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THE LAST WORD: Healthcare in poor countries


THE LAST WORD: By Andrew M. Mwenda

Why nations that are different exhibit similar health service dysfunctions

I have been rereading Melle Leenstra’s 2012 book, `Beyond the Façade; the instrumentalisation of the Zambian health sector’. It offers an interesting insight into the challenges that central African nation faces in its attempts to provide quality healthcare to its citizens. It reads like a story of the healthcare system in Uganda or any other poor country. Let us cite the book at some length.

“In the ward of a provincial hospital, some patients lie on mattresses on the ground. Many have delayed their coming having first tried the services of witchdoctors or first saved enough money to be able to afford medical care. Other ill people prefer not to come at all, considering hospital places to die rather than places to get better. In the corridors, family members flock in attendance, bringing extra food and caring for the needy. The walls bear posters teaching the ABC of sexual health beside handwritten posters professing the values of public service.

“Nurses enviously eye the doctor’s new Pajero and complain that their allowances have not been paid yet. Some patients are vexed by nurses’ rudeness and complain that drugs are out of stock. The doctor has not shown up today; maybe she has gone to moonlight at a private clinic or is attending a workshop, earning something extra as money is never sufficient. From time to time, the nurses are mobilised by the union to demand higher salaries and extra allowances from government.

“Meanwhile the laboratory technician checks blood samples and compiles horrific statistics, relieved that this month he has received their proper reagents. In the evenings, he studies, perhaps his correspondence course will bring him the qualifications to move on to a better life in South Africa or beyond. In a distant rural health centre, one can see a health worker, overworked, underfunded and yet still showing up to work, immunising children and supervising deliveries, while a cleaner is screening patients and giving them drugs.

“The limited resources government provides are inventively stretched as far as possible. Further away, a radio transmits the voice of an opposition candidate. She curses the government for incompetence and corruption and promises better education and affordable healthcare.”

I have read similar accounts of healthcare challenges in Ghana, Senegal, Tanzania, Kenya, Benin and Malawi among others in Africa. I have also read academic papers and books on the healthcare systems of India, Nepal, Pakistan, Bangladesh, Sri Lanka, Afghanistan, El Salvador, Nicaragua, Peru, Vietnam, Cambodia, Laos, etc. and the story reads almost the same as Uganda and these other African countries.


  1. While the “conditions that make Rwanda possible are rare to find and difficult to recreate”, one thing we learn from Rwanda is that it is possible provide decent health care even with little money. We don’t need to recreate Rwanda, we only have to do things differently. Using failure as yardstick for comparison is both intellectually and politically disingenuous. We are all too painfully aware that most of the policies that have been crafted and failed in Uganda, have perfectly worked in Rwanda. We are also aware that while Rwanda’s existential predicaments are different from Uganda’s, it is managerial efficiency that has produced the jewel of Rwanda. If Museveni has professionalized and created discipline in the army, he can do the same to the public service sector. Why he and his government has failed in the latter, is fodder enough for suspicion of government’s limited commitment to serve its citizenry!

    • Denis,

      You cannot easily compare the army with the civil service. The former belongs
      to a set of ‘disciplined’ professions – in which authority is rarely challenged
      – (and if so, with serious consequences). A clear headed authority – as M7 and
      PK are – will more likely shape the army as we are seeing today. The civil
      service is a mixed bag of a full range of people: some think they are
      untouchable ‘experts’, others, even when they know they are ignorant, claim and
      challenge authority under guise of ‘rights’, ‘equity’, ‘politics’, etc. That is
      one part of the problem in Uganda. The 2nd part has to do with what contributes
      to Successful Management. It is not just the ‘Manager’ but the ‘Managed’ –
      whether human or other resource as well. Independent Uganda’s human resource
      weaknesses started well before M7 came on the national management scene –
      perhaps about mid 1960s – when you had a forced exit of some ‘educated’ people
      and the nucleation of ‘Mwana wa Ggundi’ culture. Since that time, a variety of
      factors have nourished this problem, which in turn has manifested itself in
      offshoot symptoms as the various forms of corruption we are seeing today.
      Rwanda had an exodus of people even earlier than Ug Yes. But these were in
      short high pitched waves. Those who remained in the civil service were
      sectarian – Yes – but the decadency attributable to non-human resources was nowhere
      near Uganda’s demise of mid 70s to mid-80s. There are other factors which led
      to differences in ‘success rates’ of PK and M7 – which Andrew and others have
      discussed in the past. I do not have to repeat them here.

      But back to Andrew’s point of ‘poverty’ and inability to provide ‘good’ health
      services: I fault him for not looking beyond ‘poverty’ per-se. He has in the
      past fronted this same ‘animal’ for governments of underdeveloped countries to
      fail to provide other social services as well. Is it possible that ‘poverty’ is
      just one of the symptoms of an underlying cause? His long time hero, Obote, had
      identified ‘Ignorance’, ‘Disease’ and ‘Poverty’ as the principal enemies of the
      country. I put it to all and sundry that the latter two might be a result of
      the first. And that since we are all born ‘ignorant’, it is our struggles to
      come out of this ignorance that count in whether we remain relatively poor, and
      therefore unable to emancipate ourselves from the vices Obote and ‘son’ Andrew
      cry about. There might be a word for reluctance to struggle out of ignorance:
      “Laziness” – in different manifestations such as ‘Mental’ and ‘Physical’ – some
      may even add ‘Spiritual’.

      I guess at an appropriate time and in a suitable medium, I’ll have time to
      explore this line of thought.

      Eng. Kant Ateenyi Kanyarusoke – Cape Town.

  2. 1.Is a good health system all about drugs,equipment and medical personnel?i dont think so ug has all these but our health system is in bad shape..
    2.In Ug management in Hospitals can’t procure basics like Tissue,disinfectants, detergents, patients compete with snakes for space in the compound.
    3.When you check the pay roll you find so many causal workers but the hospitals are always dirty.
    4.Africans believe that there is a very big fat man called ideology who will one day solve all our problems.
    5.Doctors have now become money minded you find a surgeon pocketing 8 million in just one operation how do they get this money?they steal surgery equipment from Mulago and take their patients to private hospitals for operation.
    6.I have never understood why Mgt in hospitals cant buy uniforms & bedshhets for patients and washing machines to clean their clothes you find Omeros dressed in a gomesi doesn’t this cause more infections?
    7.For us ladies, we call Kanyamunyu “Mathew”‘ he is the kind of man our aunties would be happy to recive.

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