How Uganda’s hospital services can be improved

May 15, 2007

<b>By Dr Sam okuonzi</b><br>The recent high profile deaths have again vividly demonstrated the collapsed state of Uganda’s health system. This is evidenced by inability of the system to handle emergencies such as acute pancreatitis; lack of emergency facilities in the country; people selling off

By Dr Sam okuonzi

The recent high profile deaths have again vividly demonstrated the collapsed state of Uganda’s health system. This is evidenced by inability of the system to handle emergencies such as acute pancreatitis; lack of emergency facilities in the country; people selling off their assets or begging from the public to raise money for health services abroad; lack of drugs and equipment in all public health units; inadequate, often untrained or inappropriately trained and unmotivated staff in most rural units.

These have translated into the persistently high infant and maternal mortality, the key indicators of the health sector performance. This is shameful for a country that is supposedly undergoing “social transformation” to a modern way of life and has been enjoying economic growth of 5-7% annually for nearly 20 years.

The path to today’s dysfunctional health care system can be traced to 1987, when the government embarked on the current disastrous path of experimentation using unproven, untested and clearly unworkable market reforms of the health sector. That year, the Health Policy Review Commission made an assessment of the health situation and proposed a two-pronged strategy: to fully rehabilitate all existing health facilities and to improve all primary health care (PHC) services. A 10-year plan was subsequently developed based on the strategy. But the plan prompted an outcry from donors who argued that the budget exceeded available resources by fourfold. That what Uganda needed was not rehabilitation but “a major reform of secondary and tertiary sectors”, an euphemism for reduced public funding to and privatisation of hospitals.

Championed by the World Bank, which had assumed leadership of the health sector when the PHC was faltering under the guidance of the World Health Organisation (WHO), donors hammered out a three-year plan, 1992 – 5, which lay out five major policy measures: No further expansion of health facilities, restore the functioning of existing facilities, re-orient to PHC, provide only basic package of services, and promote user-fees to finance health services.
But these policies fell far short of what it would take for the national health system to acquire the necessary capacity to manage emergency conditions such as acute pancreatitis. With a population growth of 3% per annum, to say there should be no further expansion of health facilities, a policy which is now entrenched, was totally perplexing.

Acute pancreatitis, cancer or congestive heart failure cannot be treated in the country if the policy is to provide only “basic package of services”. These diseases require far more facilities, technology and skills than “basic”.

The only policy measure that made sense was restoring the functional capacity of existing facilities. But it turned out that this particular policy had only been inserted as a compromise at the insistence of the Ministry of Health (MOH) officials. But donors had no intention of funding the policy. And indeed no meaningful rehabilitation of the health care infrastructure has happened for the last 20 years. Instead, funding went to health sector reforms and some elements of PHC.

The reforms were more about “changes in management” than about “service delivery”. The reforms were part of the wider scheme of the new world economic order, to orient all systems and services to be compatible with and operate as part of the global free-market. The role and funding from the government would be cut back, social-welfare institutions would be privatized, and health services would be traded like textile or cars on the open market.

To enable the health system operate like a real open market, donors, especially the World Bank, urged the government to introduce user-fees for health care; reduce funding of hospitals; retrench health staff (never mind there were never adequate in he first place); fund only very basic services, mainly immunisation, “social mobilisation” and messages about HIV/AIDS; and to go into partnership with the private sector, by relegating service delivery to the private providers, NGOs and churches.

Funding of the health sector has been highly restricted, ranging from US $8-12 per capita per annum, two-thirds of which came from donors. Only about $.5-2.5 per capita per annum was allocated to hospitals. WHO recommends that a reasonable health system in a poor country like Uganda including the cost of antiretrovirals should be $40 per capita per annum.

In effect, Uganda has pursued a policy of deliberately under-funding the health sector. This is boldly acknowledged in the Poverty Eradication Action Plan (PEAP), the development blueprint for Uganda. It says on page 222 that maternal mortality reduction goals will not be met because this would require “costly medical interventions”, meaning rehabilitation and upgrading of hospitals to modern and functioning levels. Meaningful infant and maternal mortality reduction depends precisely on how efficient hospitals services are, and are linked to lower level care with a good referral system.

Whether the health system in Uganda improves or not is therefore hinged on this single policy — blocking a meaningful increase of funding to the health sector. This policy originates from a prescription formulated for poor countries by the World Bank, International Monetary Fund and the US Treasury in 1980s. It was called the Washington Consensus (WC). It advocated for four pillars economic prosperity: privatisation, liberalisation macro-stability and foreign investment. Everything else did not matter.
The policy was suspect from the beginning and its flaws have become clear even to those who strongly defended it. Yes, it has brought about some economic growth, but at what price? If Uganda government had taken a more human-based policy of economic growth, we would have halved our mortality rates by now. Annually the lives of about a million children who die needlessly and 300 mothers who die of childbirth everyday because the hospitals and maternity centres are not functional would be saved.

Tragically, Uganda has developed an extreme doctrine out of the WC: “Seek ye the kingdom of economic growth and everything will be given unto you”. Well, modern and efficient hospital care has not been given unto us, as recently demonstrated. And so many other things have not been given unto us.

After 30 years of WC around the world, the conclusion is that it is not the only or even the best formula for economic growth. That sustainable and meaningful economic growth should also address the needs of the population. That the WC leaves out or suppresses major drivers of the economy such as education and health. A minimal government is untenable in a poor country like Uganda, where there are no institutions to tame the market, or to mitigate its adverse consequences. And a strong government is necessary to shape the economy to address the needs of the population.

Moreover, studies have shown that there is always a tendency to implement the WC wrongly or partially – from Africa to Russia to Latin America – especially in the absence of corporate culture and governance. But the key lesson for Uganda is that countries in South East Asia, including China and Japan, did not attain economic growth by blindly following the WC. In fact they defied the WC. China has defied not only WC but all neoclassical market theories from the form of democracy to fixed value of the Yuan to public ownership of land. Yet it has maintained the highest economic growth ever for 30 years. These countries attained economic growth by putting various factors together on their own terms and for the benefit of their population.

Therefore, if Uganda is ever going to acquire modern, reliable and high-tech medical services it must first dispose of its policy of under-funding the health sector. Studies have shown that restricting inflow of aid to a poor country for necessary investment is flawed. There is in fact no evidence anywhere that large aid inflows lead to hyper-inflation, overvaluation of domestic currencies, reduction of external competitiveness — the reasons for this restriction. Where governments have maintained low interest rates, increased overall liquidity and maintained a relatively depreciated currency, they have not only sustained growth but created the necessary fiscal space for investing in human capital, especially health care. All that is needed is to coordinate fiscal and monetary policies, while ensuring that aid money is fully spent and absorbed.

Second, once sufficient fiscal space has been created in the economy, the government should mobilise a reasonable level of resources internally and externally to fully rehabilitate and equip Mulago Hospital as a tertiary care to international standards over the next three years. Priority should be placed on the Intensive Care Unit, Cancer Institute, Heart Institute and Casualty Department. These are the most specialised levels of care Ugandans need to access for which there may be no time to travel abroad even if one was well-off financially.

Third, within the next 3-5 years, all regional hospitals need to be rehabilitated to a reasonable level of functioning. This will cater for secondary health care. Hospitals and health centres should be fully devolved to local authorities, communities and NGOs and managed using performance-based funding as innovated and pioneered in Rwanda with remarkable success. Studies have shown that most people in Uganda can afford the treatment of minor illnesses, while preventive health services should continue to be funded fully by the government.

User-fees and community insurance schemes can be developed by different authorities to co-finance curative care at the primary level. But secondary and tertiary care should be fully funded by a national social health insurance (SHI), with a heavy reinsurance and initial investment from the state. It is estimated that the initial injection of resources over the next five years would be about $250m to rehabilitate Mulago Hospital, regional hospitals and for the start-up of a viable SHI.

Finally, the management of hospitals should be divorced from government patronage and interference. While the state may maintain ownership over hospitals, their management should be contracted to private firms or foundations. Hopefully, this will minimise the widespread and entrenched corruption in the public sector and allow Uganda to acquire the long awaited modern health care system.

The writer is the Director, Regional Centre for Quality of Health Care, Makerere University Institute of Public Health

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