Charles Onyango Obbo

Want first class hospitals in Uganda? Do absolutely nothing with the hospitals!

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By Charles Onyango-Obbo

Posted  Wednesday, August 27  2014 at  01:00

In Summary

A Ugandan with Shs60 million will figure that he can buy three matatus, and with that his wife will educate his children and keep the family fed. He checks out of the Nairobi hospital, goes back to die in Kampala, but leave his family with something

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My good friend, writer and journalism scholar Joachim Buwembo, as usual, wrote a tongue-in-cheek and scathing column in the latest issue of The East African newspaper titled “How Nairobi and Kenyatta became Ugandan hospitals”.
His point was that Ugandans with means and politicians go to Nairobi hospitals in such large numbers for treatment that they are now unofficially Uganda’s referral hospitals. And because our own hospitals are so run down, perhaps the Uganda government should actually allocate money to hospitals like Nairobi and Kenyatta, for the benefit of our citizens who go there in large numbers.

I have spent quite a bit of time trying to understand why hospitals in Nairobi – especially private ones – are years ahead of Uganda. Also why Kenyatta Hospital, which is the government-owned equivalent of Mulago, is much better.
Make no mistake, when you go outside Nairobi things get worse, but upcountry hospitals in Kenya are still not as bad as those in Uganda.
Even some Kenyans still don’t fully comprehend why the private hospitals in Nairobi are, relatively, as good as they are. The real reasons are strange.
To get a hospital like Nairobi or Aga Khan – even the state-owned Kenyatta, Uganda doesn’t have to do anything related to health.
It has to fix, first, medical insurance legislation. Most patients at Nairobi’s private hospitals pay for their treatment with medical insurance.

To understand why this is important, one needs to talk to doctors in Nairobi who treat Ugandan patients. Ugandan patients, they say, many times don’t finish their treatment or opt out of life-saving procedures because they are paying for it directly from their pocket. As one doctor told me, the effect of that is that they “calculate the cost of their treatment, against the benefit that their death would bring for their families”.
Meaning, as one of them put it, a Ugandan with Shs60 million will figure that he can buy three matatus, and with that his wife will educate his children and keep the family fed. He checks out of the Nairobi hospital, goes back to die in Kampala, but leave his family with something. Heroic and admirable, but it’s something he could have avoided.

An iron clad medical insurance means you will always have some money on the card, and that you can’t choose to divert and spend the money buying matatus for your family. The result is that hospitals and doctors don’t depend on whether you have money or are broke before you visit, they have a steady stream of ring-fenced insurance money – and patients - coming in.
But even more important, is the “Doctors Plaza”. Basically, you build private clinics attached to the hospital, and “rent” them to doctors in a complex system. Most doctors in the top hospitals – including Kenyatta, by the way – are technically only partly employed by the hospitals they work at. And some hospitals don’t actually own many of the services, including laboratories, x-ray and MRI units (they are independent, but integrated, businesses).
Because they have all these private clinics and infrastructure, people will come to them…but to see the doctors in the attached private clinics. The doctors take their cut in consultation fees, then send the patients to get medicine, be treated, get surgeries, and so forth in the hospital, and the hospitals get their cut.

Having admitted you, your doctor will come to see you, and charge you. And you will pay the hospital for its services, the pharmacy for its medicine etc.
The doctors need the hospital, and the hospital needs the Doctors Plaza.
The important thing here is an enlightened attitude toward helping each make money, its interface with the insurance industry and yes, something very critical, doctors have nothing to do with pharmacies—unlike in Uganda. Many doctors probably make more money selling you medicine you don’t need from their pharmacies, than from consultations. But that, really, is a matter of law, not medicine.
Finally, to get on a hospital roll or clinic in the lucrative Doctor’s Plaza, you are voted in by the rest of the doctors who have been there long. So, first, you have to be good. Secondly, you have to have some integrity. That would seem strange, because then they would be bringing in competition.

Actually, no. How many clients doctors get, and how much they can charge you, depends on the quality and collective reputation of the plaza and hospital. The admission of a new doctor, instead of creating competition, actually brings in more money for everyone.
That also works as a constant peer review system, because if you mess up, you lower their margins, and you will be out.
The problems Uganda needs to fix to get quality hospitals, therefore, have nothing to do with medicine or hospitals.

Mr Onyango-Obbo is the is editor of the Nairobi-headquartered Mail & Guardian Africa (mgafrica.com). Twitter:@cobbo3


Charles Onyango Obbo

From Lagos, I bring greetings and a letter from Fashola to Mayor Lukwago

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By Charles Onyango-Obbo

Posted  Wednesday, August 20  2014 at  01:00

In Summary

What the case of Fashola and before him, Tinubu, prove is that central governments trying to finish off mayors and governors is not new. The difference is that unlike Fashola, Lukwago just couldn’t figure out a way to dodge the bullet. “This is not an example from America. It is from just here here in Africa”, as a true Ugandan would say

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I just spent a week in the Nigerian commercial capital, Lagos. Now the population of Lagos is estimated to be anything between 18 million to 20 million…no one is sure, they have not counted properly.
If the Uganda population is 38 million today, that means more than half of the citizens of the Pearl of Africa live in Lagos.
Now as we all know, recently, after nearly 20 years, Nigeria re-surveyed its economy (they take forever to count things those Nigerians), and it turned out to be Africa’s largest economy, overtaking South Africa. It has a gross domestic product (GDP) of $510b.

Lagos, it is estimated, contributes at least 25 per cent of that, so its GDP is around $125b. We bring up this matter, first to say that the economy of Lagos State is nearly six times bigger than Uganda’s, which was about $22b when I last checked.
Again, this is not to belittle Uganda’s thing, but to make another point all together – that running Lagos is very complex. Also to add that in running a city that is 52 per cent of Uganda’s population, and an economy that is 600 per cent bigger than Uganda’s, Lagos Governor Babatunde Fashola has a more difficult job, at least from an economic perspective, than President Yoweri Museveni has with Uganda.

There is at least one thing he has done better than Museveni…he got rid of boda bodas from especially the upmarket areas and central business district, while our President schmoozes and canoodles with boda bodas.
If nothing else, it makes driving in Lagos a more pleasurable experience than Kampala.
However, it is treasonous to speak of the governor of an African state as having a more demanding job than an African Big Man, so we will leave that matter and compare Fashola with his political equal, the embattled Lord Mayor of Kampala, my friend Erias Lukwago.
Right now, of course the power and money in Kampala is with another (family) friend, Jennifer Musisi, the executive director of Kampala Capital City Authority (KCCA).

It is not easy choosing between friends, and the last time I wrote about this Musisi-Lukwago issue, I lost a few invitations to dinner in Kampala because it was felt I had cast my lot with Musisi and thrown Lukwago, the elected representative of the people of Kampala, under the bus.
However, we have to return to this vexing issue because while in the delivery of results here and there, one can say that Fashola is more like Musisi, and in the problems he has had to overcome, Fashola is like Lukwago.
Like Lukwago, Fashola is from the Opposition All Progress Congress (APC), like his predecessor Bola Ahmed Tinubu. The APC does not just carry the name “progress”. Quite a few of its leaders are actually quite progressive, with Fashola among the best of the lot.

Fashola came to office in very difficult times. Then president Olusegun Obasanjo, a roguish chap but likeable nonetheless, had cut off federal funds to the Lagos State in a political dispute.
Even after the courts ruled that Obasanjo was wrong to do so, he ignored them and sat on Lagos’ cheques. In Kampala, similar difficulties proved to be a disaster for Lukwago’s regime.
In Lagos, it turned into a blessing. Fashola just couldn’t fold his agbada and go back home. Essentially, he made a pact with the Lagos business community and people; “give me the money I need to run Lagos, and pay your taxes as Lagosians and I will use it to solve your problems and not steal it”. In addition, “as long as I keep delivering, you will keep the money flowing”, or something to that effect.

Both Fashola and the people of Lagos kept their bargain. He cleaned up the city, brought boda bodas to order, improved schools and health, he has built many apartments for the city they are just falling out of his ears, he is building a cable car, he is constructing the Lagos Rail Mass Transit system (only the second modern rail-based public transport after South Africa’s in sub-Saharan Africa), and such things.
And, again, he is not the president of Nigeria (i.e. the Museveni), he is the Governor (the Lukwago). When Umaru Yar’Adua succeeded Obasanjo, he ended the feud with Lagos.

But even with that, the greater source of Fashola’s success has been to be governor of everyone in Lagos, and to galvanise the consensus of all the political parties around his leadership.
What the case of Fashola and before him, Tinubu, prove is that central governments trying to finish off mayors and governors is not new. The difference is that unlike Fashola, Lukwago just couldn’t figure out a way to dodge the bullet. “This is not an example from America. It is from just here here in Africa”, as a true Ugandan would say.

Mr Onyango-Obbo is editor of Mail & Guardian Africa (mgafrica.com): Twitter: cobbo3.


Charles Onyango Obbo

The world is in a mess, but it will not all end badly…someone always wins

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By Charles Onyango-Obbo

Posted  Wednesday, August 13  2014 at  01:00
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Our world is truly in turmoil.
In the Middle East, the Israelis and Palestinians are at each other’s throats…again. In Israel’s disproportionate bombing of Gaza, we saw a troubling excessiveness often displayed by societies who themselves were forged through pain, as modern Israel was from the World War II holocaust against the Jews.
Syria is a mess, as is Libya, and Iraq. Unspeakable suffering there, then along comes the ultra-extremist Islamist group Islamic State in Syria and the Levant (ISIS). They are exterminating all non-Muslim peoples (and “bad” Muslims) in their way, and want to create a hardline Sharia law governed empire covering the Middle East, northern Africa and the Sahel, the Horn, and parts of Asia.
It might be scary, but not new. Other empires, though perhaps not always forged with such brutal means like ISIS’s, have been around before; the Roman Empire, the Mongol Empire, the Ottoman Empire, the British empire, name it.
Those days, empire-building was different. You killed, conquered, but also bribed and married into your enemies’ families, and cultivated local traitors. Not ISIS.
The Central African Republic (CAR) continues to dance with death, as is South Sudan. Nigeria is gripped by Boko Haram violence. Now, in the biggest such regional wave, Ebola is rampaging in West Africa.
Latin America is not any better. The drug lords and human traffickers are on the ascendance, again, it seems. Death stalks people every hour, and they are fleeing in droves trying to make it to America.
We have this truly strange spectacle where October 2013 to July this year, 63,000 unaccompanied children from down south entered the US illegally. Nearly 50,000 were being held at the US-Mexico border at one point!
In the US itself, gun violence remains rampant. Once thriving cities like Detroit have succumbed to decay. Even China, where the Communist Party otherwise rules with an iron-fist, there is now terrorism. And in Eastern Ukraine, Russia seems intent on gobbling every country or region (Crimea) or destabilising them (Ukraine, Georgia) in its neighbourhood.
This is not to lament, but to argue that head-turning times might be ahead.
First of all, you would think that with all these dramatic events everywhere, everyone in the world would be paying attention. Actually, no. Most citizens in the world are preoccupied with mundane things.
There are days when you turn on the TV or pick up newspapers and the big stories about presidents taking selfies or the state of Jay Z and Beyonce’s marriage.
Not all is lost. It might just be possible that these selfie-obsessed types are the ones keeping our world safe with their distractions. Can you imagine if all of them were trying to craft a caliphate like ISIS, instead of sharing photos on Instagram? We would be in a bigger mess.
But the groups that really interest me are the ones working on things that make possible an alternative “universe”…chaps like Virgin’s Richard Branson, who are pouring money into space travel. I notice that space exploration has increased, and finally human beings are taking very serious interest in what lies deep down in the oceans and seas. And those explorations to the North Pole and Antarctica are not easing up.
I see a future in which some of that post-nuclear world we see in movies, of human zombies roaming a poisoned Earth, of an elite ensconced in paradisal space communities, becoming reality.
As the experience of the US in Iraq and Afghanistan teach us, it is simply no longer possible for a single or multiple powers to dominate the world and bring it to order like the Romans and Turks did.
In the decades and centuries to come, we will probably see more and more crises and social and national breakdowns. The only way for the rich and those with “special” skills or are well born is to separate themselves from the rowdy and lawless mobs, as no army can really keep the “people” at bay.
This lot will keep themselves safe by creating a physical distance that the mob simply has no technology to overcome - living in space stations; setting up communities in cold frigid Antarctica where the rest would perish before they reach.
Or probably deep in a desert where it is easy to defend, and I fully expect that there will be a mushrooming of submarine societies. The proletariat would drown before they reached them.
We are seeing the end of the classical nation state, yes, but new powerful supranational ones will probably not replace it. Darwin was right; the strong will survive.
But even he couldn’t foresee that the good life, in the end, would belong to the rich, nimble, genius, cynical, and dreamers who secede from the strong and create other worlds. A sequel to the District 9 sequel, Elysium, with a more convincing ending. Anyone?

Mr Onyango-Obbo is editor of Mail & Guardian Africa (mgafrica.com): Twitter: cobbo3.


Charles Onyango Obbo

‘Accra-Kampala Disease’: Why Uganda needs to learn from events in Ghana

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By Charles Onyango-Obbo

Posted  Wednesday, August 6  2014 at  01:00
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Something is happening in Ghana, which should interest Ugandans because a version of it has been playing in the Pearl of Africa in the last three years.
The Ghana currency, the cedi, has tanked against others like the US dollar. Government finances are a shambles. Though Ghana now produces oil, it is plagued by fuel shortages.
Then we heard something that used to be the daily staple of news in Africa, but we haven’t heard much of in the last 10 years – Ghana suggested that it was running to the International Monetary Fund (IMF) for a bail out!
Apart from long fuel lines, Ghana got into a farce. All manner of pastors and “bishops” jumped into the economic fray, praying for the cedi to stabilise against the dollar.
Proving that there is wisdom in separating God’s matters (church) and Caesar’s (state), the cedi refused to budge to godly cajoling and continued its slide.
There is no agreement on what is wrong in Ghana. Unlike Uganda, it has low corruption levels. Its politics is also different; as its ruling parties do lose elections, so governments there are more sensitive to public sentiment unlike, again, in Uganda where the election outcome is known well before voting day.
Recently, I met a chap who researches Ghana, and he said the country’s current problem is down to oil. It was an African version of the “Dutch Disease” (the proverbial tendency for countries to neglect most other sectors of the economy and mooch off easy oil and natural resources money).
I think though that in Africa we are seeing a mutation of this disease. In Uganda, there was a time when President Yoweri Museveni used to start nearly every speech, especially when he is telling off donors whom he thought were patronising his government, with “when we begin selling our oil”.
Critics allege that the Kampala government’s binge of spending of recent years, was based on the calculation that oil in the years to come will allow it to cover up the financial holes it is digging today.
My researcher friend told me that the Ghanaians did the same. They borrowed heavily and went on a spending spree in the hope that oil money would close their deficits.
Like Uganda, the Ghanaians counted their eggs before they hatched, but they actually borrowed eggs from the neighbour, fried and ate them, with the promise that when their hens hatch in future, they would replace them ---with interest (ie where they borrowed 1,000 eggs, they would return 1,250). Call this the “Accra-Kampala Disease”.
Now there is a reason why the world has few respectable futurists (the likes of George Friedman), and good economic forecasters. The future is fickle, too changeable, and prone to too much disruption by technology, innovation, and social change. Too many people lose their reputations in that business and fall by the wayside.
Take our example of the eggs. Surely, if you are a poultry farmer and your business is doing well, there is no reason to expect that you cannot pay the neighbour from whom you borrowed 1,000 eggs with 1,250 in the future, right?
Wrong. First, a guy in the next town could set up a more efficient poultry farm with chicken that drop more eggs, allowing him to sell at half your price. With everyone flocking to buy his eggs, your business will bleed, leaving you unable to pay back even 10 eggs.
Secondly, some unforeseen disease could kill off your chicken, again leaving you hiding over eggs. Or everything will be just fine, but dietary tastes change, leading to lower demand for your eggs.
We have a live example of this. Late last year, something strange happened in East Africa. In Kenya East African Breweries (EABL), the good people who also own Uganda Breweries, surprised many when they cut back on a seven-day beer production week, work shifts, and laid off workers because business was bad.
People were drinking more, yes, only that they were drinking less beer. However, figures showed there had been a sharp rise in the drinking of whisky, although admittedly from a low base. Now this gets interesting. The multinational drinks company Diageo holds the majority shares in EABL, and it produces easily the world’s most popular whiskey - Johnnie Walker.
I haven’t spoken to anyone at EABL or Diageo, but someone in the know told me that the shift to whiskey (it is “whisky” without the “e” if it’s not Scottish, a seasoned drinker tells me) but in health attitudes. Increasingly more women and men, he alleged, believe that whiskey is less likely than beer to leave you with a potbelly.
The lesson here is that you really can’t game the market and the future. Uganda should observe Ghana and learn.

Mr Onyango-Obbo is editor of Mail & Guardian Africa (mgafrica.com): Twitter: cobbo3.


Charles Onyango Obbo

More than 20 years ago, Museveni was right…but the world brushed him off

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By Charles Onyango-Obbo

Posted  Wednesday, July 30  2014 at  01:00
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Last week, I met an expired admirer of President Yoweri Museveni, who used to work with the World Bank in Washington and quit in disillusionment.
He told me of a story from a time when, as he put it, “Museveni was still Museveni and not this strange person he has turned into today”, that he said demonstrates the cynicism of the bank, and how “visionary” his man at the time was.
His story is that at the start of the 1990s, when Museveni was still being feted in world capitals and by international finance organisations because of his reformist credentials, he travelled to Washington.
He met World Bank big wigs to discuss Uganda’s economy. At that time, infrastructure was not yet the World Bank’s and everyone’s buzzword, but Museveni told the bank’s chiefs that he thought the way forward was for the bank to lend Uganda money to invest in infrastructure.
Some of the bank officials quietly giggled, probably thinking the hot African sun had beaten Museveni’s bald head a little too much and he was not thinking clearly. He was the first African leader who had been to the Bank and pushed the infrastructure argument.
They didn’t agree with him, arguing that roads were really not helpful in a situation where millions of Ugandan children were out of school. The bank had the more emotional argument, and Museveni seemed like one of those leaders who think people can eat roads.
Museveni quickly realised the conversation needed to be more people-centred, so he explained it rather simply. He said he knew his people very well. They loved education so much, and don’t need to be persuaded to pay for it. The only problem is that most of them were poor.
However, if Uganda could invest in infrastructure and enable people to do more business and grow rich, then parents would pay their children’s school fees and they would get an education.
However, there is something else he knew about his people, Museveni said: However rich they became, there is one thing they were not going to do—“pay to build roads”.
He told me; “Whichever way one looked at it, Museveni won that argument”. However, the World Bank had the chequebook. And, as you know, we owners of chequebooks are autocrats who decide how much money we sign off on it.
There are several revelations about this story. This was before the campaigns and subsequent election of 1996. Until then, Museveni had governed without a direct voter mandate, and relying wholly on the “legitimacy and justness” of the bush war that brought him to power.
It suggests that Museveni was probably never philosophically sold on the idea of free primary education. While he believed in the value of education, he thought at that point that it would be best delivered by the free market or, at best, a mixed model like Rwanda’s where parents contribute something small to keep them interested in how schools run. It is more stable, and might have prevented the shambles that the Universal Primary Education (UPE) system has become today.
Perhaps this is further evidence that Museveni offered UPE as a kind of social bribery to voters in the 1996 campaigns, his first electoral test as president.
But one would otherwise need not be further interested in this story if it ended there. It doesn’t.
There is a depressing story about why the World Bank was obsessed with “education above everything else in Africa” at that point, but that is for another day. About 10 years after that Museveni meeting in Washington, everywhere in Africa where UPE was implemented, the early signs of trouble were showing through.
Apart from quality issues, the jobs were simply not being created at levels that would absorb all the new young people coming into the market after UPE. Those who were going on to secondary school were in turn swelling enrolment there, and there was a big rush by investors to open up private universities.
In later years, in Egypt and Tunisia, the highest percentage of youthful unemployed was the young cohort with second degrees. Ethiopia that gambled big on technology education only ended up with the region’s largest number of unemployed engineers.
Why were jobs not being created fast enough? Because the cost of business was simply too high for investors. People too were not consuming enough because prices were high. Companies were not making the levels of profits that would enable them expand partly because there were too many inefficiencies in the system. What was the cause of all these problems? Poor infrastructure!
Now the bank was converted, and singing the infrastructure and lecturing Museveni about it, when 10 years earlier they had, as Ugandans might say, “thrown him out”. I am occasionally a reasonable and fair man, I have been told, so on this day I feel for Kaguta on this one.

Mr Onyango-Obbo is editor of Mail & Guardian Africa (mgafrica.com): Twitter: cobbo3.