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A frank memo to our wannabes

Oulanyah.

Why Oulanyah’s evacuation to Seattle was not a waste of taxpayers’ money

THE LAST WORD | ANDREW M. MWENDA | On April 8, former Speaker of Parliament, Jacob Oulanyah, was finally laid to rest. But all will remember a group of wannabe Ugandans demonstrating outside a Seattle Hospital against his medical evacuation. To some Ugandans, it was a waste of taxpayers’ money to try save his life.

And for many others, the highly specialized medical attention he was receiving should be available in Uganda – preferably provided by the state for free to every citizen who needs it. This article seeks to hammer this thinking on its head.

This problem is not found only in Uganda. Across our entire continent, and indeed most (if not all) the third world, there is the conviction that the state should provide a large basket of public goods and services (roads, dams, hospitals, schools, bridges, railways, airports, clean water, electricity, education, health, sanitation, agricultural extension services, security, justice, a clean environment, etc.) for free or cheaply to all citizens who need them. This conviction is held as an article of faith.

Our minds are not a tabula rasa. We approach every subject with many assumptions, prejudices, biases, attitudes, mindsets and beliefs. The belief in a nanny state is one example. In the advanced nations of the Western world, Japan, Singapore, South Korea, Israel, etc., there is a close link between the demand for a nanny state and the capacity of the state to perform this role.

Take the example of the USA. Last year (2021), federal, state and local government spending was US$11.5 trillion. Because federal government transfers to state and local governments totaled US$1.1 trillion, actual public spending was US$10.4 trillion. If we divide this by the USA population of 332m, we get public spending per person of US$31,325. This financial year, Uganda’s total public spending is Shs 37 trillion (US$10.4 billion); divided by 42m Ugandans, public spending per person is Shs 800,000 (or US$250).

There are many problems with the government of Uganda – incompetence, corruption, wastage, etc. But even with the best of intentions and with angels from heaven running our public affairs, there is a limit to how much this money can do.

Simply put, the government of Uganda doesn’t have the financial (leave alone the human) resources to provide a large basket of public goods and services to all her citizens – everywhere, all the time and for free or cheaply. Because the modern state is assigned such a responsibility as a normative value does not mean a poor government can afford it.

The fundamental source of failure of service delivery in Uganda today therefore is lack of financial and human resources to perform this role effectively. The kinds of corruption, incompetence and wastage we see are a product of this limitation.

How? The state is overdeveloped in functions but underdeveloped in capacity. It seeks to imitate the state in the rich nations by basing its legitimacy on delivering a large basket of public goods and services to all its citizens for free or cheaply. Thus, its reach goes far beyond its grasp – its ambitions and aspiration far outstrip its means.

One would expect educated Ugandans (and Africans) to appreciate this fact. This is because the vast majority of them come from poor families where their parents struggle to provide them basic necessities of life. So, they know very well how to live under a tight budget. They grow up in modest housing, have less meals a day and of poor quality, have few and cheap clothes, walk to school, etc.

Yet, they insist that the state should provide high quality education, healthcare, clean water, good roads, highly public sector wages, etc. like the USA government does for her citizens. Yet they never insisted to their parents to provide them the same quality of life business mogul Sudhir Ruparelia provides his children.

Yet, it is the less educated (or uneducated) Ugandans in the villages that I find with a realistic view of the state. Why? Because they have not been infected with the mindset that somehow the state should provide all her citizens a large basket of public goods and services for free or cheaply.

Therefore, they do not have exaggerated and unrealistic expectations. This mindset is acquired through formal education and access to information about the role of government in rich countries through mass media.

Hence, whatever little the state provides, even when the service is poor, they see it as benevolence. Our internalization of assumptions about the state drawn from the experience of rich nations has given us the wrong mindset that blinds us from seeing our reality as a poor country.

This brings me to the wannabe Ugandans who want the best medical services in Uganda. First, the state of Uganda cannot afford to provide even her richest citizens the highly specialized medical services that force many of them to be evacuated abroad.

One evidence is the inability of the market to provide them at a commercial rate. There simply isn’t large enough scale or purchasing power in Uganda to make it comedically viable for an investor to put his money in such a service. So, seeking medical help abroad for the rich and powerful is going to continue.

Second, I think the decision to evacuate Oulanyah was political. From the information I have, everyone knew (including Oulanyah himself) that his chances of survival were minimal. But given our politics, government (or President Yoweri Museveni for that matter) may have been conscious that if the speaker died in the country, the failure of evacuate him would have been weaponized by his opponents.

And given our ethnic politics, this claim would have taken a life of its own especially because many less-senior politicians from Western and central Uganda have been evacuated before. For political reasons it was necessary to demonstrate that government did not spare anything to save his life.

Managing politics (and human affairs generally) involves many calculations and accommodations. What may be technically efficient can be politically explosive. The state, like a family, is a social, not a technical, organism. Its functioning depends on myriad calculations that may be technically wasteful but socially and politically useful.

A man who earns a take home pay of Shs 1.5m, has a family of a wife and four children, has to pay rent, buy food, pay for transport etc. He may drink four beers worth Shs 20,000 every weekend while watching soccer. This expenditure of Shs 80,000 of his income every month may seem wastage.

But it is what allows him to socially interact with friends and indulge his passion thereby getting satisfaction in living. The state may also spend on things that technically seem wasteful but which are, politically, what allows it to placate the diverse and rowdy claims of its elites.

****

amwenda@independent.co.ug

12 comments

  1. Too absurd Mr Mwenda! You wrote this article with the assumption that the majority of Ugandans are idiots who cannot see through and discern it’s fallacies therein! To start with all Ugandans rich, poor, old, young, powerful and wretched of the earth, sick or healthy etcetera pay all forms of taxes to the state of Uganda!

    To start with, you mention it several times that Uganda govt is just incompetent, too corrupt and inefficient! So what more do you need to add? So the reason why the Uganda govt (M7) dispenses public goods and services discriminativey is not because of scarcity of resources but rather his incompetence and corrupt tendencies for political expediency!

    That’s why in 2017 he got tired and told Ugandans the whole truth why he intends to die in power!
    Why do like comparing Sad world Uganda with USA govt in a very selective manner. The developed world is accountable to her tax payers which is not true with most African govts! Uganda today is a classic case of GeorgeOrwell’s animal farm where all citizens are required to toil hard to raise taxes for the enjoyment of the ruling class!

  2. Contrary to what Andrew claims; many educated Ugandans understand that Uganda is poor and cannot afford to provide first class or specialized services. They are concerned about the state of basic facilities in our hospitals, and an increasing trend of ‘well connected Ugandans’ seeking medical care abroad on tax payers money as a priority vs the neglect to equip Uganda’s main hospitals. Majority of the Ugandan referrals are to Kenya government hospitals: Top on the list Nairobi Hospital and Kenyatta University, and some to Aga Khan private hospital. So what Ugandans are asking; Museveni’s government has been in power for 36 years. In all this time, he has failed to this big extent to equip a few hospitals to lead us to the (state sponsored) medical exodus that we have? Can’t we have some of these basic facilities that hospitals in Kenya have? At least close to them? My mother has been twice to Kenya for treatment (sponsored by our family).The specialist who treated her was a Ugandan who couldn’t work home because of what he said poor pay. What we went through to take an old and sick lady to Kenya was heart breaking. Thank God she made it. But many can’t afford. In addition to the cost of treatment, the cost of transport, accommodation and distance put them off. So, many educated Ugandans don’t expect comparisons to America but they want to see our big hospitals such as Mulago, Nsambya, Mengo or even the big private ones facilitated to handle the basics.

  3. Peterson Kato Kikomeko

    amwenda@independent.co.ug, your reasoning sometimes annoys!!

  4. Another provocative argument by Andrew Mwenda! The only thing is that this seems to be too clever by half given some interesting facts which somebody as resourceful as Andrew Mwenda has access to but are just too inconvenient to examine in this case. Annually, Uganda spends in upwards of a TRILLION shillings on abroad treatment of roughly 5000 people for various medical conditions, some of which could or could not be handled in Uganda’s hospitals. FIVE THOUSAND people out of a population of over 40million people. This itself is an indicting statistic and one that seriously challenges the argument of a limited resource envelope such as the one he tries to advance.
    Now how are the lucky five thousand chosen? Apparently the Uganda Medical Board has the additional role of determining who gets to be treated abroad for a better chance to live or or who is condemned to die in Uganda’s rotting hospital system. And in not too few cases even the President of the republic may be the one to make the determination (now we know per Mwenda that it is part of normal politics). In this role both the Uganda Medical Board and the Presidency also act as death panels if they have to determine who gets to live by accessing treatment abroad and who stays to die in Ugandan hospitals. And neither the Medical Board nor the presidency should be death panels.
    It is just as well that Andrew makes no claim to being an expert on health care matters. But as a media practitioner, he would have done himself and his readers justice if he had done a bit of research to establish the nature of health matters for which well connected Ugandans are increasingly seeking treatment outside the country at obscene cost. To be fair it important to point out that some procedures including unique surgeries, organ transplants, some corrective surgeries, some unique infections etc would still warrant out of the country referrals given their complexity or lack of local professionals qualified or competent enough to handle them. However, the majority of these referrals are for issues that fall out of the big holes in Uganda’s poor primary healthcare system. Many of these cases end up being identified late and already very complicated and therefore needing very complicated interventions. Many types of cancers, endocrine , thyroid, cardiac, liver, renal and bladder, lung, macular, alimentary canal diseases if detected early on in a properly functioning primary health care system can be managed cost effectively even with the existing resource envelope in Uganda. For example the best chance and also the cheapest way to treat many cancer types is if they are detected early and in developed countries to where Uganda’s elites run to the detection happens following referrals from one’s Primary Health care provider after routine annual physical exams that the majority of people have as one element in those countries health care provision culture. A cancer that is not detected until it becomes stage IV is likely to kill you expensively regardless of where you seek treatment (as was the case with the late Jacob Oulanya), just like belatedly and poorly managed diabetes, cardiac disease and blood disorders, kidney diseases etc.
    Issues of per capita healthcare expenditures alone, there are many aspects of healthcare systems that countries like Uganda can learn from the developed world. Contrary to what the per capita expenditure figures show, health care in these countries is base on a well function Primary Health Care System based more on wellness care (staving off health care problems before they happen, or identifying them as early as possible when they happen) at the base of which is a strong and well conceived nursing system that acts as the foundation on which doctors stand to make the system work. For example in America nurses are first contacts in the health care system where they do the initial screening and health data gathering, the directing and triaging of patients for doctors, admission and discharge planning, both initial and continuing teaching of patients in the healthcare system and in the community after discharge, information disseminators of new treatments and prevention measures, in charge of immunization programs and much more. For lack of a better term nurses are trained to be the doctors’ first ears, noses and eyes for the doctors. And for Uganda’s case this will not be just a paradigm shift but also directed the limited resources where they would have the most impact.
    While politics is and will continue to be a factor that is difficult to ignore while allocating the limited available resources for health care in Uganda, it should still be tethered to reasonable bounds. Otherwise how can Mr. Museveni or anybody for that matter justify the fact that Over Uganda Shs. 5 Billion may have been spent on the one person – 1.7B/- for transport, probably over 1B/- for the intensive care, 1.2B/- for a funeral of one individual who it was known before hand had terminal stage four cancer? And now the undertaking to do additional things like spending billions to complete a deceased public official’s mansion (not even a primary residence!) for politics as Andrew would say? And if news for such perverted expenditures is carried in the same news papers with images of patients sleeping on floors or sharing beds in hospitals, and also stories informing your exalted satisfied Ugandan non-elites that thousands of health care providers they depend on in an already overstretched/overburdened system it does not become just bad optics, it is also becomes strong evidence of out of touch politics gone wild. Just like Andrew Mwenda’s thinking! Maybe it is time to jettison pretentious politics for the undisguised dictatorship like the one under Idi Amin.

  5. The writer of this article is the real wannabe. He throws in figures, simple analysis and America, thinking that we all went to UPE. What is the obsession with America, seems like a lot of Ugandans who want to talk about the fail state always want to compare it with America. That is like comparing orange and pear. So you are suggesting that Uganda should remain in a state where most people can not access basic health care even though they pay tax? That the only chosen few should be selected to access health care abroad on the blood of tax payers? Shame on you wannabe !

  6. Sir you lose the trail when you compare Uganda to USA. A smartphone and a Nokia 6150, The brain of a mosquito to that of a parrot?
    And how come the same state could provide the basicsup to 1989?
    And true to form your wannabe has lost direction because of poor modern politics . Think of it how most colonial governments constructed sewages as a bisic urban infrastructure and today most of our cities seek donations to build latrines. Yet you all know it is cheaper if the sewage system exists.

  7. Andrew Mwenda is 100% correct on this one! Based on the formula, Uganda and most 3rd world countries have to work on cutting down on population. It is our Achilles heel. I do not see us having the brains to increase GDP x100 within 10 years. For Uganda government to spend $30,000 on every Ugandan per year, (with the current GDP) over 40 million Ugandans would have to disappear from the registry. What is easier? Cut down on population or x100 the GDP. When a muzungu advice us, we say they are racists!

  8. Another silly article by Mwenda – protecting the status quo and corruption. It is silly because it is not factual or facts have been twisted to suit Mwenda’s argument. One would assume that he loves defending the Status quo and corruption because himself and family are benefiting.

    Let me start by giving him some history Uganda. I am in my 50s. I was a small child when Amin was president of Uganda. Yes Idi Amin M7 calls a swine. During that time we had very good schools ; fantastic health care system – I recall we used to be taken to hospital and you get checked and treated and you walk out. We attended schools which were stocked with scholastic materials ; teachers were paid good decent salaries and some primary head teachers used to drive cars. The population was 10 million and I believe about 15 Districts. Each district had a well staffed and qualified – public works department; Veterinary Department ; Education Department; District Administration officials headed by educated and qualified District commissioners and their assistants etc… Each District had a Farming Institute and an animal husbandry demonstration farm . The country had a functioning railway system ; A number of Co-operative unions and societies where farmers sold their cash crops. We had a an efficient and functioning bus company – UTC [Uganda Transport Company ] owed by the government and buses were transporting people into Town to villages ; town to town ; towns to City and in Kampala there were buses taking people from Nakivubo Bus Terminal all areas in the city running on time. Each district had a District hospital and the districts were subdivided into sub counties and Counties for local administration purposes. At each Subcounty and County had a medical dispensary . The hospitals and dispensaries were well stocked with drugs and all sorts of Doctors. These hospitals had a section called “Paying Wards” for those who were rich and could afford having extra and exclusive attention at their own cost [ not on tax payers’ cost] . These hospitals were supplemented by private hospitals run by churches – again these were for the monied- folks. When Milton Obote was shot, I think in 1968, it is known that he was treated in Mulago Hospital not somewhere abroad. There are no records of Idi Amin’s officials being sent abroad for treatment and on top of that at the tax-payers expense.

    Come 1986, we get the NRM and they came and destroyed everything. They grabbed, plundered, enriched themselves on all these things. The situation that had started while they were in the bush by raiding the Government demonstration farms and eating the cows/animals there extended to all areas and spheres of public life. And the results – great schools are now shadows ; Schools lack the basics for school children to learn properly , no railway system and land land was grabbed and taken by those in power or allocated to them by the president. Co-operative societies and unions were plundered . And the plundering went into every sphere. Sub counties and Counties were turned into new districts and we now have over 70 districts without any infrastructure and funds to provide any services to the people. Corruption is endemic and our dear propagandist Mwenda writes in his paper in support of it.

    So what we have been left with in terms of Health System are hospitals with staffing issues ; no drugs [ apart from that got from Government stores but sold by the same ones who have access to it and are known NRM cadres ] ; shared beds ; rats and flies infested areas; demoralised staff who are paid a pittance [hence have resorted to doing other jobs while on hospitals pay roll or selling allocated drugs etc… with impunity] . And the government has come up with a solution – send a selected few abroad on Tax Payers expenses to get preferential treatment to an extent that the president’s family even give birth to their children in foreign hospitals travelling in the tax payers’ jet ] and Mwenda ; Owiny Dollo ; Baryomunsi ; Acholi Parliamentary and all in the political class think is a normal situation and are defending it in in loud voices.

    Mwenda and his friends fail to realise that the public are not against those who want to get treatment from the bazungus/white land perse but if you do , do not use the tax payers money. Use your own looted money.

    The money to invest in a good health care system is there but the priorities are different for this corrupt , repressive and inefficient government. According to Transparency International Uganda loses over £500million per year through corruption. Think Mwenda – How many world class Hospitals would be built each year with that kind of money ? How many Doctors , Specialised staff and necessary infrastructure would be put into place with that wasted money? etc…. Every few months, your friend’s dad moans about corruptions then ties in knots the very systems he has put into place and hinders them from doing their work. Then Mwenda comes up with an article every month in support of the vice and those associated with it.

    He talks about the elite [ calls them Wanabes / Owiny Dollo called them Lumpens ] being the ones who are pushing for better health care system and has an issue with that!! Mwenda , have you not considered that the elite have travelled and well read and know the standards of public services their Government must be delivering. They know that if a government does not deliver, in democratic and rule of Law countries they are voted out of power. You are lambasting the educated because you know that the government your sister serves in as as Minister of Health is not answerable to the people. That is why you always write these arrogant articles with a message “hey guys , if you dont like it -tough. That is the way things are and will remain….”

    He applauds the illiterates in the village. The guys he does not mix much with – sees them maybe every quarter of a year when he happens to go to visit his farm. Goes with his police body guard to protect him from these have-nots ; I bet pays them some lose change from his pockets to look after his 8 legged goats and cows and because they are poor and submissive he feels they have no grievances against the government . There are two groups of these “quiet have -nots ”

    (a) Those who were there in Amin’s rule and 2nd Obote’s government who saw what real governing for the country was. They have seen all public services Broken down since 1986 . They have given up . Some have children who are either cadre who are looting the country dry or abroad and so are being ferried to private hospitals etc… Those who do not have such children have either died or are not bothered because they know nothing will change whether they speak up or not

    (b) The “Have -Nots ” who do not know anything better. They furthest they have travelled is across 2/4 villages. They were born in poverty since 1986 and since they could understand, they have seen crumbling schools ; useless hospitals and health centres ……. and have no template to compare with . No high standards to expect.

    No wonder you have found quiet and acceptance among these people – but we think among the extremely small handful you interact with.

    Ask your parents , if they are still alive, how Fort Portal Hospital or their Sub County Local Dispensaries were in 1970s ; ask them how the local schools – Nyakasura and St Leo’s College and further afield – Ibanda ; Ntare; Duhaga; Makobore ; Kabalega ; etc… (these schools are now in bushes and crumbling ) looked like and the standard of education they were producing in those gone years as compared to the advent of NRM government ?

    Now and again your government comes up with new and failed initiatives they use to syphon of money from the government coffers – Emyoga; Entandikwa; Bona Bagagawale; Operation Wealth Creation ; etc…. Billions have been sunk in these useless initiatives and nobody has ever done an audit on them. If, this money had been spent on improving education or health care and re-establishing the correct and right infrastructure in the districts , maybe the lives of people would improve and we will stop seeing the poverty we see in villages etc…..

    As a Journalist who claims to be very intelligent why dont you spend time investigating where all the billions of these failed initiatives has gone; who benefited ….. Why dont you investigate where the billions allocated for Patriotic Clubs has gone or is going if there is still that expenditure? Why dont you spend time advocating for an increase of Health and education budgets instead of spending more on Defence and Presidents office.
    You spend time trying to force Muhozi on Ugandans , what do you hope Muhozi will achieve if his father has been ruling the country on the basis of ” the government for the few by the few over the majority “. Or are you happy that Uganda gets their own Papa Doc Duvalier as long as yourself and family continue benefiting ??

    • £500million per year of looted funds, even if it was ploughed directly into the healthcare system would have Zero effect with a population of 40 million poor people and climbing. Let me try to break it down: For ambulances alone you will need at least 1500 ambulances to cover the country and if you want first class ones they will cost £250,000 each! Given the road network, you will need trauma helicopters to cover 4 regions with 4 trauma regional hospitals. These will cost £5 million each! This is just getting started.
      Even if Elon Musk was to donate £100 Billion to the Ugandan health sector to set things up. It will fail as it is not sustainable without a paying public (we are poor).
      In the developed countries, when an ambulance moves to pick up a victim, £1000 is transferred from his insurance. same with a trauma helicopter which costs a minimum £20,000 per victim pick-up including pilot costs and fuel.
      As long as the population continues exploding, it will be impossible for any future government to fulfil the capacity.
      Yes, the good times were in the 1960’s when the population was 10 million. No president can provide the miracles you expect with such a poor population (which does not even admit being poor).
      A Spanish friend told me, maybe Africa should go back to the drawing board and stop trying to copy Europe. We need to create the best possible health care system from scratch that acknowledges our handicaps and stop dreaming.

      • Educated without a critical mind but a defeatist attitude are you Andrew K. My comments rose a number of points which you ignored. I will list them for you :

        1- £500 million lost in corruption EACH YEAR since your beloved NRM imposed itself on the Ugandan Population. It would take at least £200 (on the expensive side ) to build a good and well equipped hospital. For your information, we do not need 40 million hospital – one for each person in Uganda. You need well developed and specialised hospitals in each region in Uganda. We are talking of about 10 hospitals . How many years of money lost through corruption would that take = about 4 years (out of the wasted 36 years and counting under NRM) . You then develop a tier of good stocked hospitals from former county level to District as Obote and Idi Amin had maintained after independence . Bear in mind that not all 45 million fall sick at the same time . You are taking of around 2 million people requiring medical attention at any given time for different needs ranging from a bad migraine to a cancer diagnosis.
        The template or foundation was there when these guys blasted themselves into power but they grabbed, looted, destroyed everything that now a task of building a universal health care system seems very daunting.

        2- Channel the monies spent on grandiose projects that Tibahaburwa M7 starts nearly each 4 years and forces the limp parliament to endorse then pours money into that are never costed ; no check established and no audit of what they have achieved or why they failed is ever carried out . Those projects or initiatives are – Entandikwa; Bona Bagagawale, Operation Wealth Creation, Emyoga etc…… Can you point out at least 10 people in your district who have benefited from these mindless initiatives and yet so many billions have been poured into them without any accountability.
        On top of that in last 10 years or so M7 started the office of Patriotic Clubs in State House. Each year Billions are allocated to this office to promote Patriotism in Schools (As if Ugandan kids need this more than scholastic materials ).Advise me , Andrew K where that money is going and who has benefitted ? or it is another conduit to steal money from the government coffers……..

        Mind you the infrastructure in the districts was all destroyed by our “dear NRM”.

        3- Get Uganda’s priorities straight. For years under NRM more money is spent on Defence and President’s Office than on Health, Education and Agriculture. I do not need to belabour the significance of putting more more in these three areas. Imagine, how much money has been wasted in these upside down priorities.

  9. @ Jack Pinto and MK
    1.Have you forgotten the mentality of Ugandans?Moon lighting is killing the medical fraternity.
    2.Have you forgotten how the private sector made a kill out of COVID? Did government have a hand in it?
    3.When Oulanya was flown to Seattle the US government had to make a quick decision on how fast he would be admitted because it was treated as a medical emergency.How many government hospitals can make such quick decisions regardless of the status of a patient?
    4. Who steals the drugs and medical equipment in hospitals?Aren’t they the same medical personnel?
    5.Those of you who are poor let me tell you its not a big deal to be rich;we may stay in posh areas, dine at expensive eating places,travel for holiday,drive suvs but with time you get feed up and life is normal the poor should not feel bad about it.
    6.So we should return to the 60’s Pinto?Have you forgotten the new world order?Capitalism?In the past, all nations were communist thats why all services were meant for all right now, we have a mixed economy which some how is not regulated.
    7.Most Ugandans are healthy .The few who are in hospital jut require more care from the medical staff.

    • Winnie

      I hope you would read the contributions with a learning and critical mind.

      History is there to learn from. Without learning from it, no individual person or nation can successfully map out a good and successful future. The opposite is true i.e. without learning from History, we repeat the same mistakes. Back to my contribution to Mwenda’s article, I was demonstrating that the Country had all the fundamentals of development in nearly all the various sectors [from independence till 1987] until the corrupt, oppressive and inefficient NRM government blasted itself into power. NRM came and like vultures grabbed and whatever remained destroyed was destroyed e.g. education institutions and our transport system etc…. Then they allowed corruption to be the order of the day. What we are remaining with is a broken down health system and the Mwenda’s clapping when
      members of the political class are flown abroad , on tax-payers expenses and their funerals are being paid for on the tax payers !!! They think that is the norm which should not be challenged by the wannabes /Lumpens [or the Dictator’s “Bazukulu” ]

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