The health of the nation

By Melina Platas Izama

Making sense of the contradictions and bipolar reality of Uganda’s health indices

Since Uganda hit 50 recently, it seems as good a time as any to check its vitals. There is the heartbeat of the economy and the temperature of the masses, the pressure of the politics and the weight of history. The health of this nation in one word? Resilient.

The Jubilee celebration was not made up of unfettered jubilation, as one might expect at 50 years of independence, but instead doused with a heavy coat of introspection.

The pristine Kampala Road, captured in black and white photos, is hardly recognisable today – replaced by a bustling, grating and downright stressful stretch of earth. But as cynics wandered and wondered aloud, are we better off now than we were a half-century ago? Teachers are striking, projects stalling, health clinics leaking staff, money, and drugs. Frankly, this version of events is familiar and exhausting.

The health of the nation is in part a function of the health of its people. And here we have some great stories to tell. The greatest story of all is the about the survival of children. In the last fifteen years, death in infants and young children has fallen by nearly 40%. The drop in child deaths was faster in the past five years than it has been in decades.  This is fantastic news.

When Uganda raised her flag for the first time, mothers across the newly birthed state could expect more than one in five of their children to perish before age five and 13% of newborns would not survive their first year. This year, as the flag was raised once more, the death of a child is not foreign, as it should be, but neither does it go hand in hand with motherhood.

The results of the most recent round of the Demographic and Health Surveys (DHS), which have been instrumental in documenting these trends, have just been released for Uganda. Conducted across the country in more than ten thousand households, the DHS has been conducted in 1988, 1995, 2000, 2006 and 2011. While there are a number of improvements to report, the story of child survival, particularly in the last decade, stands out. It is perhaps the greatest achievement of the new millennium in Uganda.

Maternal mortality and fertility rates have also fallen over time (albeit slowly), and immunisation rates are up. These facts and figures are at odds with the current narrative being batted about on the airwaves and over beers.  That conversation, on a daily replay, is a litany of grievances, tales of waste and shameless extravagance that has brought society to its knees.

The odd thing is that both versions of reality are accurate. Remarkable progress in health outcomes, particularly child health, has come alongside spectacular corruption, carelessness, confusion, and even criminal activity in the health sector. How do we reconcile these seemingly contradictory trends?

The standard account of health care in Uganda is a sector littered with dilapidated health facilities offering little to their desperate patients. This depiction, usually spiced with some particularly dismal anecdotes, is often fair. The 2007 Service Provision and Assessment Survey (SPA), which studied a representative sample of Uganda’s health facilities, found that only half of government health facilities and a third of private health facilities offer “all basic services”, which includes outpatient curative services, family planning, antenatal care, immunisation, and child growth monitoring. Hospitals and HCIVs were the best equipped and staffed, while HCIIs and HCIIIs fared badly, and were particularly poorly equipped for birth delivery. This is hardly a resounding accolade despite the good news in child health. So who, or what, is saving lives?

Unlikely saviour

Uganda is not an outlier in declining child mortality, but part of a broader trend throughout the region. Uganda’s infant mortality rate, at 54 deaths per 1000 births, is nearly identical to those in Kenya, Rwanda, and Tanzania. A study by the World Bank’s Demombynes and Trommlerova found that using insecticide-treated bednets was responsible for the majority of the decline in child deaths in Kenya. Dramatic improvements in child health are happening across the continent, from Senegal to Zambia. The frequent mismatch between health inputs and outputs is welcome but puzzling.

It’s quite possible that in Uganda, as in Kenya, attacking malaria head-on is the primary factor in saving children’s lives. There has yet to be a comprehensive study on this question, but some additional statistics are indicative. In 2009, a shocking 52% of children randomly sampled from across Uganda tested positive for malaria, and malaria is estimated to account for a third of all deaths in children under five. In 2007, 70% of children observed in health facilities were diagnosed with malaria, and nearly all of them received anti-malarial treatment, according to the SPA.

But malaria is also one threat that parents can help their children escape despite general disrepair in the health sector. In 2011, three-quarters of all households surveyed had some kind of bed net, and 60% had an insecticide treated net. Four in five children with a fever were taken to a health facility, provider, or pharmacy, and 40% took antimalarial medication the same day. Health facilities may lack many things, but about 80% have first-line anti-malarials. Stock-outs are common, however. Unlike adults, who are often incorrectly diagnosed (usually by themselves) for malaria and whose overzealous use of antimalarials is a menace to future drug efficacy, in children in Uganda, if it looks like malaria, it probably is.

Just squeaking by on critical medicines and staff is not an acceptable state of affairs, but it might be enough to save many lives. And when people can prevent or treat illness themselves, government provided care becomes less critical. Still, government healthcare can and should provide essential services to the populace, most especially those who cannot afford quality private care. Too often it does not. Why?

Health sector financing in Uganda is neither sufficient nor efficient. A brouhaha in parliament recently erupted over whether health or defense should receive more money. Opponents of additional health funding, including the Independent’s Andrew Mwenda, argued that the health sector is not currently structured to direct health funding and services to those who need them most. From this perspective, hurling cash at a stumbling, lumbering health sector is an exercise in futility. Mwenda pointed to a health budget that has ballooned in size from Ushs 58 billion to over 800 billion in fifteen years, with few noticeable changes in the quality of care.

Indeed, study after study reports heart-stopping wastage, so it would not be surprising if the amount actually spent on health changed little over time. It’s not clear, however, how much we should expect from current expenditures on health even if there were no leakages. This year’s health budget, larger than any other to date, is set at Shs 742 billion in the Ministry of Finance’s 2012/2012 Background to the Budget. Shs 100 billion of this is donor project support and Shs 240 billion is allocated for wages. Let’s say this leaves Shs 400 billion for all other health expenses, and let’s further say that there are 35 million Ugandans who are eligible to receive government health services. This means there is Shs 11,000 (about US$5) to spend on each person after all the health workers are paid – US$5 per person for drugs, supplies, operation and maintenance, capital costs, and more. Health economists have estimated that a basic package of health services in developing countries costs between US$28-40. Even Houdini could not wiggle his way out of this one. There simply is not enough money for health.

Donors have scrambled to the cash-strapped sector with their favourite projects in mind, from HIV to maternal health. These projects and programs have saved lives. But they have not saved the health sector. New projects pop up weekly, and often weakly, as money is thrown from one emergency to another. There is no shortage of real health crises, but we are tripping over one another in our many efforts to solve them. From the perspective of the Ministry of Health, it is difficult to turn down fully funded projects, however distracting or redundant. So the ministry has its hands more than full, and long-term policy plans get stuffed into a drawer.

The mad dash to save lives NOW is like yelling “fire” in a theater. Everyone has a legitimate reason to run, and run you do – right into your neighbour. There should be someone who takes charge, who has a plan for everyone, who does not get caught in the chaos and does not get pushed around. That someone is the Ministry of Health. But right now it looks like they have tripped and hit the deck, splayed out on all fours. They have been down there for some time too, possibly because we are getting by, somehow.

The story of child survival is among the best out there. It is a story that leans into the wind against the barrage of missteps, mistakes, and missed opportunities, against the loudly voiced grievances and quiet disappointment. There are still many outstanding health challenges, even emergencies. HIV prevalence, after many years of stagnation, is again on the rise. Rates of malaria in children are shockingly high. Maternal mortality is not falling fast enough. Treatment for cancer and other non-communicable diseases is virtually inaccessible for the majority of the populace. Malnutrition is still a scourge in a land literally flowing with milk and honey.

It’s quite a fix. And yet – the struggle for better care, aggressive demands on government, ever-higher expectations – this is the stuff of which our 50-year old mzee kijana is made. Sprightly. Cantankerous. Resilient.

The Numbers

• Shs 742 bn budgeted for Health in 2012/2012
• Shs 100 bn of this is donor project support.
• Shs 240 bn is allocated for wages.
• Shs 400 bn for all other health expenses
• 35 million Ugandans require government health services.
• Shs 11,000 (about US$5) left for each person.
• Shs 70,000 – 100,000 (US$ 28-40) is recommended basic for health services in developing country.