The Independent Uganda: You get the Truth we Pay the Price
THE LAST WORD: By Andrew M. Mwenda
Why nations that are different exhibit similar health service dysfunctions
I have been rereading Melle Leenstra’s 2012 book, `Beyond the Façade; the instrumentalisation of the Zambian health sector’. It offers an interesting insight into the challenges that central African nation faces in its attempts to provide quality healthcare to its citizens. It reads like a story of the healthcare system in Uganda or any other poor country. Let us cite the book at some length.
“In the ward of a provincial hospital, some patients lie on mattresses on the ground. Many have delayed their coming having first tried the services of witchdoctors or first saved enough money to be able to afford medical care. Other ill people prefer not to come at all, considering hospital places to die rather than places to get better. In the corridors, family members flock in attendance, bringing extra food and caring for the needy. The walls bear posters teaching the ABC of sexual health beside handwritten posters professing the values of public service.
“Nurses enviously eye the doctor’s new Pajero and complain that their allowances have not been paid yet. Some patients are vexed by nurses’ rudeness and complain that drugs are out of stock. The doctor has not shown up today; maybe she has gone to moonlight at a private clinic or is attending a workshop, earning something extra as money is never sufficient. From time to time, the nurses are mobilised by the union to demand higher salaries and extra allowances from government.
“Meanwhile the laboratory technician checks blood samples and compiles horrific statistics, relieved that this month he has received their proper reagents. In the evenings, he studies, perhaps his correspondence course will bring him the qualifications to move on to a better life in South Africa or beyond. In a distant rural health centre, one can see a health worker, overworked, underfunded and yet still showing up to work, immunising children and supervising deliveries, while a cleaner is screening patients and giving them drugs.
“The limited resources government provides are inventively stretched as far as possible. Further away, a radio transmits the voice of an opposition candidate. She curses the government for incompetence and corruption and promises better education and affordable healthcare.”
I have read similar accounts of healthcare challenges in Ghana, Senegal, Tanzania, Kenya, Benin and Malawi among others in Africa. I have also read academic papers and books on the healthcare systems of India, Nepal, Pakistan, Bangladesh, Sri Lanka, Afghanistan, El Salvador, Nicaragua, Peru, Vietnam, Cambodia, Laos, etc. and the story reads almost the same as Uganda and these other African countries.
Why do nations so distant from one another geographically, racially, religiously, historically, politically, culturally exhibit similar characteristic dysfunctions in delivering healthcare to their citizens? I suspect it is because they share one existential predicament – they are all poor.
We all think the healthcare system in Uganda is in a mess. Many people think this is because President Yoweri Museveni and his government lack incentives to serve the people since they have little risk of losing power. Therefore, if an opposition party threatened them sufficiently, they could pull up their performance socks; or if the opposition won, someone like Dr. Kizza Besigye would fix these problems.
Experience of many poor countries has led me to believe this assumption may be theoretically convincing but it has empirically proven to be false. Zambia is the ideal country when it comes to our common view of how a democracy should work. Since 1991, it has witnessed six peaceful changes of government and in three of them an opposition party and candidate has defeated an incumbent ruling party and president.
Yet while the story above only shows how Zambia’s healthcare system is similar to that of Uganda, that central African nation is much richer than ours and spends twice more money per person than the pearl of Africa. Uganda’s nominal per capita income is $620 ($2,003 at PPP). Zambia’s is $1352 ($3852 at PPP), Ghana $1402 ($4291 at PPP), Senegal is $913 ($2456 at PPP) and Kenya is $1,434 ($3,218 at PPP).
Per capita income predicts per capital spending. Thus while Uganda’s per capita spending is $155 this financial year in nominal dollars (or $510 in PPP) that of Zambia is $425 in nominal dollars (or $1,211 in PPP), Ghana is $445.26 ($1361 in PPP), Kenya $438 ($985 in PPP) and Senegal is $333 ($895 in PPP). All these countries are richer than Uganda and spend more than twice on a per capita basis. Yet they perform only marginally better than Uganda and in some instances marginally worse than it.
Only Rwanda among poor countries performs differently. It does not have many of the problems of the nations in its comparison group – overcrowding, drug stock-outs, absenteeism by health workers, etc. Its per capita income is $732 ($1,810 in PPP) and its per capita spending is $221 ($545 in PPP). Rwanda is the jewel. It demonstrates that even with less money more can be done. It performs far much better both in healthcare outcomes and quality of service delivered. Its near-equivalent is Cuba but that Caribbean nation has a per capital income of $7,274 ($10,200 at PPP).
But, in spite of its myriad problems, the state in Uganda performs better than nations within its comparison group on health outcomes like infant and child mortality (which have the most powerful influence on life expectancy), immunisation, malaria prevalence, maternal mortality, control of epidemics and the ratio of women attending antenatal care at least once during their pregnancy. I used these outcomes as proxies for the effectiveness of a nation’s healthcare system.
Thus even with all its corruption and incompetence, Uganda outperforms Ghana, Zambia, Kenya, Senegal, in efficiency i.e. if you factor in the ratio of money spent per person and the healthcare outcomes it gets. This has led me to look at Museveni and his government in an entirely different light and even shade many of the biases I used to have.
Finally, I looked at healthcare systems in two states of India – Kerala and Rajasthan which show that indeed, even in the same country, healthcare outcomes can be different. Healthcare systems in Kerala work (hardly any absenteeism or drug stock outs) and Rajasthan has the opposite behaviour.
The challenge of India is how to make Rajasthan perform like Kerela. The challenge of poor countries is NOT how to become Sweden but how to become Rwanda. Yet this conclusion may be simplistic because the conditions that make Rwanda possible are rare to find and difficult to recreate.
****
amwenda@independent.co,ug
****
editor@independent.co.ug
While the “conditions that make Rwanda possible are rare to find and difficult to recreate”, one thing we learn from Rwanda is that it is possible provide decent health care even with little money. We don’t need to recreate Rwanda, we only have to do things differently. Using failure as yardstick for comparison is both intellectually and politically disingenuous. We are all too painfully aware that most of the policies that have been crafted and failed in Uganda, have perfectly worked in Rwanda. We are also aware that while Rwanda’s existential predicaments are different from Uganda’s, it is managerial efficiency that has produced the jewel of Rwanda. If Museveni has professionalized and created discipline in the army, he can do the same to the public service sector. Why he and his government has failed in the latter, is fodder enough for suspicion of government’s limited commitment to serve its citizenry!
Denis,
You cannot easily compare the army with the civil service. The former belongs
to a set of ‘disciplined’ professions – in which authority is rarely challenged
– (and if so, with serious consequences). A clear headed authority – as M7 and
PK are – will more likely shape the army as we are seeing today. The civil
service is a mixed bag of a full range of people: some think they are
untouchable ‘experts’, others, even when they know they are ignorant, claim and
challenge authority under guise of ‘rights’, ‘equity’, ‘politics’, etc. That is
one part of the problem in Uganda. The 2nd part has to do with what contributes
to Successful Management. It is not just the ‘Manager’ but the ‘Managed’ –
whether human or other resource as well. Independent Uganda’s human resource
weaknesses started well before M7 came on the national management scene –
perhaps about mid 1960s – when you had a forced exit of some ‘educated’ people
and the nucleation of ‘Mwana wa Ggundi’ culture. Since that time, a variety of
factors have nourished this problem, which in turn has manifested itself in
offshoot symptoms as the various forms of corruption we are seeing today.
Rwanda had an exodus of people even earlier than Ug Yes. But these were in
short high pitched waves. Those who remained in the civil service were
sectarian – Yes – but the decadency attributable to non-human resources was nowhere
near Uganda’s demise of mid 70s to mid-80s. There are other factors which led
to differences in ‘success rates’ of PK and M7 – which Andrew and others have
discussed in the past. I do not have to repeat them here.
But back to Andrew’s point of ‘poverty’ and inability to provide ‘good’ health
services: I fault him for not looking beyond ‘poverty’ per-se. He has in the
past fronted this same ‘animal’ for governments of underdeveloped countries to
fail to provide other social services as well. Is it possible that ‘poverty’ is
just one of the symptoms of an underlying cause? His long time hero, Obote, had
identified ‘Ignorance’, ‘Disease’ and ‘Poverty’ as the principal enemies of the
country. I put it to all and sundry that the latter two might be a result of
the first. And that since we are all born ‘ignorant’, it is our struggles to
come out of this ignorance that count in whether we remain relatively poor, and
therefore unable to emancipate ourselves from the vices Obote and ‘son’ Andrew
cry about. There might be a word for reluctance to struggle out of ignorance:
“Laziness” – in different manifestations such as ‘Mental’ and ‘Physical’ – some
may even add ‘Spiritual’.
I guess at an appropriate time and in a suitable medium, I’ll have time to
explore this line of thought.
Eng. Kant Ateenyi Kanyarusoke – Cape Town.
1.Is a good health system all about drugs,equipment and medical personnel?i dont think so ug has all these but our health system is in bad shape..
2.In Ug management in Hospitals can’t procure basics like Tissue,disinfectants, detergents, patients compete with snakes for space in the compound.
3.When you check the pay roll you find so many causal workers but the hospitals are always dirty.
4.Africans believe that there is a very big fat man called ideology who will one day solve all our problems.
5.Doctors have now become money minded you find a surgeon pocketing 8 million in just one operation how do they get this money?they steal surgery equipment from Mulago and take their patients to private hospitals for operation.
6.I have never understood why Mgt in hospitals cant buy uniforms & bedshhets for patients and washing machines to clean their clothes you find Omeros dressed in a gomesi doesn’t this cause more infections?
7.For us ladies, we call Kanyamunyu “Mathew”‘ he is the kind of man our aunties would be happy to recive.
To the independent.co.ug webmaster, Your posts are always interesting.
Dear independent.co.ug webmaster, Your posts are always a great source of knowledge.