Health is made easier with money

By Sarah Namulondo

Two former bosses of Mulago Hospital explain why 50 years later, Uganda cannot offer colonial standards health care

Lawrence Kaggwa was possibly 15-years old when Uganda got her independence from British colonial rule in 1962. He recalls admiring the medical workers in his village in Masaka; the way they dressed, the cars they drove, and the money and affluence they appeared to have. That prompted him to aspire to become a medical doctor.

Fifty years later, Dr Lawrence Kagwa, now a retired former director for 12 years of Uganda’s leading medical facility, the Mulago National Referral Hospital in Kampala, is rueful.

“If I was young,” he asks, “would I feel the same way about the medical profession?”

Prof. John Ssali, another celebrated veteran of Uganda’s health sector was 27-years old at independence and vividly recalls the prestige associated with the medical profession and sector at the time.

Now aged 77 and still in active service at the privately-owned Kampala Hospital, the former head of the Department of Surgery at Mulago Medical School recalls the good salaries.  “We even used to buy new cars and would always buy full tanks of fuel,” he says, “This tendency of buying litres of fuel came recently; you would even never find medical doctors or workers boarding taxis to work just like the norm now.”

So what has gone wrong in the health sector since the good old days at independence?

Mulago National Referral Hospital, which was colonial Britain’s independence gift to Uganda, is a good place to start when searching for answers about the health sector in Uganda.

Just as in 1962, Mulago Hospital is today the main health facility in Uganda. But unlike 1962 when it was the most modern hospital in Africa, with services and facilities comparable to any found in Britain at the time, Mulago is today a run-down relic.

Prof. Ssali says although there were very few Ugandan medical professionals and most specialists were whites in the 1950s, as independence drew closer, more Ugandans and Asians were sent abroad to study professional medicine. He vividly recalls that when he went to Britain for his post-graduate degree studies in medicine, the level of professionalism and efficiency in Britain was comparable to that in Uganda then.

After independence, then-president Milton Obote’s government boosted the health sector by building 22 hospitals accessible in all the four provinces of Uganda then; Buganda, Eastern, Northern, and Western province.

Although the hospitals were few, the drug stock was enough for the then population which was just five million.

At the time, the hardest diseases to treat were Burkit’s cancer in children, intestinal obstructions, hernia, and tropical ulcers; a disease that has disappeared since Ugandans took to wearing trousers.

Although cars were few, Dr Ssali recalls that there were many road accidents, and, as a surgeon, he had to treat the most complicated cases.

Dr Ssali’s face lights up and his soft squeaky voice goes a notch higher as he describes those exciting days.

“General anesthesia was given to patients,” he says, “but in situations where the patient was pregnant, we would only put a wooden bit in the mouth and then carry out the operation without anesthesia. There are even times when the drugs and anesthesia were not there and we were forced to operate without anesthesia.”

He says throughout the 60s, through the darkest Idi Amin 1970s to the 80s, it was unheard of to see a patient sleeping on the floor of a hospital while receiving treatment as is the case today.

“Sometimes the hospital beds would be empty; but yet again the people were very few,” he says, “Patients used to have telephones next to their bedsides like it is in the private wings now. The patient to doctor ratio was good.”

With hindsight, however, Dr Kaggwa says Uganda’s health sector possibly started going down when then-president Milton Obote made the so-called Nakivubo Pronouncement on Labour Day 1970. Obote was implementing the Common Man’s Charter, also called “the move to the left” of his socialist-leaning Uganda Peoples Congress party ideology. Effectively, it nationalised all businesses and the former owners, mainly Asians and the British started pulling out of the economy and the social sector.

“They thought their former colony was giving into Russia and throwing away everything they had put in place for Russia to get for free,” says Ssali.

Obote was over-thrown in 1971 but Gen. Idi Amin who succeeded him made a bad situation worse when in 1972 he expelled the Asians out of Uganda. The ensuing political turmoil in Uganda adversely affected the health sector. Most of the social determinants of health were destroyed including the schools, roads, water, and electricity supply. The health sector now faced dark times.

With the departure of most British experts, the only specialists left had been mainly Asian. When they were forced out, the Amin regime pushed the few remaining specialists, mainly white doctors, to work long hours, under pressure and insecurity.  Security agents became an unwanted presence almost every day in the hospital corridors which scared even some Ugandan doctors. They fled into voluntary exile in Britain. Most got good jobs and salaries and to date some have never really returned.

‘‘I realised the situation was worsening when the operation gowns became scarce, so as a surgeon you had to improvise where by you would take off your shirt and remain in a vest if you had one, then wear an apron and roll your trousers up so that at the end you would only discard the apron.

“Those were bad times because blood would spill on you,” Ssali reminisces.

Population trouble

Switching to the present, Dr Kaggwa says the current rapid population explosion is the main hindrance to the provision of good health services. Uganda has one of the fastest growing populations in the world at 3.3% per year and a fertility rate of 6.9 children per woman. The population seems to be doubling every 20 years. In 1984 it was 14 million, 28 million in 2007, and 33 million in 2011. This suggests the Uganda’s population might hit 60 million in 25 years. That is a worrying figure given the degree of planning and rate of socio-economic development in Uganda. With the health sector budget underfunded by 50%, the reality is that net financing per capita will fall. In turn, this will increase private-out-of-pocket health expenditure.

The World Health Organisation recommends the Government’s minimum level of funding for basic health services of US$34 per person. For Uganda, the current health expenditure per person per year is US$18 (Approx. Shs 45,000) with the government contributing only 20% and donors 22%. The public (out of pocket payments) has to pay the remaining 58%.

Dr Ssali says from 1986, when President Yoweri Museveni took power, rehabilitation and recovery of the entire socio-economic sector started.  Dr Ssali was a senior lecturer at Mulago medical school in 1988 and later became Associate Professor in 1990 and professor and head of the Department Surgery Mulago Medical School until 1993; the same year Dr Kagwa was named director of Mulago Hospital.

From 1994, Dr Ssali was the head of surgery in Mbale Hospital.

His position required him to visit all hospitals in then-Eastern Region which stretched up to Karamoja. One thing he finds funny is that then patients always expected to get healed and if they died there relatives would blame you or even curse and bewitch the doctor which has quite changed now.   “Karimojongs had this notion of medical workers as miracle workers,” he says, “In circumstances where the patient died the doctor/surgeon had to flee for their lives as the Karamonjongs would postpone burial until they killed you.”

He says medical treatment was not quite embraced in the early days and doctors had to comb the villages looking for patients. The only thing that drove people to look for modern treatment was a disease that had beaten all local herbalists; the disease was gonorrhea.

Sexually transmitted diseases have been critical in the evolution of health care in Uganda. Today, HIV/AIDS is driving health care policy and budgets.

But Dr Ssali says the Father of Modern Medicine in Uganda, the British Missionary Sir Albert Cook, started what later became a government hospital in 1913 on Mulago hill to treat three main ailments; sleeping sickness, yaws, and Gonorrhea. At the time, Mulago was a 22 bed-contraption of reed walls and grass roofs.

Fifty years later at Independence, that contraption had morphed into the best health facility in sub-Saharan Africa. It had experts who did research, trained nurses, and treated complicated cases from as far as Burundi and Sudan.

Mulago was the leading teaching and referral hospital in East Africa. Its wards were supervised by world famous doctors like Dr. Dennis Burkit, who discovered Burkit’s Lymphoma and pioneered its treatment.

No money

But by 1993 when he was appointed its director, Dr Kaggwa, who is now the Technical Resource Consultant at Amref, recalls how bad Mulago had become.

He says the water system had failed, water and electricity were irregular, the Intensive Care Unit and the Laboratories were down, electrical wires were old, and the roofs in old Mulago were leaking.

“It was a mess,” Kaggwa recalls.

Soon after his appointment, Kaggwa recalls that he met the Japanese ambassador in Kenya who gave the hospital US$ 2.2 million. Japan had no embassy in Uganda then. Together with a US$35 million loan from the African development Bank, they set about rehabilitating the hospital.

He says he introduced a staff training system in Mulago where staff was sent to train in Nairobi, Japan, UK and USA in specialisations such as plastic surgery, neurosurgery, urology, cardiology surgery, cancer management, oncology, and Intensive Care Unit.  “This helped improve the health sector since Mulago is a teaching hospital the trained nurses were required to come back and train others from Mulago who did not get a chance to go abroad,” he says, “this broadened the knowledge of Ugandans who now didn’t have to come to Mulago but could stay in their home areas and access treatment from their in various diseases.”  Dr Kaggwa says they built Assessment Centres in Old Mulago, the Johns Hopkins Research Centre, the Baylor Clinic for Pediatric HIV/AIDS, and the Infectious Disease Institute for HIV/AIDS in adults, the Cancer Complex, and the Bulk Drug Store.   Still, due to competition for the limited funds, the health sector continues to receive less funding than the 15% of the national budget agreed under the 2001 Abuja Declaration.

The Ministry of Health has produced a Health Sector Policy (2010-2020) and a Health Sector Strategic and Investment Plan all of which derive from the National Development Plan and the UN’s Millennium Development Goals (MDGs). The plans cover public private partnerships, laboratory services, HIV/AIDS, malaria and TB. Other areas covered include maternal and child health, sexual and reproductive health, communicable diseases control, research and epidemic management.

As a result, the health sector performance indices are improving. Infant mortality has improved from 76/1000 to 54/1000, the under-five mortality is 137/1000 to 90/1000. Only maternal mortality remains high at 438/100,000 live births. The HIV/AIDS epidemic remains one of Uganda’s biggest problems as prevalence rates go up to 7% nationally.  Dr Kaggwa says health sector planning is not accompanied by a commensurate budget and depends on donor funding. This is coupled with a poor culture of repair and renovation leading to severe damage of the infrastructure.

Kaggwa says for the health sector to improve, individuals must be willing to take full responsibility for their health by adopting health behavior and lifestyles from their homes, their immediate neighborhood and environment at large.

“This will help reduce the disease burden which is mainly communicable diseases by 70%,” he says.   He says individuals should also find alternative funding mechanisms for health, such as health insurance schemes, which will deliver the population from catastrophic expenditures on disease management.  “Health is made easier with money,” says Kaggwa.

This philosophy appears to have been shaped by his early years in the 1960s. He says the 1960s health sector was efficient in his coffee-growing village in Masaka, central Uganda, partly because the people had money.   “Masaka never had health problems since it was a rich region,” he says, “people used to buy prescription drugs off the counter and kept them in their homes. It was a region for coffee farmers a highly sought after cash crop then.”

Finally, Dr Kaggwa wants enforcement of the patient’s charter, which empowers the population to demand quality services, gets the government to account for the failures in the health systems, and obliges clients to take care of their health and comply with the recommended normal health behavior and response.

Vision for the health sector in the next 50 years

• To promote public health (water sanitation lessons),   in the communities, schools, cultural settings and enculturation into the communities as the normal accepted way of behavior.
• Total rehabilitation and upgrading of the existing infrastructure and add more infrastructures to take care of the population density and new technological advancement.
• Appropriate recruitment and motivation of the health workers, considering the density, work load, skill mix and commensurate health facilities.
• Promote supply, demand and access of the communities to health facilities.
• Promote high standards of clinical care to reduce referral of patients abroad which makes the country lose out on all the money spent abroad, and increase investors’ confidence due to quality and reliable health services and encourage insurance companies to provide health as one of their products.
• Increase funding for the health sector especially after doing purposive unit costing of each health intervention before spending budget money.