COVID-19: Uganda Must Take Robust Measures to Defeat the Coronavirus Pandemic
By Robert Kyagulanyi Sentamu
The onset of the COVID-19 pandemic has challenged the public service infrastructure as never before. We commend the government for the efforts it has made to limit the contagion. In particular, we commend health service personnel for their tireless round-the-clock monitoring, testing and treatment of those affected by the disease.
I appreciate the 300 water points rolled out by the National Water and Sewerage Corporation and Kampala Capital City Authority on Friday 27 March. NWSC must be funded to enable them to continue to offer handwashing points in urban areas.
It is heartening to observe the positive public response to the Ministry of Health guidance and directives. I join the President of Uganda in emphasising that the contagion can only be stopped if we collectively practice physical distancing, frequent handwashing and avoiding touching our faces. These are the only preventive measures possible. There is no cure available so far.
The Director of the World Health Organisation, which is at the forefront of the fight against the pandemic, has described lockdowns as “extreme social & economic restrictions”.
In Uganda, our first confirmed case of COVID-19 was detected on 21 March 2020. As of Friday 3 April, Uganda had 48 confirmed cases. It is not easy for public servants and it is not easy for the ordinary citizen, but if we continue to cooperate, the pandemic will end. Uganda is among the countries with fewer than 100 cases and we stand a good chance of overcoming this crisis if we make the right policy choices now.
We agree with the WHO that the lockdown provides a window of opportunity to curb and finally defeat the disease but also to prevent a resurgence of infections once the lockdown is lifted. We believe it is necessary to “Refocus the whole of government on suppressing and controlling Covid19”, as Dr Tedros Ghebreyesus, Director-General of the WHO, has advised.
The World Health Organisation, which is at the forefront of the fight against the pandemic, has described lockdowns as “extreme social & economic restrictions”
We agree that “on their own, these measures will not extinguish epidemics”. We adopt the recommendation that, to be effective, the lockdown must be accompanied by measures aimed at strengthening the health service. It is our view that Uganda’s response to this pandemic can lay the foundations for a healthier and better-prepared country.
In everything we do, we must prioritise the safety of the health workers at the frontline. We therefore propose that they are provided with daily transport, risk and other duty-facilitating allowances, as well as personal protective equipment (PPE). In his address to the nation on 31 March, the President reported that health workers in upcountry facilities are avoiding suspected COVID-19 cases because they lack protective gear. This is unfortunate and must be addressed immediately at all Regional Referral Hospitals. It was shocking to hear in the Presidential Address on Friday 3 March that Uganda only has 10 per cent of the PPE required at this time.
We also support the call by some members of Parliament to pay health workers a motivational allowance, on time and during this crisis, not in arrears.
It may not be possible in the short term to expand, train and deploy our healthcare and public health workforce as recommended but the recruitment process can begin. The news that hundreds of healthcare workers are being recruited at all levels is welcome. Hopefully, the majority are clinicians and nurses.
What is possible in Uganda in the short-term is to continue efforts to “find, isolate, test, treat and trace” those who may have been exposed to the virus and who together with their families are at risk. Of the 48 cases, nearly all were incoming travellers and contacts of travellers arriving mostly from Dubai, 15 from the United Kingdom, three from the United States, one from Kenya. By 28 March, only three confirmed cases were not incoming travellers. We wish them all an easy recovery.
Uganda is among the countries with fewer than 100 cases and we stand a good chance of overcoming this crisis if we make the right policy choices now
In the two weeks prior to the airport closure, 2,661 high-risk travellers entered the country. Also, there are others that had not been identified before Dubai emerged as a high-risk country. Less than 1,000 of these people have been quarantined and tested. It would help to offer amnesty to the hundreds remaining to encourage them to come forward. The security services need only be deployed if there is further failure to cooperate after the amnesty is announced. In any event, the forces should endeavour to treat citizens with the respect they deserve. Wanton violence of the type we have seen contributes nothing to disease control and undermines faith in the government to lead us out of this crisis.
As has been noted, the more tests done, the greater the number of positive diagnoses. While we appreciate the donation of testing equipment from the WHO and Jack Ma, we note that we remain vulnerable as long as our capacity to test depends on donations. We recommend that Uganda seeks short-term measures to find funds for test kits. The public needs to be informed whether all the tests being used are WHO-approved. There is some concern about the potential for false negative results and, being a “fragile State” that is receiving multiple donations, we need assurance that all equipment is up to par.
Regional Referral Hospitals, and Naggulu and Mulago Specialised Hospitals, have been tasked with the management of COVID-19 cases. The input of the Uganda Medical Association, whose members are at the frontline of this battle, is required in signing off those entities equipped to take on the task. This will ensure healthcare workers at those designated facilities have adequate equipment, drugs and PPE. It is hoped that funds will be made available to provide testing facilities in hospitals outside Entebbe.
Wanton violence of the type we have seen contributes nothing to disease control and undermines faith in the government to lead us out of this crisis
Biosafety professionals should be involved in setting up any quarantine sites outside hospital settings to avoid healthcare-associated infections after the pandemic passes. The same should apply to General Hospitals and all Health Centre IVs if the need arises. Regional quarantine and treatment centres are needed to ensure everyone has a good chance of survival wherever in the country they may live as transporting patients across the country puts health workers at risk. Moreover, disinfection of markets, taxi parks and, where possible, other public places should take place before the lockdown is lifted.
Funding the fight
To fund the interventions we request that money currently allocated to Ministries, Departments and Agencies for non-essential activities be reallocated to increasing the number of tests carried out per day and providing transport and PPE for health workers. For example, fuel expenditure saved by grounding government vehicles and cancelling bench-marking trips, conferences, and treatment abroad for ailments that are treatable in Uganda, should also be reallocated to the health sector. Above all, we should minimise waste; expenditure on advertising in the media, printing official bulletins and so on, is not a priority. As WHO recommends, the way forward is “find, isolate, test, treat & trace”.
Most challenging, however, is the third recommendation from WHO: “Expand, train & deploy your health care & public health workforce”. Currently, we have five hospital beds per 10,000 people, 200 intensive care units and less than one (0.9) doctor per 10,000 people. To further complicate matters, other affected countries will seek to import our doctors to combat COVID-19 in their countries. The United States has already invited work visa applications from doctors. The US has 25.9 doctors per 100,000 people but 300,000 COVID-19 cases. Robust interventions on our part will serve in the current crisis and during any future health crises.
As WHO recommends, the way forward is “find, isolate, test, treat & trace”
The immediate sizeable source of funds would be the suspension of the Lubowa Specialised Hospital Project targeting health tourists. The total project cost is Sh1.4 trillion ($379 million). After the first payment of Sh327 billion ($87million), there remains a balance of Sh139 billion. These funds are needed to provide primary healthcare, intensive care and emergency care for Ugandans. (The existing budget for the 41 hospitals to be built in 39 districts is Sh1.3 trillion.) The reallocation from Lubowa Hospital should take place as soon as possible and should the lender decline, the rest of the loan should be cancelled.
Easing the Economic Impact of COVID-19
The majority of Ugandans are employed in the informal sector. In fact, 83 per cent of non-agricultural workers are in the informal sector (World Bank Databank). The majority of workers (75.2 per cent) are classified as being in “vulnerable employment” (Human Development Report 2019, UNDP). What this means is they do not have health insurance and are unlikely to have savings or any other form of social safety net. For the fishermen and small traders who pay annual licence fees, Uganda Revenue Authority could consider extending the validity of those licences to take account of trade lost during the pandemic.
Borrowers from the Youth Livelihood Programme and the Women’s Entrepreneurship Programme present a problem. The 83,000 participants in the government-funded loan schemes such as the Youth Livelihood Programme were already having difficulties making repayments and the majority defaulted. During this time we request that the government suspends the pursuing of defaulters and resumes collections when normal work resumes.
Those in debt to micro-finance companies can be assisted by freezing interest accumulation during the lockdown and extending repayment periods once work resumes. Boda boda riders who have bought their motorcycles on credit fall into this category.
Formal Small and Medium Enterprises face similar loan repayment challenges and require similar consideration. The Bank of Uganda has the responsibility to use those mechanisms as are within in its powers to maintain economic stability. It should ensure that SMEs are not forced out of business by enabling banks to extend repayment periods for loans. In this connection, borrowers forced to default should not be penalised and listed by the Credit Rating Bureau.
Both the formal and informal sectors increasingly use digital means to do business. To reduce the use of potentially infectious money, and to make transactions more affordable, we request that the government lift the OTT tax (excise duty on over-the-top services). The government is also urged to reach an agreement with Telcos to further reduce their rates for all telephony.
Mortgages and rent
Without work, the informal sector and struggling SME owners may be unable to pay rent and may face eviction. Bear in mind landlords too may rely on the rent to repay building loans and cater for their families. Therefore, for those in the informal sector we request that the government works out an arrangement with landlords to grant a month’s grace period for those forced to default on rent. The government could take on the debt for the period of the lockdown. For those in the formal sector, the government should consider guaranteeing the rent and mortgage payments and later recover them from salary or from the National Social Security Fund (NSSF) savings of the tenant. Moreover, the NSSF Act needs to be amended to give members access to their savings during emergencies in future.
Payment of electricity and water bills will become more difficult in the days ahead. The National Water and Sewerage Corporation has explained that it is unable to waive water charges because it too must meet its obligations to employees and suppliers.
What is needed are subsidies for consumers in difficulty. Two options are possible for a fixed period: a VAT waiver on water and electricity or selective subsidies through Yaka credits and water credits for those most in need. It should be possible to apply online or to regional offices and be granted these credits according to criteria agreed upon between the government and the utilities providers.
Social protection of the most vulnerable
We note the relief being distributed to the vulnerable in Kampala and Wakiso districts. It is true that many urban dwellers have been suddenly deprived of incomes and require support. However, rural people in vulnerable employment are also affected by the lockdown through loss of income. Many depend on roadside markets between towns and cities, traffic which no longer exists.
The elderly are the most vulnerable because globally fatalities have been most prevalent among this demographic and also because their caregivers will be unable to provide for them as before. Yet many of the elderly are themselves caregivers to grandchildren and employers of farm workers. The government has already compiled a list of the aged to which it pays a monthly grant. This Senior Citizens’ Grant is vital in keeping the rural economy afloat and for children being cared for during this time and therefore it must be paid in full and in a timely manner.
The incapacitated and those whose caregivers are themselves incapacitated by illness will need to be added to the list of the vulnerable as will the unemployed who will lose caregiver support. Nearly all Ugandans are at risk of financial disaster if they were to become seriously ill. The Human Development Report states that 75 per cent of Ugandans are at risk of catastrophic expenditure – expenditure which wipes them out financially – were they to require surgery. COVID-19 may not require surgery but in the worst cases (should they appear) it will require intensive care. With a reported 200 ICU beds nationally and most probably all occupied, the situation is dire.
In the absence of public transport, a special public transportation plan for patients and expectant mothers travelling to hospitals and medical centres should be put in place. The beginnings have been difficult as travel passes have not been easy to obtain. We propose hiring and branding vehicles for delivering COVID-19 patients to health facilities. The modalities can be worked out by the Joint Task Force. People Power Co-ordinators will be available to assist in locating those who require transport to health facilities.
The 21 per cent of people living in poverty forms a large part of the vulnerable section of the population. Undernourishment (caloric intake below minimum energy requirements) has been steadily rising for the last 14 years, from 29 per cent to 41 per cent. We have been advised by the Ministry of Health that people have a better chance of surviving COVID-19 infection if they are adequately nourished. To exclude them from the lockdown-affected persons requiring assistance is unfair and counter-productive as they are more likely to succumb to infection.
We cannot afford not to be prepared for other disasters. The shortage in medical masks, respirators, gowns and goggles caught Uganda unprepared yet this was forecast by the World Health Organisation on 27 February.
A resurgence of the desert locust plague in the region was forecast to begin in early May. A swarm entered Amudat district for the second time on 3 April. If it grows, there will be food shortages.
Extreme climate events such as mudslides this rainy season cannot be ruled out either. Our preparedness should reflect the seriousness of the situation and funds set aside to deal with any eventualities. A government statutory contingency fund must be put in place with immediate effect.
On an individual level, to increase food security, owners of uncultivated land are requested to either plant staple foods or allow food to be planted on their land during this rainy season. This arrangement would be limited to this season that is coinciding with the lockdown period.
Funding the safety net
To fund the social safety net, it will be necessary for the government itself to get debt relief on the national debt. Currently over 65 per cent of revenues goes towards debt payment. While we appreciate the World Bank’s call for suspension of debt repayments to development partners and offer of a loan package to finance the campaign against COVID-19, this is not a time to acquire more debt. Lenders are aware that Uganda is a fragile state and, therefore, negotiations for debt cancellation to enable us to provide a social safety net must go ahead and they must succeed. The absence of a social safety net is the direct result of ill-advised development policies.
Long-term interventions: Rehabilitation of the Health Care System
People Power has long argued that the stagnation in health and other services must be addressed as a matter of urgency, not in 2022 or in 2026 but now. This pandemic will end but without strong health and other public services, we shall remain vulnerable to the next epidemic, pandemic or extreme climate event. So we would like all interventions to go beyond the COVID-19 pandemic to cater for future needs.
The health, water and sanitation and all other sectors must be transformed into robust, life-enhancing government services.
Our expenditure on health decreases nearly every year. That trend must be reversed. We must go from spending 6 per cent of GDP on the health service to spending the 15 per cent we signed up to in the Abuja Declaration.
Not surprisingly, a review of the hospitals around the country reveals that the majority have faulty equipment. To finance a health service that meets national requirements, the health insurance scheme that has been in the pipeline for over a decade needs to be rolled out.
We must go from spending 6 per cent of GDP on the health service to spending the 15 per cent we signed up to in the Abuja Declaration.
We need to develop the capacity to manufacture items for clinical use, e.g. protective gear for health workers. We have the capacity. In 2019 young Ugandans developed life-saving and cost-saving bio-medical equipment. All are important because of the nationwide shortage of medical equipment especially in rural areas. Olivia Koburongo and Brian Turyabagye developed the Mama-Ope smart jacket for digital pneumonia diagnosis. In 2018 Phyllis Kyomuhendo invented M-Scan a portable ante-natal ultrasound device. Brian Gitta and colleagues developed a bloodless malaria test (Winner of the Africa Prize for Engineering Innovation, founded by the Royal Academy of Engineering in the UK); we often cannot afford reagents used to test blood. In 2014 Dr Chris Nsamba developed an incubator for premature babies which he donated to the government. It is in use at Mukono Health Centre IV whereby last year it had saved the lives of 243 critically ill babies. Uganda has one of the highest rates of premature deaths in the world.
In 2019 young Ugandans developed life-saving and cost-saving bio-medical equipment
However, Dr Nsamba failed to get any government funding although a government agency later claimed to have sponsored the development. The government should make a firm commitment to support local innovators by buying their products while following procurement rules to give all innovators a competitive chance.
Water and Sanitation
Only 18 per cent of the population has access to basic sanitation services with which to keep themselves and their homes healthy. Of every 100,000 deaths, 31 are related to unsafe water and poor sanitation and hygiene services. Of every 100,000 deaths, 159 are caused by household and air pollution (Human Development Report 2019, UNDP).
In the long term, there needs to be an investment in the water sector that meets the needs of the 82 per cent without access to basic sanitation services.
We are grateful for the government’s transparency in admitting that the limited water supply to homes has been caused by “poor planning and implementation of programmes over the years”. As a result, the water and environment sector now needs at least nine times the present level of funding every year for the next 12 years to meet national development targets (Budget Monitoring and Accountability Unit Briefing Paper 30/19, Ministry of Finance, June 2019).
During the lockdown many will struggle to get fuel for cooking. Under normal circumstances, less than 1 per cent of Ugandans has access to clean fuels and technologies for cooking. Apart from being unsustainable environmentally, the daily search for firewood, like the daily trip for water, takes away time children would otherwise have spent in school, acquiring skills to innovate for our survival as a people.
We have an opportunity to reflect on the type of nation we want to be. Are we willing to invest in our human development and well-being or will we forever belong to WHO’s category of “the most fragile and vulnerable countries”?
Human development costs money. We will only see a change if we manage our resources better, this goes both to government and to the population. We must eliminate non-essential expenditure; expenditure on salaries of political appointees and on electioneering – cash handouts in return for votes. We must eradicate waste; last year vehicles were bought at a cost of $5.5 million for the Commonwealth Parliamentarians Conference. It was said that they would thereafter be used for government work but they have not been surrendered to the pool for use in fighting COVID-19. The recent budget proposals for the desert locust emergency, especially by the ICT ministry, show that we have not learned this yet.
As a Nation, we need to reflect on the wisdom of splintering the country into tiny entities paying salaries for MPs, and public service but remaining financially unable to maintain decent health centres, hospitals or roads, or to deliver quality education in most local government institutions.
As individuals, each one of us must have as much integrity as we expect from our leaders. In the last four years, Uganda lost Sh28 billion in the Youth Livelihood Programme. An audit of a sampling of Youth Livelihood Project groups which received loans found that 64 per cent were non-existent (representing 71 per cent of the value of the loans). Another 25 per cent had embezzled the funds. This means that repayments were not available for re-lending to new Youth Interest Groups.
We must never again be found without sufficient medical facilities. We must never again find ourselves lacking water with which to wash our hands and prevent disease.
The physical environment in which we live and work can and must be transformed. Unsanitary working conditions in markets and other public places must be addressed beginning with the NWSC/KCCA handwashing points which we expect will become a permanent feature.
We must never again find ourselves lacking water with which to wash our hands and prevent disease.
A durable solution to the broken public transport system is needed, especially in cities and towns. This pandemic has taught us that public transport is a public good that must be supplied, regulated, maintained and sanitised by the government. Supplementary systems are well and good, but the primary responsibility for public transport lies with the government.
On behalf of the millions of People Power foot soldiers across the country, I call upon the government of Uganda and all Ugandans to reflect and consider the proposals I have laid out here.
For God and My Country.