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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amwenda@independent.co.ug
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