National universal, affordable and quality healthcare: Debate missing in political campaigns

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OPINION

By Dr John W Bahana

I was born before Uganda’s independence and have travelled throughout Africa, working in many of these nations. I have also travelled to South America, the United States, Europe and Asia, notably India and Pakistan. I also worked under the Uganda Ministry of Health as a consultant overseeing the Indoor Residual Spraying project for malaria control. So, what I am sharing is drawn from my travel, work experience and relevant research.

There is an Arabian proverb that goes: “He who has health has hope, and he who has hope has everything”. At the time that I was aware of my physical environment, sick villagers in my community would mostly revert to herbal medicine, utilising traditional knowledge. In the worst of conditions, the very sick ones would be carried by young relatives on “traditionally crafted stretchers” to the nearest hospital, to receive so-called modern medicine and services that the Government provided. No patient paid a single cent.

This article is drawn from the perspective that I have noted by following the campaigns of presidential and MP candidates. It is also a reflection of what the Permanent Secretary of the Ministry of Health is quoted in the New Vision interview on her resolutions of the year. In the words of Dr Atwine, the PS, “Health is not a destination, but a continuous journey, a long-term commitment to ensure that every Ugandan receives adequate and quality healthcare”. I am not sure if the resolutions are the official policy of her ministry.  If it were, Uganda would be on the way to retaining its past glory and beyond.

Way back, Mulago National Hospital also served as a teaching hospital for Makerere University. It was the pride of East Africa, with some professors who started the University of Nairobi Medical School at Kenyatta Hospital, having achieved valuable experience from Mulago. Some of the most famous of these Ugandan staff at Mulago included Sir Ian Macadam, who led a surgical team that oversaw the care of President Dr Milton Obote when, in an assassination attempt in 1969, he was shot in the mouth.

I cannot go into details of top Ugandan professors that were the nation’s pride, except just a few; many of these had to escape Amin’s Uganda to teach in world-renowned universities in many countries, ranging from Papua New Guinea (Professor Gilbert Bukenya) to Jamaica, Bogi Benda (aka Tumusiime Rishedge), Professor Herbert Nsanze in Kenya and the Middle East. Thus, for many decades, health care was public, in which the Government was responsible for the well-being of its citizens. This brings me to the recent developments in this sector. Interestingly, most Ugandans only realise how important health is when they are ill. Maybe that’s why our healthy and reasonably well-to-do politicians are not bothered by what needs to be done.

I happen to be a victim of unaffordable hospital bills, and so are many of my friends, whose experience is most probably shared by many readers. A few years ago, a hospital, that must remain anonymous, retained a dead body on account that hospital bills accumulated over his stay alive had not been paid.

Another instance quotes a judge of the Uganda Supreme Court who narrated her extreme frustration at the high cost of hospitalisation of her dear, fortunately still alive husband. Such examples abound. Many Ugandans cannot afford the high costs of hospitalisation in this country of ours anymore. But it is not just the cost. The quality of healthcare is now under scrutiny. To this extent, Ugandans who are well off and can afford to fly are flying to neighbouring Kenya, South Africa, India and Turkey.

This brings me to share why the Ugandan health system has come under scrutiny and thus requires urgent attention by the Government. That political campaigns, at national or local representation levels, have either not understood the gravity of the national challenge or, worse, that they have not bothered to learn its significance to the national well-being, is worrying and worth debating.

Most unfortunate is the fact that there are many Ugandans who, by coincidence or otherwise, have died while in these external hospitals or soon after their return to Uganda, having spent millions of shillings that were never budgeted for in the first place. I know of a close friend who was hospitalised in Nairobi and never returned alive.

Many well-to-do Ugandans go to India for health emergency care. This is largely because India's health care system is “multilayered” or a mixed bag of public services and a dominant private sector providing the majority of secondary and tertiary care. Procedures in India often cost about 70% less than in the Western world, in effect outranking many global peers, based on outcomes per shilling spent.

Private hospitals in India are leaders in adopting advanced technologies like AI, robotic surgery and precision medicine, thus improving diagnostic accuracy and patient outcomes. However, more than 68% of the population is underserved. The dominant payment mechanism often rewards the volume of care rather than the value of outcomes. This often leads to unnecessary diagnostic tests or procedures, as it were, a strategy of the institution to make money. It is highly suspect that Ugandan private hospitals are adopting this “thieving” unprofessional conduct.

I have visited Brazil, which is of interest to me for many reasons. The country has the second-largest black population in the world.  One wishes Uganda would learn from its successes. Brazil operates free medical services to everyone in its territory, including citizens, legal residents, undocumented individuals and short-term tourists: Free of cost health care supports emergency services, specialised outpatient care, hospitalisations, surgeries, mental health and even complex procedures like organ transplants. Many essential drugs are provided for free. About 70% of the population depends on this service of more than 155million. Can Uganda learn lessons from this?

Turkey is a destination by many Ugandans seeking healthcare. Its system is a mixed model that provides healthcare that is near-universal coverage with recordable targets in medical quality and life expectancy.

Finally, a country that Uganda was once similar in health care is China. It’s a country many of us as youngsters in the 1960s and 70s admired. It operates a near-universal healthcare system that covers approximately 95% of its population through a publicly funded basic medical insurance, the National Health Commission.

And now the four-acre model flagship. The colonialists, together with Kigezi leaders, realised way back in the 1930s that the human population far outstripped its demand for land resources. Migration became a policy in which people were encouraged to migrate to Ankole, Tooro and Bunyoro. So, it amazes me that local leaders tell our president that the four-acre model will transform the population from poverty to wealth. Really? Who in Kisoro or Ndorwa has land that measures more than one acre?

See you after the elections.

(Dr Bahana headed a national Malaria Indoor Residual Spraying Project under MOH and financed by USAID)