Subscribe to our weekly International update on Health Policies

One thousand interns’ march and the genesis of Uganda’s human resources for health paradox

By Agnes Nanyonjo
on September 9, 2016

In Uganda, a compulsory one-year internship placement at the end of five long years of medical school is long awaited. The internship placement at a hospital offers recent medical graduates an opportunity to practice the skills acquired over the five years education under supervision of a senior doctor. This compulsory placement is to groom the newly qualified doctors for licensure as independent doctors by the Uganda Medical and Dental Practitioners Association. For many of these freshly qualified doctors who are also new to the job market, the internship period means having their first-ever pay check. During this stressful internship period, the young doctors undertake compulsory rotations through the various major medical disciplines including medicine, paediatrics, (obstetrics and gynaecology) and general surgery and several other medical sub-specialities.

In Uganda, most clinics and wards are overcrowded and intern doctors are often the first medical professionals a patient will come in contact with. In many cases they are the only doctors patients will ever see when visiting a hospital. The often overworked young doctors, functioning under poor working conditions, prevalent in most health care facilities in Uganda find (some) solace in knowing that they will receive a pay check for their hard work. However, the notion that hard work pays might not hold any water for several of the new interns whose first-ever pay-check dream might remain just that – a dream – due to a recent exploitative and short-sighted policy suggested by the government.

The short-sighted policy and its genesis

Social unrest in the health sector is not new in Uganda. Over the last 10 years, Uganda has witnessed more than seven strikes by medical professionals, mostly by intern and postgraduate doctors. The strikes have been attributed to poor or delayed pay as well as poor working conditions. In 2005, a strike by postgraduate doctors who were later joined by consultants left the main national referral hospital paralyzed and able to only handle emergency cases.

An intern strike preceding the current strike happened in May this year, and was led by the batch of interns scheduled to complete their internship in August 2016. The sit-down strike was to protest against cumulative unpaid allowances which the government attributed to bureaucracy.

The wave of strikes over the past decade made the government realize that Uganda’s health system was threatened. After 2006, the government strategically expedited the opening of three more publicly funded medical schools. At the same time, a number of private medical schools popped up which were registered by the government. Ten years have elapsed since and we now have a cohort of one thousand brand new medical students who are expected to start their internship. The government does not feel equipped to pay these interns, saying there is simply no money to pay such a large number of interns.

Word has it that the government is only prepared to pay previously government sponsored students at the universities leaving masses of privately sponsored students without income during their internship.  The rationale behind this new, exploitative policy is that if the students were government sponsored, then it is the responsibility of the government to continue to financially support their internship. This “implies” that for the once privately sponsored students, it is the obligation of their sponsors to continue sponsoring them. Well, at least according to the government.

Secondly the government wants to pre-empt potential health worker migration by taking a conservative approach of binding government sponsored medical students to a government health facility for two years. For those government sponsored interns who were thinking of fleeing Uganda for greener pastures immediately after receiving their medical license, the government’s message is clear – they should not even think about it until their two-year “shift” is complete .

It was in defiance of this proposed, discriminatory and binding policy that a group of one thousand brand new intern doctors held coordinated marches on the 31st of August this year, marching on the streets of Kampala, Mbarara and Gulu. The doctors will not agree to start their internship unless the policy is reversed.

Does Uganda really have many doctors?

Uganda has a doctor patient ratio of 1: 24,000 which is a far cry from the WHO recommended ratio of 1:1000. Despite the severe shortage of doctors in Uganda, the ministry of foreign affairs surprised the whole world in 2015 when it came up with a plan to export doctors to Trinidad and Tobago. The scheme was envisaged as a pathway to strengthen diplomatic ties between the two countries. Other arguments for the plan included giving doctors an opportunity to improve their technical skills, earn more money – pretty much like a government-funded opportunity for medical professionals to move, medics who were destined to move out in any case. Stunning plan, in short. The ministry of health was quick to distance itself from having played any role in this dubious “export” plan. The plan to “export” doctors and other health workers greatly angered Ugandans and attracted heavy criticism from outside leading to government litigation. It was quickly abandoned. The recent turn of events points to the fact that Uganda does not have an excess of doctors, but limited fiscal space for the health sector.  But fiscal space for health is never carved in stone.

The current state of affairs

For the moment though, medical graduates and current interns, unhappy about the proposed policies are not about to give up their (more than justified) demand for fair pay and freedom of movement after completion of their internship. They are aggrieved by the fact that money is available for other sectors in Uganda and that health is not a priority – a situation not unfamiliar in other developing countries either! They are particularly dismayed by the fact that Uganda can spend at the same time an exorbitant two billion shillings (US$ 590,754) on legislators attending a three-day Uganda convention in America.

In a meeting between the government, intern representatives and representatives from the Uganda Medical Association (of which I am a member), the government argued that the current budget is not able to accommodate the influx of interns.  The minister of health has recently informed the parliament that medical interns will take a screening exam and only those government-sponsored interns who pass with flying colours will qualify for the internship placement, and therefore salary. However negotiations are still ongoing to find an amicable solution.

The government also argues that the two-year bond for the government-sponsored students’ policy is not yet fixed. The medical representatives have suggested that the allowances for government-sponsored interns could be reduced from 600,000 UGX (US$177) to 350,000 UGX (US$103), a reduction aimed at redistribution of the available budget in a fair way amongst all the interns regardless of who  funded their medical education. Even with this improvised budgetary redistribution, the Ministry of Finance would need to release an additional 3.4bn UGX (US$1,004,283) in order to be able to pay all the interns. If the cuts occur, it will in fact be the second time intern allowances have been trimmed this year – allowances were already slashed from US$257 to US$177 earlier this year. This ever increasing slashing of internship allowances by the Ugandan government – in some sort of B rated slasher movie – is in itself likely to escalate the ongoing strike and spark future resistance.

The way forward

There is no question that the health system in Uganda at the moment cannot function properly without interns although some ministry of health officials unrealistically deny this fact.  It is critical for Uganda to increase its financing of the health sector as recommended by the African Union (see the ‘Africa Scorecard on Domestic Financing for Health’). This isn’t as easy as it sounds, particularly with the dwindling donor funds even though the Ugandan government proudly claims it can survive without donor funds. But in essence, the limited fiscal space for the health sector (which includes the wage bill ceilings) in Uganda is a ‘political’ decision and the result of a (never ending) ideological battle on resource distribution and allocation. To put it bluntly, it is a consequence of a (rather awful) political ideology and vested interests that prioritise other sectors over health and that should be challenged. Uganda should learn from  nearby countries like Ethiopia that have already demonstrated that such disastrous ideology can be shed, which can in turn lead to significant improvements in the health workforce – and I’m saying this fully aware of the fact that the Ethiopian government is not without its flaws either.

Expansion of the fiscal space for the health sector will not only require proper taxation systems, but also curbing of corruption in all its forms and prioritization of the health sector. This might mean redistribution of finances from sectors like defence, which is over financed in many countries, to the health sector. After all, the inequities that arise from poor provision of health services to the poor can trigger security threats too and can therefore be seen as “defence” issues as well (for the “iron men” among you). It might also mean cutting down on the exorbitant expenditures that Ugandan tax payers have to incur due to an unnecessarily large parliament.  Anyhow, the government cannot continue to underestimate grievances in the health workforce as it is increasingly recognized that the impact of a productive health work force goes far beyond health outcomes – HRH is not only a cost, but it also contributes to economic growth and wellbeing.   As you might know, the UN High-Level Commission on Health Employment and Economic Growth will present its report on 20 September, in New York, along these lines.

The inability of the Ugandan government to plan appropriately for interns despite the vital role they play in the health system, together with downright silly plans like the exportation of (the already scarce) specialists overseas remains a paradox and points to a national priority setting exercise gone badly wrong. Nonetheless, it is my sincere hope that the supplementary budget of 3.4bn UGX will be found in this fiscal year and interns will be budgeted for in the years to come because no intern deserves to work in poor conditions without remuneration. Regarding implementation of the two-year bond, it is my sincere hope that this will be implemented only if there is an absolute respect for people’s right to free movement.