Uganda is among the low- and middle-income countries of East Africa, has a current population of 28 million, and is rapidly growing at an annual rate of 3.4% [12, 15]. Musculoskeletal injuries, mainly due to road traffic crashes, are common and on the rise and have a major socioeconomic impact. Resources to manage this epidemic in the country are scanty, resulting in high mortality and morbidity. This article describes the current situation to highlight the problems and recommend possible solutions.

Based on personal experience and literature review, a situational analysis of the burden of musculoskeletal injuries in Uganda is presented. Data sources include the Injury Control Centre in Uganda for the period August 2004 to July 2005 about patterns of musculoskeletal injuries in five regions of Uganda [4] and the National Planning Authority of the Republic of Uganda, Working Draft for National Dialogue of June 2005 [12]. Other sources of information include official documents from the Ministry of Health of the Republic of Uganda, namely the National Health Policy of September 1999, Health Sector Strategic Plan 11 of 2005/06–2009/2010 Volume 1, and the Financial Year 2006/07 District Transfers for Health Services of July 2006 [2, 3, 11].

The health sector budget is 9.4%, and the per capita amount spent on health throughout the districts is US$ 4 [11, 16].

Uganda is divided administratively into more than 45 districts (LC5), which are further subdivided into counties, subcounties, parishes, and villages. There are 39,692 villages or local councils (LCI), 4517 parishes (LC2), 893 subcounties (LC3), and 167 counties (LC4). The health service infrastructure follows this pattern, with health centers of increasing capacity (designated HC1, HC11, HC111, and HC1V) [11]. The health referral system starts from the lowest health unit (HC11), which serves a population of approximately 5000 people. It provides outpatient care, antenatal care, immunization and outreach, and is manned by an enrolled nurse, enrolled midwife, and two nursing assistants. An enrolled nurse or midwife is a certificate holder and not registered. HC111 serves a population of 20,000 people. It provides, in addition to the services of HC111, inpatient services and environmental services. Its staff includes one clinical officer, one enrolled nurse, two enrolled midwives, one nursing assistant, one health assistant, one laboratory assistant and a records officer. HC1V, which is a health subdistrict unit, serves a population of 100,000 people. It provides all services of HC111 plus surgery. It supervises all the lower health units, collects and analyzes data on health, and plans for the health subdistrict. It has at least one medical officer, two clinical officers, one registered midwife, one enrolled nurse, and one enrolled midwife, one comprehensive nurse, two nursing assistants, one laboratory technician, one laboratory attendant, one health inspector, one dispenser, one public dental assistant, one anesthetic officer, one assistant health educator, one records assistant, one accounts assistant, and two support staff. The district hospital (general hospital) serves a population of about 500,000 people. It is a 100-bed hospital, which provides preventive, promotive, and curative outpatient services, maternity, inpatient health services, emergency surgery, blood transfusion, laboratory, and general services. It also provides in-service training, consultation, and research in support of the community-based healthcare programs. It is equipped with two operating theatres, facilities for sterilization, diagnostic services (imaging and radiography), laboratory services, waste disposal, and mortuary services. The unit has running piped water and is connected to the national electricity supply. In addition, emergency power supply in the form of electric generators and solar is available. The budget for a general hospital is equivalent to US$147,000 per annum [2]. Two orthopaedic officers are available at this level to provide musculoskeletal services. Other staff at this level include, among others, one principal medical officer, one medical officer special grade (has a master’s degree in community medicine), four medical officers, one dental surgeon (degree holder), two public health dental officers (paramedical diploma holder), one principal nursing officer, five senior nursing officers, 17 nursing officers (nursing), and three nursing officers (midwifery) [3]. the regional referral hospital serves a region with both general and specialist services and the national referral hospital is at the national level for teaching, research, and specialist patient services. The hierarchy of referral progresses through health centers, district, regional, and finally the national referral at the apex (Fig. 2). There are two national referral hospitals, 10 regional, 56 district, and 250 subdistrict facilities (health center IV). Medical officers and paramedical staff are posted from health center IV and above. Specialist services are only available at the regional and national level. The orthopaedic surgeons are concentrated in Kampala (18 of the 23) with the other five in four units (Fig. 3).

Fig. 2 Referral system and services provided. Musculoskeletal services are offered from the general hospital level as the lowest unit, where there are basic resources. The complicated cases are referred to the regional and national level.

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Fig. 3 Orthopaedic surgeons are concentrated at the center in the capital city, with few at the regional hospitals.

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Limited orthopaedic care at the district (general) hospital is provided mainly by the orthopaedic officers with the support of medical officers. At the regional level care is principally provide by general surgeons and where available orthopaedic surgeons. A medical officer has a bachelor’s degree of medicine and surgery and is capable of providing general medical services, pediatrics, obstetrics and gynecology, and general surgical services. They are capable of doing limited obstetric and emergency surgery including herniorrhaphies, Caesarian sections, laparotomies, débridement of open fractures, and fracture stabilization by casting or traction. The clinical officers are paramedicals with diploma qualification. They are capable of providing general medical care. They cannot perform major surgical procedures, but can perform minor surgery limited to surgical toilet, sutures, and draining of abscesses. The orthopaedic officers are also paramedical and have diplomas by qualification. They can manage most simple orthopaedic conditions and are trained to detect and treat fractures by nonoperative means, have experience in plaster techniques, traction methods, nursing care of orthopaedic patients, treating of clubfeet using Ponseti method, etc. They can detect complicated orthopaedic problems and refer patients to orthopaedic surgeons. There are over 200 orthopaedic officers distributed countrywide. Fractures at the lower-level care centers are mainly managed nonoperatively, while at the regional and national referral levels, both nonoperative and operative methods are practiced. Delay for surgery at the center is common due to a shortage of anesthesia, operating time, irregular availability of supplies, and shortage of manpower.

Surgical services at the Mulago orthopaedic department includes an emergency theatre that runs daily, three operating days for elective surgery, and a separate theatre two times a week for infections. On average 1400 surgeries are performed per year: 500 emergency cases, 500 infection cases, and 400 elective procedures.

Some patients with fractures are treated by traditional bonesetters with manipulations and locally made rigid splints, and some by telepathic (psychic) means. A subset of patients develops serious complications including compartment syndrome, infection, malunion, nonunion, and joint stiffness. Amputations have sometimes been necessary in children who present with gangrene following treatment of supracondylar fractures of the humerus by traditional bonesetters.

Prehospital care is also poor and contributes to high mortality and morbidity. Data from a dissertation at Mulago suggested out of a total of 378 patients with severe musculoskeletal injuries admitted at the accident and emergency department, only 28% arrived within 1 hour of injury [14]. Ambulance personnel, police, and laypeople retrieved patients 2.4%, 12.4%, and 85.2% from injury scenes, respectively. In patients requiring circulatory stabilization, splintage, and intravenous infusions only 31%, 14%, and 11% received the appropriate treatment [14].

Training of health workers in their environment is a crucial factor at all levels to ensure a sustainable supply of personnel [1]. The Department of Orthopaedics of Makerere University began a master’s program in 1996 in collaboration with Health Volunteers Overseas (HVO). It has a faculty of eight orthopaedic surgeons who train 100 medical students per year, 16 orthopaedic residents on a 4-year program, and 100 orthopaedic officers (paramedical) per year. The orthopaedic residents’ musculoskeletal training is a postgraduate training program. It includes knowledge of basic sciences, which is done in the first year of training, and biomechanics, musculoskeletal trauma of all limbs including the spine and pelvis done during the second year of training. The program includes both theory and practical exposure in the clinical area. The orthopaedic officer training program is a 3-year training program leading to the award of a diploma in clinical orthopaedics. The course content includes essential knowledge of basic sciences done in the first year, then theory and practical knowledge of fractures, bone and joint infections and other orthopaedic conditions, plaster techniques and traction methods, and nursing principles. There are approximately 300 orthopaedic officers working in both government and private hospitals. They are certified to treat fractures by nonoperative means, which includes traction and casting. They are also allowed to see and treat other orthopaedic conditions, but may not perform surgery. They improve their skills through experience, continuing professional training, and through support and supervision by the orthopaedic surgeons.

In addition, the College of Surgeons of East Central and Southern Africa (COSECSA) has started a fellowship program in orthopaedics. This is a 5-year postgraduate program offered by the College to registered medical officers who train at accredited hospitals to the college. The program has courses in basic sciences, acute trauma management, and general surgery completed during the first 2 years of the program, followed by detailed theory and practical knowledge in orthopaedics and trauma during the last 3 years of the program. After the first 2 years, an entry exam leading to the award of MCS (Orthopaedics) is taken, and then an exit examination is completed at the end of the fifth year of training leading to the award of FCS (Orthopaedics).