Effects of Uganda's de-regulation programme

By Odrek Rwabwogo

In response to demands by the World Bank and IMF to restructure Uganda's economy and minimise government's role in the provision of social services, the Movement in 1987 begun a large de-regulation programme in the health, education, agriculture and trade sectors.

As part of our continuation of the analysis of the elements which propel the economic revolution in society, it is to these sectors which affect the ordinary person's life that we turn our attention in the next four installments.

We would like to assess the effect of this de-regulation programme on quality of life of citizens and whether it has been a good base for the economic revolution to take off.

The UNDP has developed a composite indicator of standard of living for countries that it bases on three key elements. They are; life expectancy of the population which is a function of the public health standards in a country; the adult literacy levels which is a combined enrollment rate of primary, secondary and tertiary education including the quality of teaching in classrooms and its outcomes.

The last element is the wealth of a nation in relation to its population (GDP per capita). On all the above fronts including specific yardsticks such as percentage of one year olds immunised against measles (90%), Infant mortality rate (53 per 1000 live birth), minimum average distance to the nearest health facility for the population (75% are within a radius of five kilometers because of construction of over 963 Health centre IIIs across the sub counties), Uganda under the Movement ranks strong.

In fact, in 2014/2015, the country spent sh1.2 trillion (8.5% of the national budget) on the health sector, one of the highest expenditure items after roads, energy and education.

The question to ask is, with these indicators, why are health facilities in the country poorly stocked, ill-manned and delivering a 'turn-off' service to the population? To understand the cause, I made impromptu visits to some Health centre IIIs such as Wakyaato in Nakaseke district.

I also visited Mulago national referral hospital, several times, to get a service comparison with the private health care providers and delve at the root of the problem. Wakyaato health centre on my visit had three medical staff on duty with some fairly good facilities. The medicines were available and a few patients were waiting.

On several visits to Mulago, it has been a reflection of all that has gone wrong in the health sector that must be urgently corrected. There needs to be a total rethink of the role of this health facility in particular and a broader change of mindset on how to finance, provide and equip health care infrastructure for Uganda in the next five years.

To give the reader some background, we need to remember that excessive deregulation of key social service sectors and sometimes, wholesale abandonment of some of the functions of government in response to bureaucratic inefficiencies of the public sector in the 1990s, has had effects carried into new and changed circumstances in the 21st century.

The state was weak in the 1990s and yet ceded some of its core responsibilities to an even weaker arm, the private sector. As a result, compliance standards in health and education have steadily plummeted. In many cases, this has increased the levels of corruption in service delivery, deeply affecting the low income earners, peasants, the base of the Movement.

In some cases where there are regulatory agencies, they have tended to reflect the commercial interest of the privatised and/or outsourced services industry rather than the consumer. It is the same story in the animal health sector, where drugs, equipment and treatment of livestock has been, for the largest percentage of transactions, left in the hands of private operators, with little or no capacity for regulation by the Government.

I assume this is partly the reason in human health, there are growing unethical behaviours such as the phenomenon of quack doctors operating in public facilities preying on uninformed patients.

My assumption is that anybody initiating change and successfully realigning the performance of Mulago hospital, will set a precedent for positive change in the management of our public health facilities.

As with any issue, it is better to begin with a search for understanding of the problem and hopefully arrive at the exit end with a solution. Mulago was established in 1913 by the colonial government to treat the rising cases of syphilis then when the country's population was only 1.8 million people.

The hospital was expanded in 1962 (when our population was about 7.2million) to include a training wing, research function and tertiary care for referrals from the countryside hospitals.

Today, the hospital serves a myriad of purposes that none of its outcomes is clearly recognisable or hardly pleases any of the parties involved from doctors, administrators, regulators to patients.

From the slightest cough one gets at home to, for example, the most complicated surgery on the brain, all are treated by Mulago. From the remotest part of the country to the nearest in the city of Kampala on account of thousands of low income people flocking into the city daily, Mulago now plays the role of Health centers II, III, IV and that of the national referral hospital all rolled into one, with today's population of 35 million.

In a year, the facility handles 800,000 outpatients (about 2,200 per day), an average of 40,000 visitors daily (certainly exerting pressure on space, facilities, the mood and recovery of patients and also the hospital's overused sewerage systems).

Mulago also has well over 700,000 in-patients a year, with about 120,000 new admissions annually. The hospital has the highest rate of caesarian births in the country (23%) delivering 35,000 babies annually (about 96 babies per day).

The facilities meant to deliver four mothers in labour pains at ago, now handle well over 25, the reason facilities such as baby cribs and infrastructure for premature births can't be replaced at the speed new babies are born.

It is the same story with the only CT scan machine the hospital has. While it is supposed to handle 20 patients a day and allow it to cool down for better usage, it is now stretched to handle sometimes 100 people in a 24 hour cycle. It is the reason the machine is half of the time not working needing more service and maintainance than usual.

These numbers of people are the highest in the East African region for just one hospital. Even Muhimbiri hospital in Tanzania and Kenyatta hospital in Kenya, the equivalents to Mulago, aren't subjected to these kinds of numbers with so little means, limited infrastructure and scope of service. What capacity does the hospital have to cope with the situation?

Mulago Hospital has just about 1,850 staff from senior consultants all the way down to the drivers. The required staffing level, however, stands at 6,000 people. The hospital has only 30% of its required staffing.

This low staff/patient ratio is what perhaps drives patients and their attendants to bribe any medical personnel willing to listen just to get attended to. When I walked recently on Floor 3A and B, late in the evening, some of the patients accosted me thinking I was a doctor and each wanted to share their troubles with me.

That got me deeply concerned because it seemed to me anyone can walk into the hospital and take out a patient or administer any material into his/her body and disappear, without anyone knowing. On another floor, the HDU (High Dependency Unit) for patients just out of Intensive Care Unit (ICU), was 'transferred' to the open corridors and visitors on cellphone carrying food, are mixed with patients on drip recovering.

Mosquitoes were feasting on patients as young medical personnel, probably interns, looked on so stressed. The hospital gets about sh50b annually for its budget with sh7b of this collected internally from X-ray, CT scan and ultra sound fees from patients.

Excluding wages, Mulago spends on a patient about sh7,000 ($2). The minimum recommended WHO health spend per capita is $35 (about sh120,000). Uganda's per capita health spending increased from just about $12 in 2013 to $13.7 last financial year, on account of additional government funding and GAVI funds.

The medication provided by the National Medical stores (NMS) termed as Essential drugs excludes specialised care medicine. For example orthopedic treatment support from trauma related to increased rate of boda-boda accidents, starts from $2m upwards.

Mulago Hospital receives between five to 30 bodaboda accident victims daily. Most victims are between the ages of 18 to 35, the most productive. Annually, these are about 7,280 cases. An operation for femur (a bone in the human leg extending from the pelvis to the knee) or hip replacement after injury, can cost up to sh7m.

This isn't classified under essential medicines yet it constitutes one of the major treatments required at the hospital. Because there are no implants under the medicines provided by NMS, patients cannot be taken to theatre.

This leads to longer waiting periods per patient as they 'hold' onto the beds till they purchase their own medicines before being worked on. In fact in some cases, patients stay on beds as the relatives go on a fundraising drive in the city to pay for operations.

This complicates patient care and adds further pressure on already crowded facilities in the hospital. Medicine vendors in the city knowing the pressure for specialised medication at Mulago is intense and the unavailability of this medication in many outlets because few people can hold this expensive stock, begin to hike prices.

This is because there isn't proper pharmacy supervision which complicates the situation further. To a patient seeing this kind of expensive medication recommended for purchase from outside, he begins to assume wrongly much of the time the 'doctor must  have recommended certain pharmacies because he/she owns them'.

When you add the fact that all Mulago operations are still manual and patient files have to be carried across the floors from one department to another, waiting queues get longer and longer, frustrations and tensions increase and people who came seeking health in the first place, end with more stress including their care givers.

This results sometimes in death for lack of hope that one will recover, particularly now that they are in the highest referral hospital in the land and get such shabby treatment. Where else do they go?

This is the source of anger from many of the patients and their attendants who come to Mulago hospital. While in principle it is supposed to be a free government hospital, many key things that are fundamental to healing, aren't available forcing patients to pay for a low calibre service with charges in the end no different from private hospital payments.

If Mulago were to offer this specialised medication to patients, the hospital would need about sh100b annually. Today the hospital receives only sh12b. This is why the effort has been to reduce the number of patients and decongest the hospital instead of keeping people on beds waiting for them to buy own medicine.

The payment to health service providers too is so low that it promotes 'moonlighting" across several hospitals by nurses and doctors to compensate for low pay. This means the doctors' concentration is in the private sector where compensation rates are higher and are based on how many patients a doctor has seen.

In fact, if Mulago paid well its doctors, private clinics would have no staff because they normally snatch personnel from Mulago. A senior consultant, the most sought after person in Mulago (and there are about 35 in all) earns sh2.8m ($840) while a medical officer (doctor with a first degree) earns only sh820,000 ($248).

These salary rates which are just entry points for midlevel managers in the private sector are a disincentive to offer good service by doctors. What is strange though is that if a junior doctor is working under a project and there are several at Mulago such as the Infectious Disease institute (IDI), Makerere University Johns Hopkins Collaboration or the Baylor institute for pediatric care, the earning shoots up to sh4.7m, making students earn higher than the consultants who trained them in the first place.

When the approach to these issues is to criminalise doctors and health care givers for not showing up regularly for work, our planners miss the point.

Some Doctors and health care givers in the public sector will continue to deliver a highly watered down service to the detriment of lives of millions of Ugandans unless we have new thinking about remuneration, the structural reform of how service is delivered by public servants and investment in modern infrastructure, facilities and technology.

Knowing that Kampala continues to expand with many low income settlements such as Kasokoso (Kireka) holding 150,000 people on less than 20 acres, Ki-Mombasa 4,000 people on less than 10 acres and Kifumbira with 8,000 people on less than a square kilometer in two parishes in Mulago, planners for our city's health, education, water and sewerage facilities, need to devise new ways to approach service provision.

It won't get better unless the approach changes. These numbers without a doubt exert more pressure on health facilities and Mulago is taking a punch at all levels from these settlements.

We don't want to list problems only. This doesn't help for I have seen many people criticise and don't provided alternative ways to improve our social services.  Next week, we will shed light on how this situation can be improved so that all the people of Uganda can be participants in stage two, the economic revolution.

We can't grow our country with no capacity to provide quality health care for our population. Our growing numbers are both a future market for goods and services from emerging industries and source of industrial labour we need in urban areas. They are an opportunity not a problem as many of our planners tend to see them.

The writer is a farmer and entrepreneur