Wednesday August 27 2014

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

By Charles Onyango-Obbo

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 ( Twitter:@cobbo3