Why putting more
money into the health sector is like putting more meat in a butchery controlled
by hyenas
The recent
“stand-off” between parliament and President Yoweri Museveni on whether to
allocate Shs 39 billion to health or defense is one of the many false debates
about the budget process in Uganda. An uninformed observer may easily think
that there is a serious policy difference between the legislature and the
executive. For those who have followed the budget making process in Uganda over
the last 15 years, parliament is posturing, not trying to correct executive
excesses.
Equally, the
population of Uganda at in 1997 was 20 million meaning that per capita
expenditure on health was Shs 6,350 or US$2.5. Given our current population of
35 million, this financial year’s budget translates into per capital health
spending of Shs 24,000 or US$ 9.6, an increase by 280 percent. Is there a
noticeable improvement in the quality of healthcare delivered by the government
of Uganda as a result of this budget expansion?
Anyone visiting
our hospitals and health centers would be appalled at their state of disrepair,
the poor equipment used and absenteeism of medical workers – not to mention
their poor pay. So, public debate in Uganda needs to shift from inputs to
outputs, from budget allocations to services delivered, from more money to
value for money and from policy pronouncements to policy outcomes. Before we
agree that any more money is allocated to health, let us first ask whether the
money currently allocated is being used appropriately to maintain, renovate and
build hospitals and health centers; to furnish them with medical equipment and
drugs and if it pays for the services of medical workers like doctors and
nurses.
These activities
are not an end in themselves; they are supposed to be a means to an end i.e.
produce specific healthcare outcomes like reducing infant mortality, child
morbidity, incidence of diseases like malaria, etc. Do people who go to
hospitals and health centers get a service commensurate with what is spent?
Have these services become better as the budget has increased? I have
personally visited Mulago and other hospitals like Kiryandogo in Nakasongola,
Kambuga in Kanungu, Itojo in Ntungamo and been appalled by their state of
disrepair, limited presence of medical workers, congestion, broken beds,
malfunctioning equipment and uncollected garbage.
In her
autobiography, My Life’s Journey, Mrs Janet Museveni also admits to this state
of affairs. She says that during her first campaign, she went to Itojo Hospital
to solicit for votes but what she saw made her feel like crying. “Every time I
attempted to speak, I chocked with sadness,” she writes, “Eventually I told the
staff that I was sorry that such a dejected place could be called a hospital
since a hospital is a place where the sick come to be made well, but I pointed
out that no one could get well in that place. It seemed to me that a patient
would come with one disease and leave with another.”
Some studies
suggest that there has been improvement in the health of our citizens; life
expectancy has gone up, infant mortality and child morbidity have reduced etc.
However, this may have more to do with private healthcare services than
government ones. Therefore, let the executive account for the Shs 838 billion
spent on the sector per year – not to mention what donors spend off budget
which is close to Shs 700 billion – before a dollar is thrown into the health
bottomless pit.
In fact, after
my visit to Somalia and witnessing first hand how professional UPDF has become
and how commendable the job it is doing is, I am more inclined to support a
budget increase to them. There has been real reform in the army. As a result,
we no longer have news about ghost soldiers, junk helicopters, junk tanks,
expired food rations and undersize uniforms that had turned the army into a
springboard for private profiteers and around which I built my investigative
journalism career.
In November
2009, The New Vision reported that a government audit had revealed the
existence of 100 ghost hospitals in Western and Central Uganda alone. If an
audit was conducted on the ministry of health payroll, we would be shocked at
the number of ghost medical workers and the money spent on them per year. Mid
this year, Daily Monitor reported that the president had ordered an
investigation that found that our country spends US$ 150 million (Shs 375
billion) on treatment of top government officials abroad. Can we first end this
profligacy by our rulers?
Besides, a World
Bank study in 2008 found that 80 percent of Uganda’s health budget is spent on
hospitals in urban areas that serve only 20 percent of the population. The
study also found that 80 percent of public sector medical workers in Uganda
work in urban areas where only 20 percent of the population lives. What is
clear from the above is that the democratic process in Uganda has failed to
represent the interests of the ordinary citizen. Instead, it seems to reinforce
the urban bias – a tendency to allocate ever more and more resources to serve a
narrow urban elite.
This bias is
largely because people in urban areas have voice – they form political parties,
establish civil society organisations, write in newspapers and speak on radio
and television to promote their interests. Elites have therefore used their
access or these platforms of democratic expression to enhance their power and
privileges. The standoff between Museveni and parliament is not about
delivering healthcare services to our diseased citizens. It is about which
group of elites gets the chance to steal the Shs 39 billion – whether it is
those who work in defense or those who work in health. This is not a policy
difference that Ugandans need to take seriously.
amwenda@independent.co.ug
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