THE LAST WORD | ANDREW M. MWENDA | Last week, I attended the Advocates Coalition for Development and Environment (ACODE)’s monthly State of the Nation seminar on public spending and governance on the health sector in Uganda. Like all such conferences on African issues, context is always missing. So we discuss the state’s ability to deliver public goods and services as if poor countries have the same resources – both human and financial – as rich nations.
To understand our frustrations with our governments, one has to first appreciate the mind-set. For most of the educated elites in Africa, we have been indoctrinated with the ideology of a welfare state i.e. that government should provide a large basket of public goods and services to all her citizens for free – health (especially medical), clean water, education, electricity and roads. When these services are poorly provided or not provided at all, we assume that it is because of lack of “political will”, or corruption, or greed and selfishness of our leaders.
This explanation for poor delivery is even found in the works of the most sophisticated academics and intellectuals in Africa and the Western world. Yet the problem is very simple: poor countries simply do not have the resources – both financial and human – to provide a large (or even small) basket of public goods and services to all their citizens and for free in the quantity and quality they demand and desire.
Corruption, absenteeism, incompetence, etc. are consequences of the state trying to do too much for everyone, everywhere, all the time on a string budget, not a result of “cruel, selfish and greedy African leaders who don’t care about their people” as the common narrative in the media and academia, both in Africa and the West, has postulated. Put simply, the state in most of Africa is over-developed in functions but underdeveloped in capacity, so its reach goes far beyond its grasp. That is the main source of all our continent’s frustrations and recriminations.
Let me illustrate. This financial year, Uganda’s total revenue is Shs16.2 trillion ($4.3 billion). Divided by a population of 40 million people, you have per capita revenue of Shs405,000 ($107) – in Purchasing Power Parity (PPP) it is $353. That is not enough to provide us with all the public goods and services in the quantities and quality we demand. So government goes to international creditors and the domestic market to borrow where it raises an extra Shs10 trillion. So this gives us a budget of Shs 26 trillion ($7.1 billion or $22.7 billion in PPP). This brings public spending per person to Shs 650,000 ($173 or $567 in PPP).
Compare Uganda with the USA. This year, its budget is $7.56 trillion for a population of 328 million people, giving it public spending per person of $23,000. It matters very little how wasteful the USA can be. This money is enough to provide a large basket of public goods and services in large quantities and of high quality. Even with all the best intentions and efficiencies, Uganda simply cannot match this level of providing for her people. Yet Uganda’s ideology of a welfare state and its policies on social service provision to its citizens is modelled on that of rich nations like the USA.
Coming to health specifically, look at what our most elites expect and what the government of Uganda promises: to provide every citizen, everywhere in the country, every time they are ill with all the treatment they need – for free. Anyone looking at Uganda’s resources and not burdened with the ideology of a welfare state and not blinded by the mind-set that the state has to do this would consider our government insane in making such a promise given the resources at its disposal.
Let us look at the numbers. This financial year the USA will spend $1.7 trillion on health, Uganda Shs2.3 trillion ($612m or $2.0 billion in PPP). This gives the USA per capita health spending of $5,200 while Uganda’s is Shs57,000 ($15.3 or 50.2 in PPP). I have constantly adjusted figures to PPP because it tells us better the number of hospitals, medicines, equipment, nurses, doctors etc. that Uganda has to procure and the prices it has to pay in her own national currency.
I have used the USA here because her budget and its distribution are easily available online – but it represents a typical rich country. In fact her peers in Europe do much better with slightly less spending. The point is that we are expecting Tadeo Mukasa, a peasant in Masaka, to provide his children the same quality of healthcare and education like Bill Gates does his. Its madness!
The solution for poor countries in fixing their healthcare problems has to begin by identifying important priority areas where they can have the highest impact with their meagre resources i.e. prioritisation. Prioritising everything means you have prioritised nothing. And they can begin with what we know. The biggest cause of low life expectancy is high infant and child mortality rates. Too many kids die before their first and fifth birthday. This is where we need to have the most effort.
The founder of social medicine, Thomas McKoewn, drew a series of famous diagrams (on Europe) showing, for a whole series of diseases, that mortality rates were falling before the introduction of effective treatment and continued to fall almost at the same rate after its introduction. McKoewn found that medicine was not very useful in improving health. This led him to conclude that the root of health improvement lay in economic and social progress; especially better nutrition and living conditions.
The Nobel laureate in economics, Angus Deaton, in his book: `The Great Escape’ shows that improvement in health is best realised by improvements in public health interventions such as sanitation, access to clean water, vector control and primary health interventions such as immunisation and vaccination. These interventions are effective and cheap yet positively impact the vast majority of the people. They are also the only affordable interventions by governments of poor countries.