When on 20 May 2019 the Ugandan Cabinet approved the phased creation of 15 cities across the country, I was excited by the possibility that existing hospitals in those new cities would be transformed tremendously to bring them up to city standards. My optimism that I would see new “Mulago hospitals” in the newly created cities was high (Mulago is Uganda’s main national referral hospital founded in 1913). And yet, to the present day, I am left puzzling about when the regional referral hospitals in the baby cities will be elevated to national referral hospital level.
Uganda’s health facilities are classified into seven levels based on the services they offer and the operational area they are intended to serve. The lowest level is Health Centre level one (HC I), rising through levels two and three to Health Centre Level four (HC IV); Above that are General hospital, Regional Referral hospital and National Referral hospital respectively. The country is blessed with 139 general hospitals and 14 Regional Referral Hospitals. The 05 National Referral Hospitals are Mulago National Referral Hospital, Butabika National Referral Hospital, China-Uganda Friendship Hospital, Kawempe National Referral Hospital and Kiruddu National Referral Hospital. All five are situated in Kampala and within central region.
Even though northern Uganda is indisputably peaceful, a significant number of victims and survivors of the Lord’s Resistance Army (LRA) rebellion, as well as many of the refugees Uganda generously hosts, are still far from healing after decades of war. Many nurse different forms of conflict-induced physical and psychological harms that require critical rehabilitation services that go beyond the scope of generic services. For them, accessing national referral hospitals in Kampala has for decades been challenging. While suffering from ailments that cannot be addressed at the level of health centers and regional referral hospitals, the costs of accessing national referral hospitals remain extremely high for many people across Uganda in terms of transportation, feeding and medical bills. Additionally, these costs are a huge barrier to social support visitation from informal support networks such as family members, relatives, neighbors and friends that often contribute to emotional, psychological and medical recovery of patients.
While the two best known national referral hospitals in Uganda, namely Mulago and Butabika, have done wonders in providing much needed quality health care and treatment service in Uganda, the need to extend such capacity across the country is therefore great. The elevation of seven (7) municipalities into cities in July 2020 by the Parliament could offer a roadmap for strategic health service transformation and popular access to specialized services. If national referral hospitals could be unveiled in the new cities, it would decentralize specialized medical services and help in leveraging the existing national referral hospitals that are currently overwhelmed by patient numbers, in the process enabling sustainable healing and better health services in Uganda.
In addition to building the capacity to respond to the harms of the past, upgrading regional hospitals to National Referral Hospital status should also be done with an eye to Uganda’s hoped for future; just as in other developed and developing countries worldwide, urbanization and the emergence of cities is usually accompanied by a rise in industrialization. In the case of northern Uganda, the government and citizens should prepare to respond to any health hazards related to such development. Having specialized health services will help in offering preventive and therapeutic support to vulnerabilities and ailments that might emanate from exposure to pollutants and waste toxins, as well as industrial and road accidents.
Benchmarking capabilities: whether the new cities are capable of transitioning the regional referral hospitals to national referral facilities.
When a victim of the Lord’s Resistance Army (LRA) war recently asked me why she could not be treated for her problems in Gulu, I felt disempowered and stammered in my efforts to respond to her. Although she was being medically supported by the Refugee Law Project (RLP) through St Mary’s Hospital Lacor, doctors there had referred her to Mulago Hospital because they could not extract splinters that she had retained under her scull for twenty years and that had been causing her constant headache and nose bleeds. “Why”, she asked me, “do the doctors from Gulu have to refer me [to Kampala], yet I heard that some conjoined twins were separated from Soroti Regional Referral Hospital in April 2021?” In her quest for healing she had witnessed a number of surgeons support and bring about recovery in people whose cases she believed were more complicated than her own. She therefore assumes that they are also capable of helping her and is frustrated when they say they cannot.
When elevated and fully supported, the existing regional referral hospitals in the newly created cities can do wonders, as exhibited in the case of successful complex surgery performed at the former conflict-affected Soroti city (formerly district). It attracted nationwide acknowledgement and hope for more specialized surgical successes. Interestingly, the office of the former Speaker of the Ugandan Parliament (Honorable Rebecca Kadaga) invited the Senior Surgeon from Soroti Regional Referral Hospital, Dr Joseph Epodoi and his team, for heroic recognition by the Parliament after they successfully separated conjoined twins in April 2021. I suggest that such acknowledgement should be followed by elevation of the hospital’s status, as well as that of other regional referral hospitals in northern Uganda, as a contribution towards rehabilitating the general conflict-affected communities across the regions.
The above victorious surgery was performed in the case of conjoined twins delivered through caesarian section from Amuria Health Center IV to a senior three student who became pregnant during the Covid-19 induced lock-down. It triggered optimism that similar miracles could still happen to war victims with long-standing surgical dilemmas, as well as other citizens with urgent surgical needs, particularly if the government can vertically transform the hospitals in the new cities. Despite the scientific explanation that conjoined twins occur when the hormones responsible for separating the twins are faulty, the case reminded me about ordeals from Obalanga massacre survivors during a memory dialogue in 2019 where they said they are anticipating seeing more complex impacts of the war such as birth deformities due to the chemical effects of combat explosives and bombing.
Similarly, since 2013 to present (2021), Refugee Law Project (RLP) has been involved in screening and supporting surgical treatment and rehabilitation of war victims with serious profound war harms at Lacor hospital. A number of critical surgical cases have been referred to Mulago National Referral Hospital, particularly cases involving hip replacement, bullets/splinters stuck in between bones, near the heart or brain and other delicate organs/body parts. Lacor have been working closely with Gulu Regional Referral hospitals by making cross referrals.
The recent establishment Gulu, Arua and Lira as cities is a huge blessing for post-conflict northern Uganda. I view it as a golden opportunity to be tapped and fronted to steer sustainable rehabilitation services for war victims grappling with disturbing unaddressed wartime injuries that require specialized services that are currently far from reach. Post-conflict communities struggle with unique vulnerabilities and multiple health challenges to the point where some have almost turned health centers and general hospitals into their homes due to the frequency of their visits. Unaddressed medical war ailments in the north have contributed vehemently to daunting disability and poor health, as well as bitterness among victims and survivors struggling to reintegrate and rebuild life amidst the ruins created by war. Having specialized national referral hospitals in post-conflict communities would revive hope among the many wartime victims of injustices who have lost faith that they will ever access specialized medical, surgical and mental health services they need.
Due to lack of national referral hospital in post-conflict communities in greater northern Uganda, some NGOs and mass media have been stretching their helping hands and playing a pivotal role in advocating for financial support towards transportation, feeding and treatment of vulnerable critically ill patients for specialized health services in Kampala and abroad. Decentralizing multiple specialized health services from the capital to newly created cities will reduce burdens on well-wishers and Samaritans’ purses.
Stakeholders should remember that good health is indispensable and critical for productive participation of citizens in national development and peace building. Further, good health boosts individual, household and national levels of income, which in turn can help in reducing income inequality and increase the governmental tax base of productive, healthy citizens. The government should prioritize health sector reforms and consolidate institutional reforms to elevate and equip health facilities, and to craft alliances for appropriate health financing to accelerate Uganda’s progress towards better health indices. The journey is demanding and the struggles should embrace public support and stakeholders’ participation as well as good political will.
The right to health is fundamental and my dream of seeing many needy Ugandans accessing quality health services from national referral hospitals by foot, boda-boda, bicycle or simple taxi services is still alive.
By Okot Benard Kasozi, Senior Psychosocial Research and Advocacy Officer
Conflict, Transitional Justice & Governance Programme, Refugee Law Project, Gulu Office
Refugee Law Project (RLP)
Gulu Field Office
A brief version of this blog was published as an opinion piece in The Monitor, 11 September 2021