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, November 25, 2019

The politics of Uganda’s healthcare

Why our hospitals lack ambulances as public officials indulge themselves in fancy four-wheel drive vehicles


THE LAST WORD | ANDREW M. MWENDA | Last week someone close to me had a medical emergency in Mubende referral hospital. A child died inside the womb of his fiancé. The only ambulance the hospital has had a mechanical fault that has not been fixed yet. So he could not evacuate his fiancé to Kampala.

However, a doctor in charge said they could handle the emergency and therefore no need for an evacuation. An hour later the young lady had been helped to deliver the dead baby. I was pleased but also angry. How can a regional referral hospital have one ambulance? I also learnt Mubende district has only one private ambulance.


If you are a knowledgeable Ugandan citizen and taxpayer, you get extremely angry at these things; especially because our country can do better. The last time the Ministry of Finance did a government motor vehicles census was 2006. They found the ministry of health had 3,000 four-wheel drive vehicles at its headquarters for its officials. And this waste cuts across all government ministries and agencies. These days one is sickened by the number of police or army escort vehicles that accompany public officials with sirens as they drive four-wheels; pushing everyone else off the road during rush hour. This is government by self-indulgence of the elite. 


Yet I am also aware that the ministry of health has been doing a great job of renovating and re-equipping regional and district referral hospitals. I am also aware of the increasing access of the public to essential medicines. For instance, the percentage of health facilities without stock-outs of any of the six essential drugs has improved from 43% in 2010 to 95% today. Many indicators have greatly improved over the last nine years: child, infant and maternal mortality, the percentage of women receiving antenatal care during pregnancy and giving birth in hospitals, immunisation and vaccination against common diseases, etc.


So while as a citizen I appreciate the achievements of our health sector, and also while I am not a fan of publically funded medical care in a poor country, I still believe our government can do better for its citizens. It makes no sense for a country without ambulances at public hospitals to have tens of thousands of expensive four-wheel drive vehicles for public officials to drive to office, their homes, seminars and workshops. No wonder many Ugandans are angry. To make a bad situation worse, government spends huge sums sending public officials abroad for medical attention.


The behavior of the government of Uganda baffles me. By every measure, Uganda is an increasingly democratising country. There is greater political participation and even greater political contestation. Although President Yoweri Museveni likes to cut the image of a strong and invulnerable presidential monarch, every election does threaten his survival. This was especially so in the 2006 and 2016 presidential elections when his arch rival, Dr Kizza Besigye, came close to upsetting the apple cart. More so, over 65% of all incumbent legislators are voted out of office in every election.


This high attrition rate of legislators in Uganda is a sign that our citizens do actually hold elected officials to account. Indeed, Uganda is very different from mature democracies like the USA where in any election, less than 10% of incumbent legislators lose their seats. In fact this means USA has a deeply entrenched political class to resist reform. The high anti incumbency bias in Uganda suggests our MPs would be more sensitive to public needs and therefore more responsiveness to citizens’ needs. Why then does government of Uganda continue to indulge the elite instead of serving the citizens?


It seems the productive margin in government’s search for votes does not lie in serving the citizens (even though that is part of the calculus) but in feathering the nests of elites. I suspect this is because of the incentives created by structural circumstances in a poor, ethnically diverse peasant society. Ethnic diversity creates a desire by different ethnic groups to see the presence of one of their own in power as actual representation. Power is seen as driving in big cars, living in big houses and the ability to be generous to one’s co-ethnics.


Secondly, being poor means the state cannot afford to provide a large basket of public goods and services to all citizens to the quality and quantity desired. Elites act as a bridge between the leaders and their co-ethnics. It is cheaper to win the whole of Karamoja by incorporating a few of its powerful elites in government than delivering there roads, electricity, schools, health facilities etc. For a poor country, patronage for the elite is therefore not only a cost-efficient and cost-effective strategy of building electoral and governing coalition, it is most critically the only affordable option given the cost of public goods and services.


Thus what seems a socially and economically dysfunctional public policy (privileges for a few elites instead of public goods and services for the majority of citizens) is actually rational and politically profitable. This also means that the more you deepen democracy in a poor and ethnically diverse peasant society, the more you entrench the privileges of a few elites. But this can also happens in rich democracies where well-organised special interests can usurp public policy to their advantage at the expense of the masses.


Take the healthcare system of the USA as an example. The country spends 17% of its GDP on healthcare compared to the UK 9%, Japan 10%, France 11.5% and Singapore 5%. Yet on health outcomes like life expectancy, infant mortality etc., these countries are better off than the U.S. Why?  In the USA, the health industry’s formidable lobbying machine ensures that laws in Washington DC are made with the interests of healthcare providers in mind: insurance and pharmaceutical companies, then associations representing doctors, hospitals, nursing homes etc. These spend billions of dollars lobbying Congress for favourable policies at the expense of the voting majority.


The lesson is that democratic competition, which is a very good thing, just like free markets, does not automatically guarantee the voter (or consumer) gets the best service. In Uganda’s case (as America’s healthcare system shows), it shifts resources to a minority that is best organised and articulate. So next time you see sirens pushing you off the road in Kampala’s rush hour, while your auntie has no access to an ambulance, know that such crass exhibition of power is the stuff that gets politicians elected in our villages.

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