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, September 2, 2019

Missing insights in our healthcare

The lesson from pictures of many newly born babies packed on beds and chairs at Kawempe Hospital
THE LAST WORD | Andrew M. Mwenda | Last week, someone took pictures of Kawempe Hospital with a multitude of newly born babies laying on congested hospital beds and plastic chairs. This provided considerable grist for the anti-President Yoweri Museveni and anti-government of Uganda mill. As expected, Uganda’s chattering elites went wild on social and other media; they denounced government for its corruption, incompetence and selfishness with self-righteous indignation.

We have highly exaggerated expectations of our poverty stricken and revenue starved governments. This is based on ignorance of our states’ capabilities. When this is combined with excessive prejudice about our governments, it turns self-righteous indignation into a toxic mixture of emotional debates and bad public policy.

Journalists who cannot get basic facts right or write proper grammar or spell words correctly or punctuate their sentences properly expect and demand that laboratory technicians get their diagnosis right, nurses be competent to a fault and teachers and policemen do similar. It never occurs to them that their mistakes as journalists and pundits, just like those of nurses, doctors and policemen, are a reflection of low levels of skills i.e. poor human capital.

I want to criticize this behavior with a lot of humility because for many years I was a leading priest of this attitude. Then I reached the road to Damascus. Over the years of self-reflection, it became apparent to me that we need to change our mindset. This realisation came in large part because I became deeply conscious of my own weaknesses. Once this happened, I felt liberated from self-righteous anger and what it leads to – the delusion that I am perfect and everyone else is incompetent and corrupt.

Yet the paradox is that the pictures of kids congested on beds and plastic chairs at Kawempe Hospital are evidence of success, not failure, of the Ugandan healthcare system. They demonstrate increasing public confidence in public health facilities. Ugandan mothers used to deliver babies at home in the attendance of relatives, neighbours and/or traditional doctors.

According to the Uganda Demographic and Health Survey (UDHS), in 2001 only 37% of mothers were delivering babies in a health facility. However, in 2006, this number had increased to 42%. In 2011 it had jumped to 57% and then 73% in 2016. We can infer from this rate of growth that it has increased to 83% today. This must be a product of two things.

First, there is increased access to health facilities as government has built many Health Centers even in the far reaches of the country. Today 86% of our population lives within 5km of a health facility mostly owned by government. Second, that there is increasing public confidence in our public health facilities – that is why people are flocking there and the facilities are getting overwhelmed. In the specific case of Kawempe Hospital, it was designed for a smaller capacity, and is now overwhelmed by the closure of Mulago for renovations.

I am also conscious of the fact that public health facilities perform better than private ones in Uganda. There is no private hospital better than Mulago in Uganda – the highest concentration of medical expertise in our country. When it reopens in January next year after its renovation and refurbishment, it will be the most well-equipped and well-staffed hospital in East Africa – and among the top ten in Africa. I have been there and inspected the works several times to speak with authority.

Yet it is not always good for public facilities – be they education or health – to be the best in, especially, a poor country. This would attract the rich to opt out of private services to public ones and thereby compete with poor citizens for the same facilities. The taxpayer is better served when rich people pay taxes and also pick their own and their families’ medical and education bills. This allows the rich to actually subsidise the poor.

When I listen to and read the writings of many Ugandan elites, I am only reminded of the gap between expectations and reality. Uganda spends about $20 (Shs73,000) per person per year on health. Even if we discount those who go to private health facilities (the rich few) and those who do not fall sick, this money is too small for our development needs (building, renovating and equipping health centers) and recurrent expenditures (paying medical staff and buying drugs). Ugandans speak as if their country has the resources of Belgium, Norway or the USA.

We are fixated with the excuse of corruption. Nowhere is propaganda more effective (and dangerous) than when it uses (and abuses) actual facts. Of course there is corruption. But it does not explain the fundamental causes of poor health delivery in our country. Its contribution is negligible. The real issue is low levels of public revenues to finance the very many competing demands on a poor government. While it is very important to improve efficiency and minimise corruption and abuse, its contribution to overall healthcare outcomes is negligible.

This lesson came vividly to me following Rwanda, the most efficient government in use of public resources in Africa. At a very low level of income ($800 in per capita income and about $250 in per capita spending), Rwanda is governed like a rich country. Indeed, the World Economic Forum index of efficiency in the utilisation of public finances places Rwanda 5th in the world behind the richest nations such as United Arab Emirates, Singapore, USA and Qatar – all of which have 50 times its per capita income.

Yet when I look at healthcare outcomes of Uganda and Rwanda (such as life expectancy, child, infant and maternal mortality, malaria prevalence, rate of vaccination for things like measles, polio, DPT3 etc. – the things that really matter in health) the differences are negligible. (Uganda is number 100 in the index i.e. very inefficient in the use of public resources). This is quite discouraging for all the efforts Rwanda puts in fighting graft and serving the public good.

The lesson here is simple but fundamental: efficiency gives you very little return. The real challenge is sustaining rapid economic and, therefore, revenue growth. As long as a country is poor, even the highest levels of honest government and the public spirit cannot change the fundamentals of poor outcomes. This is not to say honest and efficient government is not desirable. Rather it is to demonstrate the limits of efficiency i.e. that at best you become a well-managed poor country but a poor country nonetheless.


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