Health Systems and Policy Research

Keywords

UK’s healthcare; Health workers; Public health

Introduction

The United Kingdom’s health system is described as one of the most efficient health systems in the world, while Uganda’s health system is often referred to as one of the worst healthcare systems on record, for example, by The Guardian [1]. In the United Kingdom, Universal Healthcare is provided to all citizens and permanent residents by the National Health Service (NHS)-a population of approximately 58 million people. Public health systems matters have been vital in health system reforms across the globe. Service delivery and health workforce are the building blocks of a health system, and are two of the six contributors to a health system, as set by the World Health Organization (WHO). An adequate health service delivery is one that is effective and safe, with well-trained health and non-health personnel. It should be equipped to deliver interventions to that in need when and wherever they may be, with minimum waste. A wellperforming health workforce consists of sufficient staff that is fairly distributed and is competent and productive. This paper critically reflects on and assesses the service delivery and health workforce of Uganda in comparison to the service delivery and health workforce of the United Kingdom.

Materials and Methods

The quality of the respective country ’ s service delivery is determined using the five core indicators set by the WHO. Service quality assessed by analyzing the distribution of health facilities per 10,000 people, the number and distribution of inpatient beds per 10,000 people, and the annual number of outpatient department visits per 10,000 people. The general service-readiness score of its facilities is compared. It is examining and analyzing the proportion of health facilities that offer specific health services, as well as the number and distribution of health facilities that provide these particular services per 10,000 people—service-specific readiness score for health facilities and general service quality. For the health workforce, the sources of information for the health workforce in the country is assessed, and the WHO’s three core indicators to analyze and compare the country’s health workforce. The first core indicator is the number of health workers per 10,000 people. The second is the distribution of health workers by occupation-specific specialization, region, and sex. The last is the annual number of graduates at education institutions, as well as level and field of education.

Data collected from the UK health review, The UK ’ s Department of Health, Organization for Economic Cooperation and Development (OECD), United States Agency for International Development, The World Bank, The Ugandan Ministry of Health, in collaboration with the World Health Organization, The Ugandan consensus survey and Service availability Survey, Health Workforce. In terms of Health Workforce: data were collected from service availability mapping from The Republic of Uganda Ministry of Health, in collaboration with the World Health Organization [2] and the NHS [3], The UK’s Department of Health and the Royal College, for the UK. For the general service readiness and availability scores for both the UK and Uganda, looked at the findings of Service Availability and Readiness Assessment (SARA) censuses, which were collected by questionnaires. In terms of representation, data collected NHS Digital [2], Ugandan Ministry of Health, Ugandan Health review [4] and UK Health Review [5]. For Service Delivery Assessment, assessed the availability of some specific services and the presence of items, as well as the systems and practices for ensuring the safety of patients and staff while delivering quality health services. The service-specific availability of Anti- Retroviral Therapy (ARV), the Prevention of Mother to Child Transmission (PMTCT) of HIV/AIDS, and the Voluntary Counseling and Testing (VCT) of HIV/AIDS, as the data for these, were readily available for Uganda. Health Workforce data from UK ’ s statistics and facts and the Ugandan Health review, in conjunction with data from the World Bank [6].

Results

In the UK, 9.7% of the Gross Domestic Product (GDP) is spent on health. Although healthcare in Uganda is also provided by the government, it is highly drained and underfunded, thus explaining the rise of private healthcare and healthcare from international Non-Governmental Organizations (NGOs). Uganda spends 8.4% of its GDP on health. Uganda has 1708 governmental hospitals, 554 NGO-led hospitals, and 280 private hospitals [2]. In the UK, 448 hospitals are consisting of specialists, non-specialists, community providers, and mental health practitioners. Although this number seems bleak, these facilities are far more superior when compared to those in Uganda, specifically in terms of infrastructure, staffing, and equipment. The waiting period in these hospitals is only a fraction of the waiting period in Uganda for similar care. When it comes to the number and distribution of beds, Uganda has 6164 total beds across the country, while 2309363 temporary beds are required for outpatients, and 382784 inpatients require admission to facilities. According to data collected from 45 general hospitals across the country. Most of these beds are in the provinces located in the southwestern regions of Uganda; facilities decrease in the central and northern areas. Generally associated with political unrest in those regions.

There are only 395 inpatient beds in the UK per 100,000 people, and the number of beds is decreasing throughout Europe. Due to improvements in home care for those in need, as well as advances in Aged Care in the UK. Patients are not required to stay in hospital facilities to access quality care (Service Availability Mapping, 2013). With regards to servicesspecific availability, there were 20 million inpatient and daycare admissions funded by the NHS alone in the UK (UK Health Review, 2009/2010). There were 7.5 contacts per person per year, which equals to an average of 2.2-12.1 per person in the UK.

There are no significant zone differences in service delivery in the UK. It is virtually nonexistent, due to the availability and affordability of access to efficient public transport systems. In Uganda, however, zonal differences are relatively significant, as people have to travel far for healthcare, particularly in the northern regions of the country. Zonal differences in the numbers of outpatient care were considered moderate in Uganda because of the lack of neonatal referral hospital data. The consensus survey was also not conducted in 17 major primary care hospitals in the Ugandan 2013 health review survey.

The Service Delivery Assessment of Uganda more accurate, representative, and comparable with the UK health service delivery, as these data sets were available for both countries in the same year. In the UK, every hospital, clinic, and institution offered PMTCT, VCT is available everywhere, and pre-and post- HIV/AIDS testing is encouraged. There are also specialized HIV service providers that provide treatment adherence, peer support, self-management and care support services to HIVpositive individuals, mental health community services for rehabilitation, and personal care or housing to HIV-positive individuals. End of life care to those patients that are terminally ill due to the co-morbidities of HIV/AIDS provided across the UK. There are also self-referral-based HIV centers and specialized pediatric HIV services for patients under the age of 18. In Uganda, on the other hand, less than half of all the districts surveyed had facilities that provide PMTCT. 70% of the areas had 2 or more counseling and HIV testing facilities. For health facilities surveyed across Uganda, there were 53 PMTCT, 23 VCT, and 80 ARV with no facilities. 22 PMTCT, 16 VCT, and 18 ARV facilities had just one facility, and only 23 PMTCT, 61 VCT, and 2 ARV facilities had more than two facilities. This trend relatively equally distributed across Uganda.

There are 132,662 doctors working in the NHS, which represents 9.6% of staff, 17,451 qualified ambulance staff (1.2% of staff), 408 16 qualified nurses (29.81% of staff), 142,588 scientific, therapeutic, and technical staff (10.4% of staff), 355 07 support and clinical (25.9% of staff), 58,572 support general practitioners (4.3% of staff), 219,064 NHS infrastructure (16% primary healthcare providers), and 353 other (0.02% of staff) for the 66 million UK population. In Uganda, meanwhile, there are less than 5000 doctors, 28 senior consultants (1.3% of hospital staff), 50 medical specialty medical officers (2.4% of hospital staff), 44 medical officers (2.1% of staff), 74 senior health officers (3.6% of staff), 100 intern doctors (4.8% of staff), 1030 nurses and midwives (49.6% of staff), 517 allied health professionals (24.9% of staff), and 201 staff not on payroll (9.7%).

Women account for three-quarters of the UK’s healthcare and are still the minority in senior roles. Women in the NHS hold only 37% of senior positions. Women account for 51% of psychiatry and 53% of clinical oncology, while surgery continues to be predominantly male, with only 27% being women. In Uganda, men occupy 77% of senior management, 63% of middle management in Uganda ’ s health workforce. Nursing and midwifery are almost entirely dominated by women, while men dominate clinical services such as medicine [6-8].

Both Uganda and the UK have shortages in the health workforce. The annual number of graduates of health professionals in both the UK and Uganda are significantly under producing the number of healthcare professionals needed to fill the required positions. In Uganda, 27% of healthcare positions not filled. Educational institutions are not equipped to produce the required healthcare professionals. Uganda also battles with the “brain drain” of doctors and specialists.

Discussion

According to data collected from 45 general hospitals across the country; most of these beds are in the provinces located in the southwestern regions of Uganda; facilities decrease in the central and northern areas. They are generally associated with political unrest in those regions. While people in the UK use health facilities multiple times per person per year, Uganda struggles to provide necessary and much-needed care to its people. According to Uganda ’ s Service Availability Mapping Review, there were nearly 6.9 million outpatient visits in government and NGO hospitals per month, representing a utilization rate of about 2000 stays per 10,000 people, or 0.2 visits per person per year. One-third of those visits were pediatric. Hospital visits are not routine among Ugandans, and healthcare is sought out only in adverse conditions.

In both countries, the majority of hospital staff consists of nurses, almost a quarter of staff (24.9%) in Uganda allied health professionals with no formal training to deal with serious medical issues, and a board of healthcare does not regulate nearly 10 percent of staff .

Women account for three-quarters of the UK’s healthcare and are still the minority in senior roles. Data demonstrates that in Uganda, men occupy 77% of senior management, 63% of middle management in Uganda ’ s health workforce. Nursing and midwifery are almost entirely dominated by women, while men dominate clinical services such as medicine. Although the UK health system is far superior to that of Uganda in terms of equipment, infrastructure, and access, gender disparities are almost identical [9].

Although data availability is abundant for the UK, data was used from 2013, as there was insufficient data available for Uganda, and the most data recorded in the year 2013. Thus data from The Republic of Uganda Ministry of Health in collaboration with the World Health Organization [2] and the NHS for the UK [3] for the data more accurately compared [10]. From the statistics mentioned above, although health workforce staff is scarce in both countries, Uganda fills posts with low-ranking hospital staff, and only one percent of the staff represents medical doctors in hospitals. Adequate service delivery not achieved without adequately-trained health workforce in hospitals. Contrary to the UK, patients in Uganda only come to hospitals in times of sickness, and they hardly go to public hospitals and NGOs for regular checkups, resulting in a dire need for staffing of the health workforce in Uganda.

The UK has similar concerns in terms of producing healthcare professionals. The UK has set up policies to create 2000 more General Practitioners by the year 2020, and the Health Secretary, Jeremy Hunt, has committed to a new 1500 medical school places beginning in 2018. The UK’s Department of Health (DH), in response to the October 2016 health workforce policy, started on March 14th, 2017 to achieve the increased number of doctors (“ Jeremy Hunt ”) [11]. Meanwhile, the Ugandan Government is criticized for not creating enough incentive to ensure that medical professionals stay in Uganda (“Healthcare Challenge for Uganda ”). Data from the Organization for Economic Co-operation and Development (OECD) [6] showed that there was an output of 118,437 health care professionals in the UK, consisting of British and international students. Reaching the target of producing an extra 1500 more physicians per year until 2020 does not seem promising, as there has not been an increase of 1500 more admissions into medical school in the UK [12], according to data from the UK has produced 12.6 per 100 000 people of medical doctors, and 30.0 per 100 000 people of nurses from graduate institutions across the UK in the year 2017. Uganda, unlike the UK, is recovering from years of civil unrest and colonialism, and when one looks at their health system in context, their health system is moving in a positive direction [13].

Conclusion

The UK has a highly more efficient health system than Uganda in terms of both service delivery and the health workforce. Although both countries spend a relatively similar portion of their GDP on health, the UK spends a lot more money on the maintenance and promotion of the health of its citizens and residents. Both countries’ health systems have their challenges, as is the global trend of shortages of the health workforce. The UK system works better in ensuring that its residents are better cared for throughout life, due to at-home care, end of life care, and HIV-related special care. The UK ’ s health system is concerned more with the maintenance of health and promoting quality of life, while Uganda’s health system is overwhelmed with managing the disease. While service delivery is more uniform throughout the UK, Uganda is faced with severe disparities in the equal distribution of access to health facilities, as the citizens and residence of Uganda travel far and wide to gain access to needed treatments. Both the UK and Uganda have relatively long waiting periods for more advanced specialized care, due to the low number of a doctor to patient ratios. The UK has put measures in place to attract more doctors, while Uganda struggles to maintain locally trained staff to work in the public sector. Private and NGO-based healthcare is vast, and plays a significant part in Uganda’s health system, while the UK’s private health sector is significantly small and NGO healthcare non-existent. Gender disparities are rampant equally in both the UK and Uganda, as women struggle to gain access to more senior positions, although women do account for the more significant number of collective healthcare workers. Women are more crowded at lower levels in the hierarchy of both countries’ health systems. Both Uganda and the UK strive to produce more healthcare workers, especially doctors, to reduce the gap of doctor-to-patient ratio. Both the UK and Uganda should look at ways to move their health systems from reactive to more proactive health systems that are centered on public health and health maintenance.

References

1. WHO (2013) Service availability mapping: The republic of Uganda Ministry Of Health in collaboration with the World Health Organization. World Health Organisation.
2. NA (2013) National Health Service (NHS) UK-statistics & facts. Statista.
3. Cylus J, Richardson E, Findley L, Longley M, O'Neill C, et al. (2015) United Kingdom: Health system review. Health Syst Transit 17: 1-126.
4. USAID (2017). Country Specific Information (CSI): Karamoja, Uganda U.S. agency for international development office of food for peace fiscal year 2017. USAID
5. Keogh KKBE (2013) Review into the quality of care and treatment provided by 14 hospital trusts in England: Overview report. NHS.
6. Alex Matthews-King (2018) Jeremy Hunt to announce five new medical schools as part of bid to train 1,500 extra doctors. Independent.
7. WHO (2010) Monitoring the building blocks of health systems: A handbook of indicators and their measurement strategies. WHO Library Cataloguing-in-Publication Data.