Barriers to orthopaedic care and medical devices
One of the largest identified obstacles in providing appropriate care to injured patients was perceived corruption. Participants easily identified many of the corrupt practices common to the health care sector at worker, hospital and government levels. These included misappropriation of funds, theft of equipment, resale of drugs and medical devices, fraud and absenteeism. They expressed the need for anti-corruption measures and improved transparency in government.
Misappropriation of funds
Participants reported theft and misuse of resources both financial and material. Both government funds and grants from donor agencies were reported as lost or misappropriated.
“Money in the government is not always accounted for and doesn’t always make it to the hospitals.” [Health care professional]
“There is a lot of corruption and wasted money in the government. For example, here there is a 60 000 US dollar Toyota Prado for the medical superintendent to use. It sits in the front of the hospital. It was bought by the government. I see the superintendent use it maybe only once or twice a day” [Health care professional]
“Why can people afford to buy 4x4s but not pay for their health care? In the end, I think that all East African countries can afford [orthopaedic] implants if they use their public money properly. There is so much wasted money.” [Industry representative]
Participants also identified a lack of transparency and accountability in government policy decisions (particularly for health budget allocation) and procedures in the health system. A dominant theme identified was the lack of publicly disclosed oversight of government procurement procedures. Donated funds are typically associated with a higher degree of oversight and accountability, and one participant suggested that donated funds for health care might encourage more transparency.
Theft and resale of drugs and medical equipment
In Uganda’s universal healthcare system, the government attempts to supply all its hospitals with the necessary equipment and medicines. Hospitals can access what they need through the National Medical Stores, a centralized depot of medical supplies run and paid for by the government
]. The National Medical Stores however, do not regularly carry orthopaedic equipment other than plaster, forcing orthopaedic departments to rely on donated supplies. Many other supplies and drugs are also frequently out of stock or cost more than hospitals or patients can afford.
“[There is] corruption. The health care budget has a budget for sutures, but when we ask for them they never come.” [Health care professional]
Depleted stocks and high costs force hospitals, physicians and patients to buy from private pharmacies or distributors (Observational Field Notes). This can also incite theft. Stolen orthopaedic implants, donated or government supplied, are reported taken from public hospitals and resold to patients in private hospitals (Observational Field Notes). The lack of inventory systems, clear policies, price lists, and oversight mechanisms make the health care system vulnerable to corrupt practices.
“There is theft of equipment in government hospitals by people who want to set up their own practice. Some stolen instruments are consumables but some are permanent fixtures.” [Health care professional]
Interviews with orthopaedic industry representatives and orthopaedic surgeons who work in other low-income countries reveal the problems of theft and resale also exist outside Uganda. These participants relate the problems of theft to the lack of suppliers of medical equipment, making medical devices difficult to come by even in legitimate ways.
“Once in the 1970’s, Synthes [one of the big five orthopaedic medical device manufacturers] set up a plant in India. Everything they made in India was sent directly to Switzerland, so it could not be sold directly to the market. The labor was really cheap but the quality was the same. But they closed the plant because the manager in India started selling directly to the market. I have tried to convince them to set up a plant in Kenya so Africans can have better access to implants, but they say ‘we don’t want to start a plant here’. They fear their products will end up on the black market.” [Industry representative]
Uganda, like most low-income countries, has a serious lack of orthopaedic specialists, from surgeons to orthopaedic officers and nurses
]. There are only 28 orthopaedic surgeons in Uganda
], and only a handful in rural areas
]. There is no provision to encourage healthcare professionals to work in underserviced areas; this is not uncommon for many health professions. The government will not fund orthopaedic care or supply orthopaedic equipment to a hospital if there is no orthopaedic surgeon present, compounding this problem. Health care professionals and government officials in many low-income countries are paid meager wages and are rarely rewarded for exceptional performance
]. The median surgeon salary in a public hospital setting is $6000USD per year, while it is $18000 per year in a private setting
]. In contrast, the median annual income for a ward nurse is $1000
]. Under these conditions, many workers engage in other economic activities during working hours or pursue opportunities for financial gain through public service, including the acceptance of informal payments
]. One study participant described that in Ethiopia, even private hospitals practice corrupt behaviors in order to make private gains. In this case, it is by overcharging patients for medical equipment.
“The private hospital will charge a patient the same whether they use an Indian [generic] or European [brand name] implant. Unless a patient specifies which one they want, the hospital will use the cheapest device, charge for the most expensive, and take the extra money.” [Health care professional]
In Uganda, as hospital stocks are often depleted, patients are frequently asked to buy drugs or equipment from private distributors. Patients worry however, whether they are getting the best price for the medical equipment and drugs they need. The low wages, lack of benefits, and poorly supplied hospitals of the public health care system motivate surgeons to work in the private system partially or exclusively. Fiftyeight percent of all medical professionals interviewed in Uganda worked at least parttime in the private system. Many participants reported needing the income from the private system to support their families (Observational Field Notes). Even though we focus on corruption in this paper, it is important to note that fraud in the forms of informal payments and absenteeism are often viewed as coping mechanisms for health professionals given their low salaries in the public sector.
The current private system negatively affects the public system. The first author participated in clinical care and in the orthopedic operating room while in Uganda. In the larger cities, the operating room rarely started before 11
AM as the nurse, anesthetist or surgeon was coming from an earlier case at a private hospital (Observational Field Notes). Other times, delays were simply because of lack of motivation from the staff. Since they were salaried it did not matter to them financially how many cases per day they achieved (Observational Field Notes). The growing list of patients waiting for surgery did not seem to inspire the staff to work harder or longer. These findings are consistent with other studies on absenteeism and health worker motivation
]. Furthermore, there is a significant increased cost to the government and public health sector when such absenteeism occurs. Although meager, the government-paid salaries for full-time health care professionals ultimately pay for only part-time employees when workers spend up to half of their time in a private hospital instead providing undivided care in the public sector. The resulting backlog of patients waiting for care and occupying hospital beds for longer periods also increase health care costs and potentially negatively impact patient outcomes.
We found that another consequence of absenteeism is a slowdown in the procurement system for medical devices. All procurement in Uganda is through a lengthy government process (Observational Field Notes,). Absenteeism of physicians and government officials on the procurement committees further slows the process.
“The supply procurement process is incredible. To prevent corruption, there are two to three committees at the district and hospital levels you have to submit your request to. The process takes 6 to 8
months. It always has to go through the government. It can happen that the committees don’t meet because people are away. This can create yearlong delays. When you finally get the tender, sometimes the supplier in the end is not able to supply, then you have to start all over again.” [Health care professional]
Although corruption in law enforcement is not directly related to corrupt behavior in the health sector, most cases of orthopaedic trauma are due to road traffic crashes and lack of regulation on the road. There is little consequence for reckless or unsafe driving because the police rarely halt or prevent it, or alternatively because there is a lack of policy or legislation against a particular act of dangerous driving.
“Law enforcement here is not good. No traffic rules are enforced. Careless driving is performed by everyone here, rich or poor.” [Health care professional]
For example, boda-bodas are the motorcycle taxis in Uganda. A law exists that mandates drivers to wear helmets. Few drivers where helmets, and yet the police rarely discipline the drivers (Observational Field Notes).
Participants hypothesized that similar to health care, police are poorly paid and inadequately rewarded for good performance, they may be unmotivated to properly perform their jobs and more likely to accept bribes or other forms of personal gain. This is also a result of a lack of monitoring and enforcement of professional standards.
“We need increased police enforcement, but I don’t know how to increase their interest. Maybe the police aren’t supervised well, they don’t have enough money or high enough salaries, and they don’t have enough knowledge.” [Government Official]
Many participants related corruption in law enforcement as a barrier to access of orthopaedic care as the unpunished reckless driving consistently causes the disabling and fatal injuries that overload the emergency rooms, wards and operating rooms.