It’s bad laws failing Covid fight - Atwine

The permanent secretary of Ministry of Health, Dr Diana Atwine, has blamed the current oxygen crisis in Mulago National Referral Hospital and the regional referral hospitals across the country on high global demand that has affected supplies.

This follows a recent audit report that faulted the ministry for flouting procurement laws. Top on the list of the audit queries were advancing full payment before delivery and installation of oxygen plants at Mulago hospital and other hospitals, delays in deliveries of supplies and irregular procurement.

Dr Atwine in an interview with this newspaper yesterday said while they had planned for procurement of an oxygen plant and other supplies, the global demand is overwhelming the manufacturers, leading to delays in deliveries.

“Right now we are supposed to procure oxygen plants, but all the manufacturers are fully booked. Countries like India have booked all those machines with fully paid up-front. Now I must order manufacturing of those machines and wait. Now when the things come a little late, am I at fault? Why must I be lambasted for the delays by [the] manufacturer when there are too many orders?” she questioned.

Dr Atwine also blamed the cumbersome procurement and public finance management laws in the country for delays to respond to emergencies. 

She said the country is dealing with a pandemic and that laws which inhibit prompt responses need to be dealt with to pave way for emergencies. 

“When we are dealing with human lives, there must be some special considerations as we are talking about the law. The law has its own advantages but when it comes to saving lives, we must ensure that there is the law, but first we must save lives. The public finance management act does not provide that leeway when you have epidemics,” she said.

She also said currently, government has installed Genexpert machines in all the regional referral hospitals, but there are no cartridges to use the machines with. 

Dr Atwine said while other test methods take longer, Genexpert machine is able to give you polymerase chain reaction (PCR) results in one hour. 

She said the challenge the country is facing is that  cartridges which is only manufactured by one company.
“I have put the machines in all regional referral hospitals and the manufacturer is saying to hell with you if you are not paying fully for booking, so what do I have to do?” she said.

She said the ministry is being unfairly criticised over Covid-19 management and yet the same Ugandans have refused to heed to the advice of the ministry. 

“But I have heard people out of ignorance, out lack of knowledge shouting… How can we work in this kind of hostile environment? Isn’t that unfair to us? We who never take leave even on Sundays and are always in office working, even on Christmas and Easter, isn’t that really unfair?” she questioned.

As of June  25, the country had registered 78,394 Covid-19 cases, 903 deaths and 51,348 recoveries. 

Issue...Oxygen crisis
Early this month, Mulago National Referral Hospital management  admitted that oxygen production in their plants is no longer adequate for the Covid-19 patients   at the facility following a surge in numbers of patients.

According to a statement by the hospital management, the facility has turned to private firms such as Oxygas, Roofing and Steel and Tube to source medical oxygen. Mulago purchases 100 cylinders of oxygen daily. However, plans are underway to establish another oxygen plant at the facility.

Dr Baterana Byarugaba, the Mulago hospital director, said one Covid-19 patient requires about 70 litres of oxygen per minute yet the four plants at the hospital can only produce 2,083 litres per minute.

This means the plant can only efficiently supply high-quality oxygen at the recommended pressure to only 30 Covid-19 patients.
“It is true that we need more oxygen here. But the plants can produce enough oxygen for non-Covid-19 patients in the Intensive Care Unit (ICU),” Dr Baterana.

He revealed that non-Covid-19 patients in ICU require a maximum of 10 litres of oxygen per minute.

Private manufacturers of oxygen in Uganda can only make up to 27.7 million litres of oxygen per day, according to our computations, slightly less than half of the current demand, explaining chronic shortages of the life-saving gas for Covid-19 patients.
A Daily Monitor mini-survey shows that Tembo Steel, the biggest producer of oxygen in the country, makes up to 18 million litres of oxygen at their Lugazi and Iganga oxygen plants a day.

The other producers are Oxygas, which manufactures 4.8 million litres per day; Uganda Oxygen Limited, which makes 2.4 million litres a day; and, Roofings, which produces up to 2.5 million litres every 24 hours. These total 27.7 million litres.

Shortage of oxygen has been cited by hospitals as a major reason for the less-than-satisfactory services to critically-ill Covid patients, many of who die due to inadequate oxygen.

Full interview 

We appeared as a country to have had control over the pandemic. Where and how did things go wrong?
At the beginning in March 2020, the Head of State (President Museveni), together with the [National Covid-19] Taskforce, instituted the measures early including closing of schools and locking down [the country] that helped us to reduce the infections.

I want to tell you that this infection comes in waves and that’s its epidemiological pattern. What we are seeing is not strange, it has happened to other countries that have instituted some measures. So, I will not say that we have failed to control it.

The [second] wave went up because of the season of campaign. [Vote-canvassing and the 2021 elections ended in February while the second Covid wave in the country erupted in May, almost three months later, beyond the 42-day maximum threshold for the pandemic to manifest. – Editor]

This time because of the impact of the last lockdown, government had to take time to weigh … the risks and benefits of lockdown [and] we took time to take decision. On the side of us the citizens of Uganda, we took it (Covid) for granted because [during] the first wave, there was so much politicking and [some people said] that corona was not there and the Head of the State was using corona to stifle the Opposition from campaigning and that message sank into the people’s minds.

I think when the second wave came, people were still thinking about the previous message, but also, they relaxed because what we were seeing in other countries [mass deaths] did not happen here [in Uganda and] people took it for granted that this [second wave would be similar].

That after all last time people didn’t die, it was just mild and it is not a big deal; so, they relaxed. [It was alleged] that these people [bureaucrats] are just using [Covid] to steal money...

Secondly, we got so many mixed up messages that people got confused because everyone picks up anything and throws it on the social media and our people apparently tend to believe what they read on social media than what the scientist say. That is the problem. Also, the reopening [of] schools [caused a spike in infections].

Many schools feared to inform us that infections had entered schools and by the time we closed, many children had been infected and they took it to homes and [the students] became super-spreaders in communities.

Thirdly, we are a transit country and many people cross from other countries …[and] many of these people coming in were [had] forged results and that’s how we ended up getting different variants in our country. All these made this second wave a serious threat.

So, what did you do as a ministry when you saw people were not observing SOPs and other guidelines issued?
We had to do our part to prepare, we had to bring it to the attention of the taskforce and the entire country that we are heading into this kind of problem and we alerted people. We told them and we actually predicted the months that we were going to see the real massive deaths, which we are beginning to see now. So, it’s not really that we lost it [as a ministry], but people just relaxed.

Wouldn’t it have been logical to first test the students, and isolate those who test positive for Covid at schools, instead of  sending them to infect communities en masse?
We would have lost time to go and test every school in this country. Remember there are many day scholars who would come and study and go back home who were also super-spreaders… to test 15 million children is not a joke. Secondly, at schools there was some kind of indiscipline. Some of the children who were sick would not show symptoms and schools tended to concentrate on and isolate those who showed symptoms.

You have locked down the country again while allowing foreigners to come in and infect Ugandans, do you take responsibility for what is happening now?
I am not aware that Ugandans were not allowed to move. We put a ban on the public transport because that medium is a super-spreader. If I am a Ugandan coming back home, I shouldn’t be locked out of my country. The tourists bring in money. When they come, they come with negative results and when they arrive here, we test them again.

So, we allow them to move to their destinations freely because we are sure they don’t have infections. It is not equivalent to allowing public transport where everyone mixes.

Remember before we locked down, how the taxi parks were … a big super-spreader. Whatever we do, it is backed by science. We first analyse where the risks are and take actions based on assessed risks.

The Auditor General report on use of Coid-19 money shows that the Ministry of Health spent more than Shs100b without fully adhering to procurement rules. Some of the listed anomalies include irregular use of direct procurements, procurements without signed contracts, late delivery of goods, payments before receiving goods and failure to involve the contracts committee. What level of responsibility, as the Permanent Secretary, do you take for these anomalies?

It is quite an interesting thing. When they say we spent [public money] irregularly, I think that is not right. There is where there was money that was not going to be used and yet it could save lives. That Mulago (National Referral Hospital) was under construction and the contractor was on site, we had to agree that they vacate and we take over [the place] as a Covid-19 facility.

[For some] construction works, we had obligations to pay for certain certificates yet we had not received funds for that so to pick money from one section and put it to another, there is consensus between us and the Ministry of Finance. That is what the law [on virement] provides.

So, what should be done with the laws in regards to procurements and public finance management during the times of a pandemic?

We are not talking about spare parts of a car, computers or furniture. When we are dealing with human lives, there must be some special considerations. The law has its own advantages but when it comes to saving lives, we must ensure that we must first save lives. Which is more important; human lives or the law?

The Public Finance Management Act does not provide that leeway when you have epidemics. Let me give an example of the issue the Auditor General raised; giving advance on purchase of oxygen and Intensive Care Unit (ICU) equipment and test kits. Everyone in the world is scampering for the same commodity.

People come with upfront 100 per cent payment and take [the stock] and for you, you are still grappling with your [procurement] law! [The manufacturers] are not begging you, it’s you who needs those goods. Right now, we are supposed to procure oxygen plants, but all the manufacturers are fully-booked. Countries like India have booked all those machines and fully paid upfront.

Now I must order manufacturing of those machines and wait, now when the things come a little late, am I at fault? Why must I be lambasted for the delays by manufacturer when there are too many orders?

What rot did [the Auditor General] find; because ICU equipment came late? Was that my plan? Did I have power over the manufacturers? Did I have power of the shipment over how long it would take on the sea? So how can someone be faulted because the ICU equipment came late and it becomes a headline?

As a physician who took oath not to do harm, but to save lives at all times and all costs, there are certain provisions of the [Public Finance Management Act] law that I will have to ignore in order to save a life. If I need oxygen now, I must pay 100 per cent to procure the supply. Yes, someone will come and say you broke the law, but at least I would have saved lives.

We are rolling out Genexpert to all regional referral hospitals so that the turnaround time for getting [Covid test] results is shortened. Genexpert machine is able to give you PCR results in one hour, in the whole world, there is only one manufacturer of Genexpert cartridge and everyone is booking in advance with full pay to get those cartridges.

I have put the machines in all regional referral hospitals and the manufacturers are saying to hell with you if you are not paying fully for booking, so what do I have to do? In this circumstance, I will have to close my ears and eyes to the law, pay 100 per cent to secure the cartridges and put them in laboratories so that I am able to reduce the turn-around time for testing for Covid-19. Some of the laws of Uganda have issues and we need to put them into context.

Do you feel you are being unfairly criticised?
For me, I get sad when some people run after such things without putting them into context. These are not normal times; we are in the middle of the war. It’s like people expect that when people are dying in the middle of the war and someone comes up and says, ‘oh! I need a massage when others are dying’. We are obsessed with the law.

The law is good and I am a law-abiding citizen, but in situations like this, we first need to save lives before thinking of the law. For us, we are not in money-making venture … our daily work is to save lives so anything that stands in our way to save lives, we cannot stand it.

In emergencies, you must deal with the problem as it is. Epidemics … are expensive and you spend a lot of money to manage them. While we are talking about procedures and many things, when it comes to epidemics, we need to agree that we need to do away with procedures that stifle us.

When the money comes here, it comes to the budgeted lines.

Some people, either out of ignorance or out lack of knowledge, are shouting that you have not accounted [for money], even some of them are members of Parliament who sit on different accountability committees. How can we work in this kind of hostile environment? Isn’t that unfair to us?

Uganda is facing an oxygen crisis. Which company did you contract to supply oxygen at Mulago hospital and has it done its job?
There are companies that represent the manufacturers with whom we deal. You know in business you find companies that represent different manufacturers and those are the ones we deal with.

We have about five companies right now we are dealing with, though their details I don’t have them right now. On when the oxygen plants and cylinders will come, we don’t know. All we do is deposit money and wait, but here we are wasting time on laws. So how are we going to manage and secure these machines?

Have we deposited the money for the procurement of oxygen plants and the cylinders?
I am waiting for Ministry of Finance officials. Yesterday (on Saturday) we had our taskforce meeting and Cabinet is sitting (today) to approve the budget. Yes, the procurement has started, but it cannot be completed until you have paid the money. Engineers are installing one additional plant at Mulago.

How much money are we talking about to procure all these oxygen plants, ICU equipment and other facilities needed?
I don’t have the figures off head, but we had asked for Shs194 billion. However, not all this will come at once, it will come in phases. We want to put these oxygen machines in all regions. Even after Covid-19, these oxygen machines are very necessary.

The other time the President said we must prepare for 42,000 beds and that’s part of the budget we have presented. The other time [of the first lockdown] we presented [the budget] and they were not able to finance it. So, this time, I hope they will be able to get money for it.

On when the beds will come, it will depend on the manufacturers. You know we are supporting ‘Buy Uganda, Build Uganda’ programme because the President wants us to support our local manufacturers. There are two good (local) manufacturers that we have been showing the types of beds we want and they have really mastered it. But their challenge has been on getting materials from abroad because the same commodities are run after [by other countries]. So, we don’t know how long [the wait will be], but we shall continue to work with them. We don’t want to import beds from abroad.

The government by word of mouth is praising health workers as frontline risk takers in Covid treatment yet it is failing to pay them, why is this the case?
You know these allowances are supposed to be paid every day and these are a huge number of health workers and huge amount of money that is required. The money that we received was not enough to take us through, but only enough to pay for arrears.
We had not received money from the Ministry of Finance, which is struggling with cash flow [problems]. [But now] we have paid majority of our workers …

Why are Covid test results from government testing facilities, including Uganda Virus Research Institute (UVRI), not accepted at Entebbe International Airport when flying out of the country or while coming back?
What happened last year was when the airport was opened and we took a decision to allow people to come, people would come to us and test and pretend that they are contacts. So, we took a decision that they should pay for their tests to fly.

We later detected fraud because even in our systems, there are fraudsters who would register these people as contacts and pocket the money.  So, from that time, we said ‘no, private sector should handle that and whatever they do, we are not part of that’.

Before the second lockdown, the number of tests were always high – 8,000-plus – resulting in corresponding high positive cases. Immediately after lockdown was imposed, both numbers began reducing. Are the pandemic statistics being politicised?

We were doing many tests and many were testing positive because people were moving and that informs the decision to lockdown [the country]. Now many people are at home and the sick ones are confined either at home or hospitals and that explains why the tests are fewer and the rate of those testing positive are even lower.

How is the Ministry of Health prepared to conduct vaccination during lockdown?
We have made sure in metropolitan Kampala, we have put [vaccination centres] in different divisions where people can access easily. In districts, the team will be moving from one sub-county to another.

You started the inoculation with priority groups; health workers, security forces,  and teachers. This was followed by mass vaccination where the young dominated yet a few of them who catch Covid-19 suffer severe illness. Wasn’t mass vaccination a waste of limited vaccines?
We have not achieved the target of vaccinating the earlier target because when started, some people were hesitant. [That’s is why] we opened up to other people. But this small portion of vaccines [175,200 doses] we have received [in the second round] will be dedicated to the frontline workers and those who didn’t get vaccinated, but also [those receiving their] second dose.

In July, we are going to get more vaccines, about 800,000 doses, which will give us some boost. We are also expecting 300,000 doses from China that in total will be like more than one million doses. We had the target of 21.9 million vaccinations, but at least if we can cover the first five million - the vulnerable population - it will be much better as we continue to procure more vaccines.

President Museveni has repeatedly said Uganda is prospecting getting vaccines from Russia and Cuba, among other countries. What is the current status of those efforts?
Yeah, we were very excited to know that Cuba has come up with a very potent vaccine, we are going to approach them and we are approaching all manufactures who are open to us and who can allow us to purchase from them. We are going through the embassies because we cannot go directly to the manufacturers.

We are negotiating with Chinese embassy and government to see whether we can buy from them, but their vaccines are more costly than others. They cost $40 (Shs142,249) per dose [compared with $8 (Shs28,456) for Oxford-AstraZeneca vaccine dose]. We shall weigh the accessibility and pricing before making a decision.

Users of the Ugandan-developed Covidex say the herbal medicine works, but experts claim its production skipped established scientific protocol and approval. What is the government stand?
Covidex is a new drug locally-manufactured by our medical personnel at Mbarara (University of Science and Technology). I think they are yet to conduct the clinical trials. If the process is done and the results show positively, it will be approved by the regulator because for us, you know science does not lie.

We depend so much on data, we depend on evidence, once that is done, we welcome this initiative. I am really glad that he is being supported and we hope this medicine will be able to help us.

There is widespread public outcry about exorbitant billing by private hospitals for Covid treatment. Are these charges justified and, if not, why hasn’t your ministry intervened?
It is unfortunate that some private hospitals have taken advantage of the situation. As government we have a policy. We support private not-for-profit hospitals. Every financial year, we give them money though I don’t remember the amount of the money. We give them quite a lot of money and we agreed that we are giving you this money to subsidise the services and when you look at the mission hospitals, they have not been charging so exorbitantly because of the money we give them.

We give the primary healthcare services; we give them medicines; we even second health workers to work with them; and, we pay their salaries. But when Covid came, it was not possible to divide the resources between the government and the private [health facilities] because the demand was so much.

The management of this pandemic is very expensive and even we needed resources to take immediate need as government. In the first wave, we took over most of the patients and they [private hospitals] actually started complaining why don’t you accredit us so that we also treat Covid patients.

But I think some of them took advantage and started charging very exorbitantly. We didn’t know until patients started complaining, we started engaging facilities and asking them why are you charging this? Of course, they started saying we are hiring ventilators, we are hiring expensive equipment, we didn’t have money to do that but we had to do that, so they started justifying. But this discussion is still ongoing, we think there is a window that these people can cut their costs to a reasonable rate.

We do not have the law to push by force even if we told them. I think the best is for people not to go there. Unfortunately, people are desperate and sometimes they have nowhere to go, but to private hospitals.

They wanted us to give them equipment, money and Personal Protection Equipment, but at the moment, government does not have the money. On our side, we want to expand the bed capacity so that the vulnerable people who do not have resources come to public facilities, because even in our ICUs, government is paying for the sick.

What is the plan to manage other diseases, other than Covid, especially in the context of a lockdown?
The reason why we didn’t roll out Covid-19 treatment to all hospitals was because we knew that there are other diseases which we have to manage. We are handling all the other diseases. We only designated one section of the regional referral hospitals for Covid management and the rest of the sections are open.