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.
Dear Andrew Mwenda:
Thanks for keeping up the spirit and culture of writing. I hope 10,000 or more of us do indeed find time to read and write about Africa. We need that critical narrative by Africans about Africa and the World. I enjoy reading extensively about other countries too, Uganda and USA included. I enjoyed the article titled " Healthcare in poor countries."
Sometimes I wonder if the term "poor" has not corrupted some of us into complacency. While in Uganda, I mostly worked in the regional health districts, urban areas, on the big islands, rural areas and in emergency situations like the two Ebola episodes we had. I saw more idiopathic, neurological, trauma, mental health, physiotherapy and psychological cases that went unaddressed. It is no wonder that many patients see our hospitals or clinics as "death destinations that need not be embarked upon."
Medicalizing medicine and the practicing of medicine in Uganda (perhaps in Africa too) have created power structures. I have closely followed African country-based health outputs as far as the Millennium Development Goals/Sustainable Development Goals go. I have written comparison reports and shared with people from other continents. I am a member of the International AIDS Society and Africa AIDS Society. In those capacities, it is my opinion that integration is the way to go. A change of mindset was due by 1970. This means we have to redefine our sense of health by imagining a spectrum. At one extreme, we should have any parameter defining a condition e.g., maternal mortality. At another end we can have wellness measures such as how many people are able to afford full antimalarials; have shuttered (with good ventilation, windows and doors) homes; can afford to control or avoid mosquito bites and other aspects.
Health is so immediate a context and we need to define the good and problematic parameters equally if we are to talk of progress. We need to combine the medical and social aspects, evidence-based medicine and contextualize the belief models experienced by Africans. Hospitals or clinics should not be shaming spaces for patients who want to take the after-birth back with them and place it at a sacred place in their home gardens. We should look into the patterns of African empathy and how these add to the numbers of people who visit loved one in the hospitals. We should use statistical reports to predict trends in demand and supply. We can motivate health workers through provision of better work conditions, task shifting and proper housing. We may have solutions to overcrowding, drug stock-outs and absenteeism. Lastly, I still think in place of words like "poor" or "backward," we can actually borrow from social science research or theories and contextualize African situations in a more proactive way with a goal of upliftment. I posit the following adjectival epithet: "low resource context countries" instead of "poor." Thanks for adding a narration to what matters in Africa and other low resource context countries.
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