One of the most challenging aspects of medical care at government hospitals here in Uganda is the fee structure. Several years ago, Uganda instituted universal health coverage for its population. This ambitious program allowed for free care at all the nation’s public hospitals. Patients in Uganda can go to a district hospital or a referral center and they won’t have to pay any doctor’s fees and won’t receive a bill from the hospital. That is the good news. The bad news is that families still have to pay out-of-pocket for any services the hospital is unable to provide or for any items the hospital has run out of. The public hospital system has a very small budget, and therefore the list of things that families have to pay for out-of-pocket is very long.
Let me tell you what this looks like for an average patient. A Ugandan is injured in a road traffic incident. He was riding his Boda Boda (small motorcycle) with no helmet on poorly maintained roads in heavy traffic when he was hit by a car that didn’t see him amongst the hundreds of other Boda drivers. He is then brought to the emergency ward by a “good Samaritan” because there is no ambulance service.
He is evaluated in the emergency ward by an intern. He is diagnosed with a head injury and a broken leg but little care can be provided until his “attendant” (family member) shows up. The attendant then has to pay for his head CT because the scanner at this hospital has been broken for a year. They also pay for the chest X-Ray because even the plain film machine is not functional. This requires the family member to take the patient out of the hospital to a private imaging center, get the scans/X-rays and return with the patient to the hospital. His broken leg needs a splint, but all we have are cardboard boxes. So, the doctor cuts up the boxes to make a splint. But first the family must go and buy bandages to complete the splint. He has several injuries and needs some basic lab work. Blood is drawn in the emergency ward and the attendant takes the blood and pays a private lab to run the tests. He then needs some pain medication but we are out of that also. The attendant then returns to the pharmacy and buys that as well. Finally, the patient is stabilized and admitted to the surgical ward. Once they are admitted the family member must feed the patient, walk the patient, wash the patient and often help with the dressing changes.
All of these charges must be paid up-front before any care can be rendered. Most Ugandans are very poor and have no savings. This means the average Ugandan in a car accident will need a family member to go borrow money or sell some possessions before they can go to the imaging center or the pharmacy. The family members will have to leave work and come to the hospital daily (or live on the hospital grounds) for the duration of their loved one’s hospital stay.
The staff works very hard to care for patients but there are not enough staff members, not enough materials with which to care for the patients and not enough space in which to treat them. It is a challenging system to be a provider and a difficult place to be a patient.
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