Fight between govt and doctors: A case of cutting off the nose to spite the face

The simmering fight between medical workers and the government over pay and working conditions has escalated again, this time over plans to import expatriate doctors from Cuba.
There are conflicting messages about the motive. Health ministry officials say the Cuban interventionists are to supplement, rather than replace locals. Some of these revolutionary doctors, we hear, hardened by life on the Communist island, are to be deployed to far-flung places where our local reactionaries, unable to find café lattes and butterscotch cookies, prefer not to go.
Another view, voiced by the President at the Labour Day fete, suggests that the Cuban doctors are an antidote to the “blackmail” by doctors when they went on strike a few months back.
Time to draw blood and put this problem under the microscope. The first question, and an easy one to answer, is whether we need more doctors. The most recent data I could find, from 2013, show a doctor-to-patient ratio of 1:24,725, way off the recommended 1:1,000. In addition, there are many specialised fields of medicine in which we have very few, or no doctors. So yes, we need more doctors, including specialists. Cuba, with a surprisingly robust and resilient health system, could be a good source.
But that isn’t the full story. You see, there was a time when Uganda was the Cuba of Africa: A small country with a surprisingly robust and resilient health system. You can go back to Mulago Hospital and the attached Makerere Medical School, farther back to Mengo Hospital and early colonial medical efforts, or way back: Traditional doctors in Buganda and Bunyoro were delivering babies by caesarian section centuries before the missionaries. In addition, and thanks in part to investments by this government, in Mbarara and other universities, we produce more doctors each year than our neighbours.
The problem isn’t how to produce doctors. It is how to keep them. This is where things get sticky. ‘Outside countries’, is full of Ugandan doctors and medical workers. You can tell by their age whether they fled for their lives during Amin’s time, or for their money during Museveni’s.
In fact, doctors have not been exempted from the current policy of ‘exporting labour’, as this modern-day practice of the ancient dark trade is euphemistically referred to. The government has been trying to export a year’s worth of medical school graduates to Trinidad and Tobago, despite the island having a much better doctor-to-patient ratio, and a much stronger health system. So fed up are some of the Ugandan doctors that when the call went out for volunteers to board the ship to the West Indies, 20 out of our 28 radiologists and four out of our six urologists signed up.
You don’t have to be a brain surgeon to see that exporting Ugandan doctors to Trinidad and Tobago and bringing back Cuban doctors on the return flight is, well, a no-brainer. At best it is the equivalent of borrowing from Peter to pay Paul. At worst, the moral hazard of having a few well-paid expatriate doctors and many poorly paid locals will only dampen morale further and perhaps even lead to sabotage (the man with the ambulance key has gone).
This fight represents a bigger problem of unhappy public and civil servants. Doctors are able to speak up and fight back because they, unlike police officers, RDCs or Luganda teachers, have skills they can easily transfer across borders.
There are two exits off this highway to hell. One is to end the sham of ‘free healthcare’ and allow hospitals to charge fair and transparent user fees in order to keep the lights on and keep the doctors happy. Patients already pay these bribes; all you need are receipt books.
The other is to reduce the financial pain to patients by rolling out a national medical insurance scheme to which all adults should contribute. Enter economies of scale in the purchase of medical goods and services, as well as allocative efficiencies: Good doctors and hospitals will make more money; the bad ones will stowaway on ships to the Caribbean where anonymity might offer fresh beginnings.
It is better for the government to keep its nose clean and allow a market mechanism to find equilibrium between what doctors should make and what patients should pay. Threatening doctors or bringing in ‘Bacuba’ to replace them is akin to cutting off the nose to spite the face.

Mr Kalinaki is a journalist and a poor man’s freedom fighter. [email protected]
Twitter: @Kalinaki.