Why govt should focus on ICU beds, ventilators, not new pick-ups

President Museveni likes cars. For Uganda’s independence golden anniversary on October 9, 2012, he arrived at Kololo Ceremonial Grounds in a new Mercedes Maybach S500 Pullman Guard armoured car, one of the two that had just been added to the presidential fleet.

Both cars cost Shs6 billion, or just over a million dollars in 2012 money. They are part of a presidential fleet that, on occasion, stretches to more than 40 vehicles, including high-end luxury four-wheel-drive SUVs.

In April 2017, the Observer newspaper reported that State House spent Shs21.7 billion on vehicles between 2010 and 2015. This did not include purchases by the Office of the President, where vehicles allocated to resident district commissioners, presidential advisers and the like are accounted for.

But it is more than the presidential fleet. Cars are the go-to presidential gifts for political allies and opinion leaders. Newly chosen Bishops choose their consecration dates carefully, and in consultation with State House, for the President’s attendance guarantees a gift of a new 4WD car.

Those in the know say State House keeps a fleet of new 4WD pickup trucks, ready to be gifted to the President’s allies and supporters. A recent favourite, the Mitsubishi L200 double-cabin pickup, costs about $50,000 (about Shs188.6m) on the road.

Thus it was not surprising to hear President Museveni announce that a $150,000 (about Shs566.0m) donation by the Tony Elumelu Foundation for Uganda’s efforts to combat the coronavirus disease would be used to buy 4WD pickups for the Health ministry.

In a subsequent national address, the President said Covid-19-related donations from the private sector should, as a matter of priority, be used to buy “4WD pickups, brand new”. Many corporate bodies that have queued up to donate have, since the presidential guidance, dutifully offered 4WD pickups, brand new.

The President says he wants to build a fleet of 10 such vehicles for every district, or about 1,350 vehicles.

The wrong lane
There are so many things wrong with the idea, it is difficult to decide where to start. Let us begin with the logistics.

In the eight months to February 2019, 217 new cars were sold in Uganda or, we can safely assume, less than 500 new cars annually. So even if enough companies stepped up to provide the money for the fleet, there would probably be fewer than 100 units on the market. It could take at least several weeks, if not months, for new stock to arrive.

Even if the cars, somehow, arrived before the worst of the pandemic had passed, car sellers would jack up their prices knowing exactly what product the country was keen to buy – “4WD pickups, brand new”.

The last time the government undertook an emergency procurement of vehicles, the Vice President, Minister of Foreign Affairs, and the Minister of Works and Transport ended up in the dock, accused of influencing the process for personal gain.

The on-going scandal over the procurement of relief food for the urban poor affected by the lockdown shows that a repeat cannot be ruled out and should, in fact, be expected.

But let us assume that, somehow, the President was able to get even a third of his “4WD pickups, brand new”; 450 cars. Buying cars is a one-off capital expenditure, admittedly a big one. At $50,000 each, the entire lot would cost $67.5 million (ShS253 billion), or Shs84b for the 450.

Sticking with the lower number, and assuming 450 drivers can be swiftly interviewed and recruited without scandal, and assuming a monthly salary of Shs500,000 each, that is another Shs225m per month, Shs2.7b per year.

Then there are the running costs. A May 2017 internal report from the Ministry of Health, produced in consultation with the government chief mechanical engineer, reported that the ministry spent Shs1.8m per month, or Shs22m per year, to maintain each car in its fleet – excluding the cost of fuel.

The new fleet would therefore require Shs9.9b per year in maintenance, excluding fuel. Over five years, the cost of owning and operating the new fleet of 450 “4WD pickups, brand new”, would be Shs30b per year, excluding fuel.

Now let’s put that figure into context. Remember that May 2017 internal report? It was the result of efforts to streamline vehicle ownership and allocation in the Health ministry. The review found that the ministry had 295 vehicles, many in the hands of “non-core junior and middle-level managers”.

After the contracts of two ministry officials expired, they simply abandoned the cars allocated to them in Wakiso and Kiryandondo districts. In fact, the Health ministry had so many cars, including many that were grounded for lack of maintenance, that its transport officer proposed donating 130 to the Ministry of Education to be used as teaching aids in vocational schools.

By 2017 the Health ministry was spending about Shs6.5b per year to maintain its fleet. This, according to a story in this newspaper from the time, was “higher than the annual individual budgets of all, except four, of the 13 regional hospitals”.

A Shs30b annual spend on a new fleet of 450 “4WD pickups, brand new”, would be as much as government plans to spend this year on Arua, Kabale and Masaka referral hospitals, as well as the Uganda Virus Research Institute, combined.

Not only does such massive expenditure on vehicles seem unwise, it also appears to be unplanned. In the national budget framework paper for Financial Year (FY) 2019/2020, the Ministry of Health planned to upgrade 41 health centre IIs to level III and ensure 40 health centre IIIs are “functionalised” in 56 districts.

This “functionalising”, officials familiar with the sector say, simply means buying basic equipment and hiring doctors to work in the many brick-and-mortar health centres built by the government across the country, but which lie empty.

For instance, health centre IVs are mini hospitals that should have wards to admit patients, as well as facilities and personnel to carry out emergency surgeries. In the first quarter of FY 2018/2019, only one in two health centre IVs could offer caesarean sections and blood transfusion services, and the Health ministry planned to raise this number for 75 per cent by the end of June 2020.

Similarly, only half of the hospitals had functional imaging and radiography equipment at the start of FY 2018/2019, with a target of 80 per cent by June 2020. By its own planning, at least according to the submission to the national budget framework paper, the Ministry of Health needs to invest in basic medical equipment, not vehicles.

Emergencies tend to knock even the best of plans out of sync, and the coronavirus pandemic is no exception. Still, it is hard to see how the purchase of vehicles can be a priority.
Countries that are ahead of Uganda in the disease curve show the need for at least four key interventions or supplies.

Wayforward
The first is increasing the number of medical workers available to treat patients. Uganda’s doctor-to-patient ratio, of about 1:24,000 is well below the recommended 1:600, but since this is a recurrent cost, let’s set it aside for now.

The second is kits to test for the disease, identify infected people and their contacts and help contain the spread. Thanks to earlier battles against HIV/Aids, Zika, and Ebola, Uganda has some reasonable experience and testing infrastructure to deal with viral outbreaks.

Prof Pontiano Kaleebu, the director of the Uganda Virus Research Institute, told this newspaper earlier this week that his facility has the capacity to do 500 tests a day.

Another 20,081 testing kits, donated to Uganda by the Chinese e-commerce magnate, Mr Jack Ma, as part of a wider donation to African countries, expands the ability, at least in the short-term.

While the number of people tested has increased over the past two weeks, the President has ruled out mass testing, which has proved effective in other countries, majorly on account of cost, said to be $65 (about Shs245,276) per test in Uganda.

Investing in developing cheaper testing or buying cheaper testing kits, and expanding the number of tests done every day could be a better way to spend the cash donations.

At a current cost of Shs245,276, each “4WD pickup, brand new”, could pay for more than 750 tests. If the price were to fall to $10 to $20 (about Shs37,739 to Shs75,478) as in other countries, each vehicle could pay for 3,333 tests – more than half all the tests Uganda had run by the end of this week since the pandemic broke out.

The third intervention is intensive-care beds. Research conducted in 2019 and released in January on the current capacity of Intensive Care Unit (ICUs) in Uganda by Patience Atumanya and others, found that Uganda has 55 functional intensive care beds in the 12 ICUs that are operational (Two other ICUs were not working due to a lack of medical workers). Only four of the 12 ICUs were in public hospitals.

The Ministry of Health says adding the beds in the recently reopened Mulago Specialised Hospital raises the number to about 100. This is commendable, but far from ideal in a country of more than 40 million people.

A quick internet search reveals that an ICU bed sourced in the United States of America, with its eye-watering healthcare costs, costs around $25,000 to $30,000 (about Shs94.3m to Shs113.2m), definitely cheaper if sourced in China or elsewhere.

ICU beds need specialised medical workers and might cost more than Shs1.8m per month to maintain, all told, but they would save many lives and would be useful even after the current pandemic passes. Why not ask corporate donors to sponsor ICU beds instead of 4WD pickups, brand new?

One in six people affected by Covid-19 could end up in ICU and a smaller but significant number ends up requiring assisted or artificial breathing, using a ventilator.

Accurate data on the number of ventilators in Uganda is hard to find, but if we assume that each of the ICU beds, whether 55 or 100, comes with a ventilator, surely buying another 10, or 20, or more would be helpful.

Internet prices show a cost of about $25,000 (Shs94.3m) per ventilator but many Chinese, Indian and American companies are scrambling to build models that cost a tenth of the price. Even Makerere University is working on a low-cost model ventilator.

Would it not make more sense to invest some of the donated money into off-the-shelf ventilators and a bit more into the research and development of lower-cost models?

None of this is to say that there is no need for ambulatory services in Uganda. An assessment of emergency medical services in Uganda in 2018 by a team of medical experts led by Dr Olive Kobusingye found that the relevant department in the Ministry of Health received total funding of Shs700 million for FY 2017/2018. The President receives 100 times more for donations.

Time for priorities
The coronavirus crisis presents Uganda with a short-term choice: invest in the ability to quickly get sick people to hospitals that lack equipment and doctors, or invest in doctors and equipment so that those able to get there get better treatment.

These, obviously, aren’t, and shouldn’t, be mutually exclusive choices. But logically the former always ends badly, while the latter gives those able to get through the door a fighting chance.

The President has said the new fleet would be mothballed at the end of the pandemic. If cars are a priority, why not use the government vehicles that are currently parked since most government offices are closed?

Why spend billions on cars when health workers are openly begging for personal protective equipment like gloves and face masks to keep them safe from picking up or passing on infections?

President Museveni likes cars, but it is about time he fell in love with hospital equipment like ventilators. He could even get into the habit of donating a few ICU beds, brand new.

Annual Health Sector Performance Report
The government last year named the best and worst performing hospitals and districts in the Financial Year 2018/2019, with Mbale and Serere District- hospitals, all in eastern Uganda, topping the table.
The worst performing district, according to the Ministry of Health’s 25th Health Sector Joint Review report, was Nabilatuk in the Karamoja Sub-region.
Moroto Regional Referral Hospital was listed as the worst performing in the same financial year. This was followed by St Francis Nsambya, Kabale, Lira, Rubaga and Mubende hospitals
To determine the best performing hospital, Health ministry officials assessed efficiency parametres using bed occupancy rate (BOR) and Average Length of Stay (ALoS) [in hospital]. The ALoS reduced to an average of four days in FY 2018/2019 from five days in 2017/2018.
The best and worst districts were determined using the District League Table (DLT) composed of input, process, output and outcome indicators such as staffing levels, Tuberculosis (TB) case detection rate, deliveries in health facilities, immunisation coverage, and latrine coverage, among others.
Purpose
The Annual Health Sector Performance Report evaluates progress of the health sector against the annual work plans as well as the overall health sector performance against the annual targets and performance indicators.
It is a review of what has been achieved, what has not been achieved and provides reasons why the set targets have not been achieved.
Dr Jane Ruth Aceng, the Health minister, however, challenged performance indicators used to rank hospitals, saying they should be revised so that the report is focused on “preventive” and not “curative strategy”.