About me.

Andrew M. Mwenda is the founding Managing Editor of The Independent, Uganda’s premier current affairs newsmagazine. One of Foreign Policy magazine 's top 100 Global Thinkers, TED Speaker and Foreign aid Critic

Monday, April 25, 2016

A frank memo to our elite

Why we should downplay anecdotal evidence by looking at scientific data that gives a broader picture

So last week the cancer machine at Mulago Hospital collapsed, causing uproar in mainstream and social media. Every newspaper columnist or television/radio pundit of any heft weighed in. Daily Monitor devoted its whole Thursday opinions page on this subject. Pundits outdid each other in over-stating how this is a sign that the entire health sector “has fallen apart”. Yet cancer is not a major killer, not even among the top 20 killer diseases. So why all this self-righteous indignation?

The cancer institute. The problems at Mulago are not new nor are they unique to Uganda.
The cancer institute. The problems at Mulago are not new nor are they unique to Uganda.

I think it is because cancer is a disease the elite pay attention to – because it can kill them. So the outrage is not about the ordinary masses but the interests of those that control weapons of mass propaganda.
The eight most common killer diseases in our country in order of their killing rate are maternal mortality, malaria, tuberculosis, pneumonia, kids dying during child birth, injuries due to motor accidents, cardiovascular diseases, and HIV/AIDS. How often does the punditry address them? Hardly!

The thing I admire about Ugandan elites is our self-indulgence. We write in holierthan-thou tones, appealing to public emotions domestically and perhaps for recognition among the donor elite. We denounce those who have “failed the public trust” insinuating that if we were in their positions things would do better. Our audiences applaud us in silent (sometimes loud) admiration. This is the political point-scoring and public grand-standing we hypocritically indulge in to deceive ourselves that we care more about “the common man” than those who are elected to serve him.

Our health sector is not managed by people from England or Chad but by our alumni, friends, relatives, relatives of friends, neighbours, in-laws etc. They are not mean, cruel and heartless people out to destroy the country and harm its citizens. Besides the people who die are their friends, family and fellow citizens. It is true some are corrupt, others negligent and many incompetent and this causes myriad dysfunctions in our public health sector. But equally many public servants try to do a good job.

Secondly, Uganda is governed largely by elected public officials. Our citizens have a very high anti-incumbency bias – over 65% of incumbent MPs including ministers and powerful opposition figures – are not returned in every election. This is the opposite of countries like USA where only about 10% of incumbent congressmen and women lose their seats in an election. Hence we cannot say our country is saddled with entrenched politicians who are resisting reform.

So what have been the implications of elections on health policy? There has been a massive shift of focus from high-value elite based clinical medical treatment (like for cancer) to low-value mass-based preventive health and clinical medicine strategies. This has gone unnoticed by our elites because it addresses the needs of the common man. Democratically elected politicians can be corrupt and selfish but at least their bread is buttered by voters. So they cannot ignore the majority interest.

Over the last 20 years, government has poured a lot of money in spreading health services to the far reaches of the country, building health centres and expanding the capacity of existing facilities. Today Uganda has two national referral hospitals, 14 regional referral hospitals, 144 general hospitals, 197 Health Centre (HC) Four, 1,289 Health Centre Three and 2,461 Health Centre Two. All the national and regional referral hospitals are owned by government. Government owns 88 general referral hospitals, 185 HC4, 1,063 HC3 and 2,461 HC2. The rest of the facilities are owned by private not-for-profit institutions.

However, rapid expansion has not been accompanied by a similar increase in human skills and funding to ensure effective and efficient management and supervision – in the short term. You cannot increase
access this massively and at the same time acquire the requisite skills, drugs and equipment. Building effective institutions is an arduous task whose results appear only with a long time-lag. So rapid expansion (call it democratisation of healthcare) has led to poor quality of clinical care, corruption, incompetence and absenteeism. These costs are inevitable.

Yet Uganda has registered commendable improvement in healthcare outcomes especially for the poor. For example, between 2000 and 2014, maternal mortality has fallen from 550 to 360 deaths per 100,000 mothers; our country beats every country in its per capita income range on this score. Malaria prevalence has fallen from 42% in 2009 to 19% in 2015, immunisation for DPT reached 104% in 2014 (due to influx of refugees) and of measles to 90%. Delivery in a health facility has grown from 39% in 2010 to 53% in 2014 perhaps because today, HC4s that can now perform a caesarean have grown from 24% in 2010 to 51% in 2014.

Infant and under five mortality has significantly reduced and life expectancy increased. Health facilities without stockout for any of the six essential medicines have increased from 43% in 2010 to 64% in 2014. Pregnant women who attend antenatal care at least once during their pregnancy are over 90%. Yet the levels of staffing, the skills of our people and the funds available are too low to meet the ever growing demands.

There are many problems in our health sector – corruption, wastage, misallocation of funds to a few elites etc. My dad died in Mulago because of poor nursing care. I am aware that even within our limited skills and budget, a lot can still be improved. But I also do not expect 100% perfection in our public health sector. However, doomsday stories by our pundits about the health sector are ill-informed and unhelpful in promoting a constructive conversation on how to improve healthcare delivery in Uganda.

Most are regurgitations of prejudices about Uganda (and Africa generally). I am happy I out grew them. Rather than pontificate from a high yet false moral pedestal, we need new and original thinking about the problems of the health sector in Uganda. This is what will help us understand the source of the problem and thereby begin a conversation about the practical solutions.

The problems at Mulago are not new nor are they unique to Uganda. Across Africa and with the exception of a few countries like Botswana and post-genocide Rwanda, the ability of the state to deliver healthcare is characterised by absenteeism, corruption, incompetence and apathy. And for most of
our countries, the situation has been getting worse not better in spite of injections of foreign financial aid, technical experts and myriad policy and institutional reforms.

This is largely because public services have been rapidly expanded yet financial capacity and human skills are still low. Therefore, the government should halt further expansion and focus on improving the quality of the services. That should be the debate we should be having.


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