Pay or Die: The Urgent Care Dilemma in Uganda

A new health sector performance report shows the deaths came amid falling ambulance use and gaps in care. The new performance report released on October 23 indicates that Karamoja and Ankole have the highest proportion of emergency patients evacuated by ambulance at over 17 percent, while South-Buganda and Kampala have a very low utilization of four percent. indicating disparities.

The report, in addition to showing the disparities, also reveals that the use of ambulances in the country has fallen by around five percentage points in five years. This raises questions about the effectiveness of the government’s emergency medical services.

The report shows that there were 38,996 deaths among patients treated in emergency units across the country in the 2023/2024 financial year.

“The national average ambulance utilization was 7.5 percent. Karamoja had the highest proportion of patients evacuated by ambulance at 18.9%, followed by Ankole (17.3%), Bugisu (14.7%) and West Nile (13.4%). On the other hand, South-Central reported the lowest use of ambulance services at 3.9 percent,” the report said.

“The decline in the number of emergency patients arriving at health facilities by ambulance over the past five years highlights gaps in reporting from various departments within health facilities and resource constraints such as fuel and limited staff,” the report said.

The authors of the ministry report recommended that addressing these gaps requires “better collaboration between programs, standardized reporting, staff training and improved monitoring to accurately capture the use of ambulance services and improve the delivery of emergency care”. However, health facilities in the Lango sub-region had the highest number of deaths in their emergency units at 40% of patients, signaling gaps in care. Lango had an ambulance evacuation rate of six percent which was better than Buganda South, Kampala and four other sub-regions.

“We need to investigate this. It may be a reporting problem because 40 percent is high,” said Dr. John Baptist Waniaye, the Commissioner for Emergency Medical Services at the Ministry of Health.

Ankole, in terms of deaths in emergency units, followed Lango with 19.7 per cent, while Tooro was 16 per cent, South-Central 11 per cent and West Nile, Acholi and Kigezi had the lower death rates in about four percent of patients.

The variations here seem to indicate that although access to an ambulance contributes to a good medical outcome, access to an ambulance may not be a guarantee that someone will receive quality emergency care when they arrive at the hospital.

Dr Waniaye added that he was still trying to understand the exact reason behind the variations in the use of ambulances in the sub-regions.

He, however, believes that variations between sub-regions could result from differences in population density, responsiveness of health workers, donor support, willingness of communities to use ambulances and reporting by health facilities.

“South-Buganda has more ambulances but it is densely populated. In a densely populated community, the number of emergencies is higher than in a sparsely populated community,” he explained.

“So a lot of people in densely populated communities may not be able to get services, but we’re going to question that so we can see why South-Central, which has had more investment in emergency medical services, reports one less answer,” he added.

Dr. Waniaye also said because of the insecurity in Karamoja, the likelihood of the community calling an ambulance is higher than in areas with less insecurity. But this argument may not support the good performance of Ankole, which has few insecurity problems compared to Karamoja.

“In Karamoja, health workers seem to be more responsive to the community compared to other places. But overall, if reporting (of ambulance use by health facilities) increases across the board, we’ll see a different picture,” he argues.

“But we have some regions that get additional support from development partners, so you see performance differences,” he adds.

Dr. Waniaye also disclosed that they are facing inadequacies in funding.

“This is a very big problem. We need about Shs17 billion for our operations – in terms of fuel, repairs and other things for the ambulances,” he said.

“But now, we are running at an average of Shs5 billion – that is 25 per cent of our needs are covered and that leaves a big gap,” he added.

Areas of leadership in emergency situations

The performance report shows that Kampala reported the highest number of emergency cases, followed by South-Central, Acholi, Busoga and West Nile. In contrast, Teso reported the lowest number of emergency cases during the 2023/2024 financial year.

“On average, 54.8 percent of all emergency cases received care at the scene of the emergency and only 7.4 percent reached health facilities using ambulance services. Of these, 80.8 percent accessed care within one hour of arrival at EDs, with a 10.2 percent mortality rate recorded in EDs,” the report said.

The country, according to information from the ministry, has 276 ambulances in the national ambulance service. These are the ones certified as standard ambulances. This falls short of the ministry’s need for at least 460 standard ambulances to reduce preventable deaths from emergencies.

Standard ambulances available are also below the minimum requirement of at least one ambulance per constituency, each averaging 120,000 people. There are 353 constituencies in the country, according to the Electoral Commission. But Dr Waniaye says there are other ambulances, which help the communities, but “they are not standard and there are around 178”.

During emergencies, people use a wide range of means including ambulances, private vehicles, bicycles, boda bodas, taxis and foot. Some patients, especially accident victims, are brought to the hospital in police vans.

This practice has been challenged by doctors at Mulago Hospital, who say some patients arrive with multiple wounds and are at risk of exposure to HIV because of the sharp edges in the cubicles and the crowding of patients.

Amid the limited number of standard ambulances in the country and limited funding for operations, some health workers and drivers are taking advantage of patients.

In a recent study report by researchers at Johns Hopkins University and Makerere University, titled “Dying from Poverty and Lack of Easy Transportation,” patients are sometimes asked to make upfront payments for transportation and care.

“While some ambulance services were apparently free, in most cases patients or their relatives had to pay for transport, with costs ranging from Shs 500,000 to Shs 750,000, which is about US$135-202,” the pre-printed report said published in 2019 by Research Square.

Some ambulance drivers were also found using the vehicles to transport food and do personal work instead of transporting patients in need.

Mr. Dunstan Kasango told this publication that he lost his sister, Mrs. Angel Nakasango, who died on June 18, 2021 at a major hospital after she failed to receive emergency care because the family could not raise the payment in advance of 2 lei for the treatment. .

The researchers say that the distance to the health facility, the condition of the patient and the type of vehicle dictated the cost of transportation. There are three types of ambulances – A, B and C.

A-type ambulances are basically a patient carrier without medical equipment, and B-type ambulances are equipped with various medical equipment, such as diagnostic equipment, cardiopulmonary support equipment, monitors, suction machines and so on. Type C ambulances are intensive care ambulances that have advanced life support equipment.

“All over the country we need 460 ambulances. We will phase out the A-type ambulances. The plan is for every 100,000 people to have a B-type ambulance and every two million people to have a C-type ambulance,” reveals Dr Waniaye.

The report by the two universities says that even after arriving at a health facility, there can be delays in receiving treatment.

“Some of the reasons for this delay are related to poor communication, limited human resources or lack of medical materials. Hospital emergency staff will continue triage and treatment on ambulance trolleys due to an insufficient number of hospital beds. Sometimes ambulances inform private hospitals about the transfer of patients,” the report said.

Private hospitals, charge somewhere between Shs 2 and 5 per day to manage a critically ill patient in the ICU, starting with an initial advance of Shs 10. Failure to increase the advance may mean the patient will not have access to care and thus die.