The government is short-changing Ugandans by under-spending on their healthcare, and in effect limiting poorest families’ access to quality health services, in spite of committing to “facilitate attainment of good standard of health” for all citizens.
Findings in the latest National Health Accounts (NHA) survey, an international technique for tracking financial flows in a country’s health sector, show the government’s annual spending on each citizen’s health is about one-third of its own target – of $28 (Shs72,000) - and far below international minimum thresholds. The government’s annual per capita health expenditure stands at $11 (Shs28, 000) or roughly about $1 a month, an equivalent of Shs2,500 at current conversion rates. This, for instance, is half the price of Rough Rider condoms at private clinics in the capital.
The Commission for Macroeconomics for Health recommends that a government should annually spend at least $34 (Shs87,000) on the health of every citizen - from its own resources. Uganda’s problem is not just that it cannot meet its international health financing commitments. Like a student that sets and fails their own examination, the government is unable to achieve its domestic target specified in the Health Sector Strategic Investment Plan - to spend $28 on each Ugandan’s health each year.
Also, the government has back-pedalled by averagely assigning just 8-9 per cent of its national budget to improve things in the ailing health sector, 12 years after signing onto the April 2001 Abuja Declaration.
The pact by the heads of state and government obliges African countries to allocate at least 15 per cent of their national budgets to Health. Museveni was Uganda’s President then, and still is, but hardly makes reference to, or gives an explanation for the unfulfilled Abuja commitments.
On the other hand, the neighbouring Rwanda, which has a smaller population and national wealth compared to Uganda, and which in 1994 was scarred by genocide as Uganda registered roaring economic growth, is among six African countries that have met the Abuja health threshold, a revelation made at the July 2013 African Union Special Summit on HIV/Aids, TB, Malaria.
Whereas there has been marked quantitative improvement in Uganda’s health sector marked by a swell in physical heath units, including in the country’s remotest corners, a shortage of doctors and medical equipment means many of the facilities have remained shells or wasteful investments.
Officials are in doubt if the country would have achieved three of the 8 Millennium Development Goals that touch on health by the 2015 deadline even as the 2011 Demographic Health Survey shows an improvement in most health indicators compared to the 2006 statistics, except maternal mortality.
So, what is Uganda’s millstone?
Some health experts point to the mismatch between policy prescriptions and implementation coupled with topsy-turvy prioritisation. Indeed in December 2012, donors withheld $300 million in aid to Uganda over alleged theft of $13 million by Office of the Prime Minister staff, precipitating a financial hardship that saw government default on paying its employees, including health workers some of who had months earlier received salary raise.
As such, the success and failure of Uganda’s healthcare is invariably tied to what donors do or choose not to. It is mostly in areas such as HIV/Aids, immunisation, malaria and Tuberculosis fight where donors pump a lot of cash, that performance indicators are improved. For instance, HIV prevalence began to climb and national immunisation coverage staggered following a decision in 2005 and 2011 by the Global Fund and Global Alliance for Vaccine for Immunisation (GAVI), respectively, to freeze grants over theft of their monies.
According to Dr Freddie Ssengooba, a health economist and Makerere lecturer, the downside to mortgaging health financing to external actors is that it introduces expensive drugs, mosquito net brand and equipment which are unsustainable for a resource-constrained country; distorts local decision-making and prioritisation due to government malleability; and, holds up money in the upper hierarchy with little or no resources filtering to frontline health workers who need them most.
And district health authorities, according to a former MoH analyst, use finances as directed by the central government and are not allowed to deploy to address the most pressing of local health challenges.
Also, many skilled medical officers have been snapped up and turned away from clinical work to managers of lucrative donor-financed projects, resulting in internal brain drain.
In the corridors of the ministry of Health headquarters in Kampala, there is a sad joke – some say lamentation - that Uganda has two health ministries: One on a shoe-string budget under line minister Ruhakana Rugunda and the other a well-lubricated modern version run by the US government that in 2012 alone spent $420 million (Shs1 trillion), more than what the Uganda government injected in the sector the same year.
An analysis of the latest NHA report, which covers the 2008/2009 and 2009/2000 Financial Year period, shows perennial under-financing has deprived the government of its sovereign right to drive the health agenda while giving donors the legroom to determine health priorities, which has subsequently imposed unsustainable costs on millions of Ugandans.
The donors bring in high-grade, more-expensive medicines and vaccines – creating overseas markets for their domestic drug manufacturers - and government accepts them for public use because they are supplied free yet it already cannot afford the existing cheaper varieties on the market, leading to drug stock-outs at public health facilities across the country. Put another way, the bright side of donor altruism is adulterated by the jarring associated external interference - much to the distaste of recipients.
A former top Health official six years ago declared Uganda’s health system as “a failure”, premised on attempted liberal reforms that the World Bank and International Monetary Fund imposed, and which government imbibed, as a pre-condition to access loans or debt waivers.
In a 2007 paper ‘Learning from failed health reform in Uganda’, Dr Sam Okuonzi, who was head of policy analysis in the Ministry of Health from 1999 to 2002, attributed government’s staggering approach to health matters on market-oriented western policies. Yet, he argued, health is a social good; a pre-requisite for a population’s enhanced productivity.
“Although access to health services is said to have increased as a result of the growth in private clinics, socio-economic inequality within Uganda has grown and the poor, who make up the majority of the population, have become worse off, Dr Okuonzi, now Vurra County MP, noted.
The Bretten Woods institutions hoped market reforms would open up economic opportunities, make Ugandans richer so that enterprising citizens could afford quality care at private health facilities in a private sector-led economy.
Both the calculations and implementation turned out wrong. Whereas liberalisation revived Uganda’s ailing economy and made it wealthier overall, the policy downside was that it concentrated wealth in the hands of bureaucrats or their politically-connected allies in the private sector, widening the income disparity and condemning one-third of the population into absolute poverty.
The affluent combined to set up private health facilities, whose services are beyond the reach of millions of ordinary citizens. Those on the fringes suddenly cannot buy good health when they fall ill. According to the World Health Organisation, households are unduly pushed into poverty if they shoulder 15 per cent of a country’s overall healthcare costs and describes as “catastrophic expenditure” when out-of-pocket spending caps 40 per cent. NHA’s findings are that Ugandan families bear 43 per cent of total national healthcare expenditure, beyond the UN health agency’s redline.
This means more citizens are falling deeper into poverty by incurring more expenses just to keep alive, increasingly becoming less productive and that wide income disparities create financial barriers, making access to quality healthcare inequitable. Thus healthcare-seekers without commensurate disposable income are forced to die unattended to, including preventable diseases, which is commonplace in the countryside.
Such an unforeseen ramification partly forced government to scrap the user fees it had introduced at public hospitals in 1993 because the levies generated less than 5 per cent of a hospital’s total expenditure; limited access to health for the majority poor; and, became a political liability in election time. Those trial-and-error approaches created in their clouded paths a thriving private-for-profit healthcare system that has become an attraction for the well-to-do for their range of services arguably better in quality than at most public health facilities.
Mr Tom Aliti, the Health ministry acting assistant commissioner for budget, who coordinated the 4th NHA survey, said there is an urgent need to re-think health service delivery by focusing and spending more on prevention and promotion rather than curative care, and, ensuring every decision is evidence-based. “It requires the government to shift policy direction toward primary healthcare financing; more money should go to decentralised services such as prevention, primary healthcare, health education and promotion, immunisation and reproductive health,” he said.
Because malaria, HIV/Aids, pneumonia, anaemia and tuberculosis that are the leading killer diseases in Uganda are preventable and so are respiratory infections and (accident) injuries, which are among the top five diagnosis for hospital admission.
Put another way, the government’s already below-par allocation to health would yield better dividends for citizens’ wellbeing if the money was spent on stopping people from getting infected than treating them.
Because human resource – especially one that is skilled – is a country’s most seminal asset, a healthier and more productive population would therefore add more rapidly to national wealth if the government got a right footing on public health financing, economic drive of prosperity-for-all.
That may be far in coming considering that the government’s top priority as articulated in the National Development Plan, signings with regional neighbours and this year’s budget has shifted to development of infrastructure; roads, railway and electricity.
Ondoa’s fight with Health team
When consultant pediatrician Christine Joyce Dradidi Ondoa, then executive director of Mbarara hospital, was unexpectedly named the Health minister, this newspaper the next day asked: Will the touch of a woman heal Uganda’s sick health sector?
Dr Ondoa, 45, who moonlights as a pastor at Lifeline Ministry’s Mbuya-Kinawataka church in Kampala, was the first female out of 20 Health ministers in Uganda since 1955. Like many before her, she was sacked after two years, and has now been re-deployed as a senior presidential adviser on Health. The former minister looked a great addition to President Museveni’s female holy warriors such as URA’s Allen Kagina and KCCA’s Jennifer Musisi.
Dr Ondoa’s report card reads interesting. She was not on talking terms with PS Asuman Lukwago by the time she was dropped from Cabinet. The pediatrician was seen as an outsider, a religious fanatic who run the ministry as if it was a church, and stepped on toes of many technocrats with her strict accountability demands. Epidemics such as ebola and hemorrhagic fever battered the country like the nodding disease before them under her watch. Critics say initial response to the emergency was jaded.
However, the ebola deaths were lower compared to the 2007 outbreak and spread of the latest cases was contained fast. Ironically, it is reforms that Dr Ondoa undertook to move things in Health forward, such as reforming medicine distribution, which ironically made her unpopular because it shut the oxygen for backhanders in the procurement world.
Forthrightness may have turned out her liability, but it earned her a name abroad, with rewards for the country. The Global Fund resumed funding to Uganda after a seven-year lull and the Fund retained Dr Ondoa on its executive committee so she can keep a watch to ensure the funds go to intended work.
She fought hard last year for an increase of certain health workers’ pay, setting her on a collision course with colleagues in the Executive; she got 8, 143 more health workers recruited to address the manpower shortage and presided over ongoing rehabilitation and construction works at Mulago and other referral hospitals.
Sixty additional accredited antiretroviral sites were opened and immunisation coverage during her tenure went up to 52 per cent from 48 per cent, according to a June 2013 handover report. By the time she left, the African Society of Laboratory Medicine had voted Uganda one of the best TB reference labs in the world.
However, the Heart and Cancer institutes remain under-resourced and potential death traps than cure centres; six health-related bills are stuck in the legislative traffic; many Health Centre IVs are shells; the National Drug Authority board awaits cabinet approval and there are fewer than required workers at health centres III, IV and general hospitals.