Uganda, East Africa, is a landlocked country sharing borders with Kenya, Rwanda, Tanzania, The Democratic Republic of Congo and Sudan. Its varied terrain includes mountains to the east, west and south as well as safari plains and tropical forests, home to Uganda’s gorilla population. It shares the northern shores of Lake Victoria, one of the biggest lakes in the world (roughly the size of Ireland) with Tanzania and Rwanda.
The population was recently estimated at 28,816,000 and is the second fastest growing in the world. Roughly two-thirds of its people are Christian and one-third Muslim.
Population Health
Living conditions vary between urban or rural dwellings. Piped water and electricity are strictly urban and for those considered better off. However, even in Kampala, electricity is at best on/off every 24 hours. Paraffin lamps, candles and gas are essentials for most. Wages are little, but people manage to survive on a dollar a day.
The World Health Organisation reports that health indicators in Uganda are steadily improving, but identifies that the humanitarian situation in the northern regions is still considered to be dire. The ongoing war, over two decades, involving the LRA (Lords Resistance Army) and UPDF (Ugandan Army) has devastated communities in northern Uganda. The LRA have abducted over 25,000 children and around 1.8 million people live in IDP (Internally Displaced Persons) camps. These camps have limited assistance with regards to food, health care, water and sanitation and the situation has been described as ‘the world’s worst forgotten humanitarian crisis.’
Health System
Nationwide health infrastructure is poor. In rural areas, 51% of households don’t have access to healthcare and in the northern regions; healthcare delivery is heavily dependant upon humanitarian assistance for drugs and other supplies. Throughout the country, hospitals and clinics are generally under-equipped. Human resources in the health services are insufficient and there is a significant lack of skilled professionals. Nursing care is shared with the relatives who are often present by the bedside most of the day and take on the responsibility of toileting, cleaning and feeding the patient. Specialists are few and are generally not based in one hospital full-time, subsequently; people often have long waits in hospital before being operated on due to absence of the surgeon.
Seventy-five to eighty percent (75-85%) of the population fits in to criteria for malnutrition and this is a significant factor underlying infant mortality alongside malaria, measles and pneumonia. Nationwide, HIV/AIDS has an average prevalence of 5.4%. It is the leading cause of death in adults followed by T.B and malaria. The average life expectancy is estimated at 48.
The government is working hard to develop the health services and have a number of priorities including immunization and improving availability of drugs and equipment. Unfortunately though, the process is slow. Throughout the country, there is a mix of government and private hospitals and also many native healing medicine centres, which is commonly the preferred choice especially in rural areas.
Disability and Rehabilitation
Disability is so common that it is generally accepted as part of life. The family cope with little or no support in the community. Domiciliary care, if available, is usually private. Provision of walking aids or wheelchairs is costly, so people usually innovate and use alternative equipment. Most people discharged from hospital are not aware of the possibility of continued outpatient rehabilitation. In the majority of areas, this is not even an option. In Kampala, where there are facilities, referrals tend to be few. Rehabilitation is a low priority considering the average families other needs.
Physiotherapists are recognised in Uganda, although we are generally referred to as doctors, and misunderstood by some to be masseuses! There is an established three-year diploma course in physiotherapy, but at present the school is struggling due to the lack of teachers, none of which hold a BSc degree. However finding a job post qualification is not difficult and many physios tend to work in both public and private sectors to boost their wages. Physiotherapists are more numerous than occupational therapists, but other professionals such as speech language pathologists, dieticians and podiatrists are barely existent.
Personal Experience
I arrived in Uganda in May 2006 following an offer of employment in a private hospital. The hospital is two-years old and is committed to raising its standards to an international level. The International Hospital Kampala (IHK) is recognised by ISO and because of this there are plenty of training opportunities for staff. Issues of equipment and HR are problematic but the hospital is still by far the best in Uganda.
I began by making enquiries to the Ugandan physiotherapy board, whose contact details I obtained through the WCPT website. I was advised that voluntary work was a possibility. With a large number of aid and voluntary organisations, the majority of westerners work here on a voluntary basis; paid work is rare. Generally, the population of non-African health professionals employed to work here on a long-term basis is small.
I found my job independently by emailing the CEO of the hospital directly with my CV and cover letter. There was a vacancy at the time and I was offered a position at the hospital. After an initial research trip I handed in my notice in the UK and moved to Kampala a couple of months later with my partner. I arrived on a single entry tourist visa, and then applied for a special pass, which allows you to enter and leave the country freely. The special pass precedes the work permit, which takes longer and has recently been increased in price to $1000. The amount of time it takes to process your work permit application depends on your place of work.
You must register with the Ugandan Physiotherapy Association before you start any voluntary or paid work. This took me 3 months, but could potentially take a lot longer. Additionally, you need to pay $100 at the Ministry of Health to register as an Allied Health Professional, and then sit a pre-arranged interview with the physiotherapy board.
My official working hours are 8 am to 5 pm, though days are often longer and there is rarely a quiet moment. I run the department here and work with two Ugandan physios. Mornings are taken up with inpatient rounds including general hospital cases, a charity ward, which admits mainly oncology, burns and plastics patients, as well as those affected with injuries from the war in the north. For the rest of the time I see outpatients. As in the UK the low back pain patient predominates. Peripheral musculoskeletal disorders are somewhat overlooked and are frequently not referred. Twice a week, I join the orthopaedic surgeon for his clinics and I run a sports clinic in association with the hospital two afternoons a week. This complements my voluntary work for the Ugandan National Rugby team which takes up some time most evenings. Many of my days are scheduled to incorporate teaching; to my department as part of continuing education; to the nursing staff on various rehabilitation issues and manual handling training; and to nursing students on what physiotherapy and rehabilitation is, and how we all work together as part of a multidisciplinary team.
I am thoroughly enjoying my time here and endeavour to raise the standard of the physiotherapy department everyday! It’s been great to transfer some of my skills to my colleagues and educate other staff on exactly what physiotherapists do and our role within the hospital. I get to use the whole range of my skills on a daily basis and have worked with challenging neurological cases such as Gullain-Barré syndrome. Working alongside the Ugandan Rugby team and having the opportunity to travel with them has been a highlight, but mainly, being accepted so readily by the hospital staff and the general friendliness of Ugandans has made working here a great experience.
The main challenges are limited resources, which can ultimately affect the quality of the service you deliver. I brought out some equipment to donate to the hospital but we lack some basics essential for health and safety. The economic status of the people means that many just stop attending physiotherapy as they become unable to afford the service at our facility and government hospitals, with their extensive waiting lists, offer no alternative.,
