Why trying to do everything for everyone, everywhere has ended up doing little for anyone, anywhere
The debate on health policy in Uganda is frustrating. Our health services are characterized by corruption, absenteeism, incompetence and apathy. Everyone is angry and frustrated including President Yoweri Museveni. This misery is self-inflicted because we refuse to acknowledge the limits on the state’s ability to do everything for everyone everywhere.
Uganda is a very poor country with public spending per person of Sh 635,000 ($171) annually. Health spending per person is Sh 55,000 ($12) per year. The public, most especially elites who should know better, demand that our health policy should be like that of Denmark and Norway. Yet these countries spend 100 times more money per person than Uganda, have high human skills and rich institutional endowments.
Here is the crisis: public policy on health in Uganda is that the state pays for the healthcare to all its citizens. There is no limit to this promise: whether someone is suffering from malaria (which is cheap to cure) or cancer (which is expensive to treat) public expectation and government policy is that the state will take care of them. Why no one sees this absurdity defies imagination. How can a state with a shoe-string budget make such a commitment?
The result is that limited resources – technological, infrastructural, human and financial – are spread too thin to have meaningful impact. For example, by 2014 government had two national referral hospitals, 14 regional referral hospitals, 88 district referral hospitals, 185 Health Centre (HC) Four, 1,063 HC3 and 2,461 HC2.This is too many health facilities for a poor government. Institutionalised dysfunction becomes inevitable when a governmenttries to chew much more than it can swallow.
Hence, even with the best intentions and no corruption, government cannot equip all of these health facilities with the necessarymedical equipment; staff them with the required number of medical workers and provide them with sufficient drugs to function optimally.Across every hospital and health centre in Uganda there is less than what is required.
For instance, although Uganda needs Shs 1.2 trillion to purchase drugs, government only givesShs 276 billion i.e. less than 25%. This is not to mention that nearly 40% of drugs get stolen largely at the level of the health facility. As demonstrated through budget allocation above, this is not the main reason for drug stock outs.Government can increase health spending only at the price of cutting something else.
In my earlier days I would have recommended cutting the budget for political patronage. This is a good moral decision. But when you do the numbers, it only scratches the problem. The real issue is Uganda does not have the resources – financial and human – to serve everyone’s healthcare needs. Indeed, rapid expansion has eroded even the limited ability of the state to supervise attendance by medical workers, stop theft of medicines and equipment. Critics of Museveniargue that this is a problem created by him personally and his NRM government.
This criticism makes good sound bytes but tells us little of substance. Studies on the health sector in varied nations as Zambia, Senegal and Kenya (which have three times Uganda’s per capita spending) and Cambodia and Vietnam (which have seven times Uganda’s per capita spending) show that the problems we see in Uganda are endemic to all poor countries. Rwanda manages them far much better than all her peers but it has not overcome them.
The problems of the healthcare sector in Uganda are not the fault of anyone. On the contrary they are a product of our shared mentality i.e. the belief that the state should take care of all the healthcare needs of all its citizens – regardless. But blaming our shared mentality is too abstract to attract mass hysteria. In Uganda’s case, it makes sense to identify a villain (Museveni) and blame him for the problems in the health sector.
Reading about comparative experience liberated me from conjectures that made a good sound byte but were hardly a source of good public policy. In fact, accounting for her low per capita spending, and factoring in the destruction of her physical infrastructure (hospitals and their equipment), human capital (death or exile of medical professionals) and social capital (loss of values, norms and ethics) during the Idi Amin years and civil wars that lasted from 1979 to 2005, Uganda’s healthcare outcomes show the country performs better than most of her peers.
So what health policy is best suited for Uganda given her context of limited financial and human resources – and her politics of multiple ethnicities? Our government needs to focus on primary healthcare, which is affordable and affects the vast majority of our citizens. Here it can do things like vector control (e.g. killing mosquitoes to reduce the incidence of malaria), ensure mass vaccination and immunisation (which reduces infant and child mortality) and implement public hygiene measures (like provision of clean water).
Government should abandon its pretence to take care of such illnesses as cancer, brain surgery, heart disease, diabetes, hypertension, organ transplants, etc. because it cannot afford them. If someone needs such expensive treatment they should pay it themselves and their families or rely on charitable institutions.
Government needs to ask itself whether it makes sense to spend Shs 50 million of public funds trying to save the life a 70-year old (or even a child) suffering from cancer when the same amount can save the lives of 100,000 kids if spent on immunisation and vaccination. Many people may not share this utilitarian vision (the highest good for the largest number), but public policy should not be based on emotions.
People rightlyask whether government should watch its citizens die ofcomplicated illnesses that are expensive to treat.Doctors care about every patient. If allowed to make policy they will insist everyone should be treated. But our resources are limited and need to be used selectively. This requires making hardnosed trade offs that doctors’ training may not permit.
The biggest cause of low life expectancy in poor countries is child and infant mortality. Public health measures such as immunisation, vaccination and vector control, if implemented well, can significantly increase life expectancy, taking it closer to that of rich nations. Government has not focused on these measures, as it should, because huge resources are spent trying to cure complicated illnesses. Who will speak for the children of Uganda, especially from poor families, when public debate on health policy is dominated by ignorant and self-interested adult elites?
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