that of the area surrounding health institutions. This effect is even more marked in the case of rural facilities. At national level, it comes in the form of ensuring a healthy productive population and saving costs that would have otherwise been spent on treatment, thus liberating them for use on other developmental purposes. However, being a labour-intensive industry, it also contributes by providing employment for a significant section of the working-age population. At local level, in addition to the general benefits mentioned above, it comes in the form of attracting significant government and external investment to the area, and providing a market for local goods and services. It also helps to ‘keep health dollars at home’by ensuring that locals are treated within their area and thus retaining their health expenditure within their own economy. Yet, the economic impact of the health care industry is still under-estimated the world over, Uganda inclusive. Until recently, most studies of economic impact concentrated on the contribution of activities other than health care (Scorsone 2001; Scorsone 2002) and as such, there are few articles available to be reviewed about healthcare. Although healthcare contributes to economic growth, some studies have not found it to be among the leading causes of rural economic growth. In a study of rural USA, presence of healthcare services was not perceived by the respondents to be even one of the top 25 causes of rural economic growth (Aldrich and Kusmin 1997). This study in Lacor was therefore done to try to identify and highlight the economic contribution of St. Mary’s Lacor Hospital to the war-torn Gulu region of northern Uganda, which contribution though quietly perceived, has never been quantified and, as such, appears to have been ignored. By the economic impact of an organisation on an area, we refer to the influence of that organization on the local economy in terms of the level of economic activity generated as a result of the presence of that organisation. This could be the amount of money it injects into the area from its budget, the employment it provides, the goods and services it consumes from the area thus providing a market for them, the money it attracts to the area from the government, donors and researchers, and its role in the attraction and retention of businesses and other gainful economic activity in that area. The net economic impact of such an organisation is, therefore, the expansion or contraction of an area’s economy. This should, however, be distinguished from the gross economic effects due to mere influence on the jobs, businesses or incomes (Weisbrod and Weisbrod 1997). The diagram below shows a model of the interaction between an industry like a healthcare institution producing health care and the community, containing other industries and households. The institution absorbs inputs from outside the local economy and uses some from the local economy to produce its products. Its products are consumed by the local community and beyond. The institution may also make expenditures and investments outside the local economy as shown in this second model. Economic impact studies try to measure the direct, indirect and induced effects of an institution on the economy. The institution’s direct expenditure, such as when a hospital pays its local staff, is a direct input into the local economy. Purchase of goods and contracted services from the local area such as office and medical supplies, kitchen, cleaning and laundry supplies, masonry etc. is an indirect input. When the employees of the health care institution and those of its suppliers of goods and services get and spend their money in the local economy, this is an induced impact on that economy due to the presence of that institution. Thus, initial expenditures in the health sector cause a ripple of expenditures in the economy, the so-called ‘ripple effect’. The health sector and hospitals in particular are regarded by many a policy maker as economic ‘black boxes’, merely absorbing resources with, in most cases, no light on how they spend them or as ‘bottomless black holes’ consuming resources on end. Rarely are they seen as “economic boosters” or ‘productive’ entities. In reality, however, the health sector leads to the creation and thriving of support business and payment of taxes around it (Philippakos et al. 2002). That is not to mention the economic impact that is gained by the local economy when the people are treated and gain energy to produce or the gains due to the cost of illness and death saved by receiving health education on health promotion and prevention of illness or actually being treated or rehabilitated in the hospital. Apart from health care provision at various levels, Lacor hospital makes similar economic contributions to the area of Gulu District.
A Review of Human Resource for Health in Uganda
(Uganda Martyrs University, Department of Health Sciences, 2003-12) Matsiko, Charles Wycliffe; Kiwanuka, Julie
The importance of human resources in health systems needs not to be over-emphasised. Expenditure on health workers forms a significant proportion of total health expenditure in many countries. In order to effectively implement cost-effective interventions, health workers must have the appropriate skills, competencies, training and motivation to do so. However, current evidence (MoH 2001, WHO 2002) suggests that health systems in developing countries are understaffed and exhibit mal-distribution of health workers. Health workers are generally de-motivated and less productive due to inappropriate incentive environment. Demographic, epidemiological, technological, economic and political changes have created huge human resource challenges for such constrained health systems. The situation has been worsened by the spread of the deadly HIV/AIDS pandemic that has had an immense impact on health systems capacity particularly in sub-Saharan Africa. The depletion rate of health workers due to HIV/AIDS related deaths is much higher than the replacement rate, leaving most health systems incapacitated in many ways. Internal and external migration of health workers is a large global challenge that seems to be affecting many developing countries.
Listening to Voices That Matter: Placing Women’s Concerns at the Core of Health Programmes
(Uganda Martyrs University, Department of Health Sciences, 2003-12) Nduhukhire, Owa-Mataze
One of the hallmark achievements in the world today is the increasing recognition that the health of women is central in the development process. Many individuals, governments, non-governmental organizations (NGOs), corporations, policy-makers, and even multinational corporations today talk of increasing women’s access to affordable quality health. They pronounce their commitment to ensuring women’s full participation in decisions, including the development of health policies and programmes, and empowering women to protect and care for themselves. Their commitments extent to maternal and infant mortality, HIV/AIDS and other infectious diseases. Thus, at least at the level of rhetoric, there is a growing consensus that women have claims to social arrangements that protect them from the worst deprivations and abuses. The seeming `re-awakening’ towards women’s interests is against the background of various international concerns that have been expressed in various fora and documents. For example, the International Convention on Economic, Social and Cultural Rights (1966), the Convention on the Elimination of All Forms of Discrimination Against Women (1979), and the African Charter on Human and Peoples’Rights (1981) called for recognition of women’s rights. The 1987 Safe Motherhood Conference in Nairobi, in its “Call to Action”, recognized that: ...the causes of poor health among women and their children are deeply rooted in the adverse social, cultural, political, and economic environment of societies characterized by widespread poverty, lack of educational opportunities, and substandard living conditions, among other factors. They are especially rooted in the environment that societies create for women, who are discriminated against in terms of legal status and access to food and proper nutrition, education, employment, financial resources and health care. This discrimination begins at birth and continues through adolescence and adulthood, where women’s contributions and roles are ignored and undervalued (Isaac S. et. al. 1987) More importantly, since the 1994 Cairo Programme of Action, the 1995 Beijing Platform for Action, the WHO’s Women’s Health and Development Programme (1998), the Commonwealth Plan of Action on Gender and Development (1995), and the International Planned Parenthood Federation’s Charter on Sexual and Reproductive Rights (1999) significant gains have been made in women’s rights, gender equality and reproductive health issuers in most parts of the world. The right of women to live longer and in a less stressful environment and their right of women to survive and enjoy their lives is in the context of enhancing women’s capabilities, that is, expanding their choices and opportunities so that they can lead a life of respect and value. No wonder, the agenda for sustainable human development places women's health and access to resources at the centre. However, the rosy picture stops at pronouncements and much remains to be achieved.
Building Social Capital for Health Information
(Uganda Martyrs University, Department of Health Sciences, 2003-12) Okuonzi Agatre, Sam
The concept of “social capital” has been re-engineered to reflect the level and use of knowledge within society. It includes the extent to which society can create, innovate and use knowledge. This new understanding of social capital is a reconstruction of the World Bank. But the original idea of social capitalism was rooted in the trust of individuals in society. Later, it extended to the trust of the Government and its systems. Social capital was taken to be the trust, solidarity, friendship and good neighbourliness among individuals of a community. It included the social protection networks within a family and in the wider community. A society where individuals reasonably trusted each other, showed solidarity with one another and showed a spirit of good neighbourliness was regarded as community with high social capital. Most societal ideals have these elements of social capital.
International Trade and Health: Before and After CANCUN
(Uganda Martyrs University, Department of Health Sciences, 2003-12) Murru, Maurizio
International trade is potentially critical in stimulating increased production, economic growth and poverty reduction. For this potential to be achieved, transparent and equitable international rules are necessary together with national policies clearly oriented towards social objectives and resource redistribution. Economic globalization, so far, seems to have produced more inequalities both between and within nations. The Poverty, as it is currently structured and ruled, is a tool in the hands of powerful nations used to perpetuate their dominance on international trade. It should, rather, be a forum where inequities and inequalities are corrected to the benefit of millions of people struggling with abject poverty around the world. The recently collapsed WTO Conference held in Cancun Mexico, offers an opportunity for some few considerations on the present state of world trade, its uncertain future and the possible implications of this for the livelihoods of the world poor.
Selective Salary Reward for Health Workers: Realistic or a Distortion?
(Uganda Martyrs University, Department of Health Sciences, 2003-12) Kanyesigye, Edward K.
Uganda’s civil service is perhaps one of those with some of the lowest salaries in the world. This has remained the case in spite of improvements in the pay package over the last decade. Staff working in the delivery of health services (here referred to as Medical Workers) are not spared. In fact, because of their peculiar working conditions, the Medical Workers have been among the most discontented civil servants since Uganda entered the era of misrule and mismanagement of the early 1970s. In 1995, the Uganda Medical Workers’ Union (UMWU) called for and eventually instituted a sit-down, non-violent strike as a method of pressing for better working conditions. The initial reaction from the administration of the Ministry of Health was hostile. There was a blanket condemnation of the strikers who were singled out as individual “antipeople, unethical hooligans”. The executive members of UMWU were picked and locked up, and had to report to the police station every week and later monthly for over a period of year. However, after the dissolution of this strike, Government decided to award an extra pay increase to Medical Workers alone. Since this was in the middle of a budget year, which had seen salary increase in the whole service, it was decided that Medical workers alone receive a monthly lunch allowance. This had an effect of giving them a differential pay rise without having to appear so open and this incited workers in other sectors of the service. Initially, lunch allowances of Ug. Shs. 66,000 for all established Medical Workers and Ug. Shs. 44,000 for support staff were introduced with effect from 1st July 1996. The administrative staff and other common cadres in the health sector did complain and eventually the lunch allowance was extended to them as well. This seemed to quench the fire and although the Medical Workers continued to press for increase in salary, there was no real crisis until 7th July 2003 when the Circular Standing Instruction No.2 of 2003 (CSI. 2) was issued.
Health Workers Demand for Better Pay
(Uganda Martyrs University, Department of Health Sciences, 2003-12) Mungherera, Margaret
hough the recent health reforms which include decentralisation of health services and creation of ‘minihospitals’ at every sub-county indicate that Government is committed to improving the state of health services in this country, not much has been done to retain and motivate staff. For the past 30 years, health workers working in the Public Service have suffered from poor remuneration with subsequent massive brain drain to South Africa, U.S.A, Canada, U.K and Saudi Arabia and various other places. The few who have chosen to stay, have either abandoned the Public Sector entirely, and have either joined U.N agencies, faith-based NGOs, or have opted for full time private practice. The majority of those who continue to work for Government are forced to supplement their meagre salaries through ‘moonlighting’(dual employment) in private clinics. The result has been a grossly understaffed health service with overworked and demoralised health workers, often showing negative attitudes to their patients and their work. Following the strikes of the 1990s, Government set up a Commission of Inquiry to look into the grievances of health workers. The Commission comprised of representatives of the Ministries of Health and Public Service, Uganda Medical Association and the Uganda Medical Workers Union. In addition to low salaries, health workers complained about gross delays in appointments, confirmations and promotions. Other concerns were related to lack of accommodation, transport and protective gear. Recommendations of the Commission included establishment of a constitutional body comprising of experienced health professionals whose main task would be address the delayed appointments, confirmations and promotions. The Health Service Commission has done a commendable job in this regard and in developing recruitment guidelines for the districts. Indeed, its continued existence as an autonomous body will be vital in ensuring a quality Health Service. Another recommendation of the Commission was to evaluate and appropriately grade jobs in the Health Service with the aim of improving the remuneration of health workers hence the Job Evaluation Exercise whose report was eventually completed and passed by Cabinet in 2000.

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