Healthcare corruption in Uganda is a matter of life and death

Dear Tingasiga;
As we continue our conversation about the dangerous levels of corruption in Uganda’s healthcare service, there are two points that need emphasis.

First, the majority of Ugandan doctors and other health workers are dedicated, honest professionals. A lot of what I am sharing with you is informed by conversations and correspondence with many medical colleagues who are concerned about the situation in the healthcare service in Uganda. So, while the behaviour of a few individuals has sullied the profession’s reputation, there is no collective guilt implied in the alarm we are compelled to sound.

Second, the fact that corruption is a universal human failing does not obviate the need to expose it and deal with it in Uganda, the country that matters most to us. Furthermore, the impact of corruption in a developmentally struggling country is multiplied many times compared to its effect in a developed economy.

Here in Canada, whenever incidents of corruption in healthcare have been detected, they have been exposed and thoroughly investigated. Punishments have been meted out and corrective measures have been taken to try and prevent recurrence. This approach to corruption has been aided by a general societal culture that abhors the scourge and recognises the personal and collective impact of unchecked corruption, however small it may appear.

For the most part, corruption in the healthcare system of an advanced economy like Canada is a mere nuisance that adds to the taxpayer’s and patient’s burden. It does not directly threaten lives. Similar corruption in Uganda is a matter of life and death, a recurring tragedy that invites us to speak boldly and seek a solution before the system passes breaking point.
It is tempting to blame the challenges of Uganda’s health service on poor funding. It is true that Uganda continues to fall far short of the Abuja Declaration of 2001 in which the African Union Heads of State agreed to allocate at least 15 per cent of the annual Budget to the health sector.

Out of this financial year’s projected spending of Shs27 trillion ($7.3 billion), the Uganda Government allocated only Shs2.3 trillion ($620 million) or 8.5 per cent of the Budget to the health sector. A shift of priorities from wasteful spending would go a long way towards the Abuja target of 15 per cent. However, if the currently allocated funds were judiciously, equitably and honestly managed and spent on priority needs, we would see positive growth of the health service. In fact, the bulk of $1.76 billion received as foreign aid in 2016 went to the health sector. The story was the same in 2017 and probably this year as well. The problem is that the money is thrown into wide open mouths of sharks that steal what they can.

Over the years, we have heard about petty bribes demanded by frontline healthcare workers. Endemic absenteeism and other irresponsible behaviours have undermined patient care and confidence in the system. Theft of medicines and other materials have become so routine that they hardly attract our attention any more. Yet these and other petty misdeeds should never be ignored. Indeed, by interesting himself in this petty corruption by frontline workers, President Yoweri Museveni has scored some success in reducing the problem at this level. His Health Monitoring Unit (HMU) has launched raids that have caught healthcare personnel red-handed.

This was dramatised last year by Sarah Achieng Opendi, the Minister of State for Health – General Duties, when she presented to Naguru Hospital in disguise, pretended to be a patient and was promptly invited to pay cash bribes before getting care. A couple of health workers were arrested, and the news spread across the land. The result of the HMU’s work has been quantified by Transparency International’s Global Corruption Barometer, which showed that bribery in Uganda’s health services decreased by 50 per cent in the years between 2010 and 2015. It appears that frontline health workers have been scared into mending their ways.

However, this petty bribery, though harmful and worth fighting, is not as big a threat as the escalating mega-deals that are a product of the neoliberalisation measures that have commercialised the healthcare industry. Patients are now sought-after commodities, with cash changing hands in pursuit of increased referrals.

A popular hospital in Kampala is said to routinely raid Mulago and other public hospitals to steal their patients. Some private hospitals pay cash incentives to doctors in an effort to increase patient traffic. Private hospitals pay insurance companies to direct patients to them. At least one insurance company has a major financial stake in a private hospital in Kampala. Others use a health maintenance organisation (HMO) model that encourages minimum cost of care that may well compromise the patient’s health outcome. The conflict of interests is readily evident.

One senior administrator at a private hospital in Kampala told me that a representative of a Uganda-based regional peace-keeping mission asked that hospital to pay him (the peace-keeping guy) a hefty commission so that he would preferentially send patients to that hospital. These patients’ fees would be paid by the peace-keeping organisation. The administrator refused the offer. The peace-keeper took his business elsewhere.

There are allegations of patients undergoing laboratory, imaging and other tests that they do not need. Many allegedly receive piles of medicines that hit their wallets without touching their illnesses. Pharmaceutical sales representatives routinely pay some doctors to preferentially prescribe certain drugs. The payment is often in the form of bribes such as free petrol refill cards, fully paid holiday trips to Dubai, sponsored seminars and training abroad. One doctor, an administrator of a major clinical department at a private hospital, told me that a pharmaceutical company offered him a brand new car. He declined the offer.

Procurement staff in some of the private hospitals stock substandard drugs and equipment in exchange for cash incentives. And this is just scratching the surface of the rot in the system.

The obvious treatment for Uganda’s sick healthcare system would be an effective, comprehensive regulatory system. In fact, there is no shortage of a monitoring system for the public health service. There is the Ministry of Health, the State House Health Monitoring Unit, the Uganda Medical and Dental Practitioners’ Council, Uganda Nurses and Midwives’ Council, the Allied Health Professionals’ Council Uganda, the Inspector General of Government and, of course, the Auditor General. One hopes that these monitoring units are staffed by people of integrity, not enablers and participants in the scams.

To what extent the private clinics and hospitals are regulated and monitored is not clear. What is clear is that the neoliberal policies that continue to weaken public health care institutions in favour of private enterprise are a threat to the health of the vast majority of citizens.

A thorough audit of the entire health system – public and private – followed by a non-partisan reassessment of Uganda’s health care direction would be a first step towards finding a solution.
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