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THE LAST WORD: Rethinking healthcare in Africa


FILE PHOTO: Lab research being done to get solutions in Africa recently

Why attempts to provide too much too fast are the cause of corruption and institutionalised incompetence

The Last Word | ANDREW M. MWENDA|  Last week I moderated a World Health Organisation panel on providing universal healthcare in Africa. These ambitions assume that poor countries have the ability to deliver the set goals and what is missing is honest government and political will. The debate took place in Rwanda where a poor country has achieved universal medical insurance. I have come to believe that using Rwanda as a reference point is misleading because the conditions that have made it successful are rare to find and difficult to recreate. This article’s central message is that we need to unlearn assumptions that inform our policy prescriptions for poor countries.

The concept of universal publicly funded healthcare is slightly more than 100 years old. It developed in the Western world in the early 20th Century and gained full expression after the Second World War. This development was occasioned by the transformation of the West from agricultural to industrial and from rural to urban societies. This transformation produced a large and educated middle class, a professional class, organised labour and civil society and most critically massive growth in state revenues.

In other words, the state in Western Europe and her offshoots in North America, New Zeeland and Australia began providing healthcare to all citizens when they could afford it. That is to say when they had developed the financial and human (institutions backed by skilled people) capacity to do the job. Indeed, the veritable National Health Services (NHS) of the United Kingdom was created in 1946. In the United States, Medicare and Medicaid began in 1965.

This was an entirely new governance model. Henceforth, the legitimacy of the government depended to a large degree on the ability of the state to provide a wide range of public goods and services to all citizens equitably. While European governments did this at home, they did not do it in their colonies. There, they relied largely on traditional systems (indirect rule) to secure the consent of the governed. This was done by using public resources to co-opt powerful traditional, religious, and other influential leaders of public opinion in local communities i.e. patronage. Where there was resistance to colonial rule, they used repression.

Within the colonial territories, the Europeans governed their expatriate staff and its “native” allies by actually providing a modest basket of these public goods and services – education, piped water, healthcare, electricity, paved roads etc. However, the majority of the population was not catered for. The services were also, for the most part, (especially health and education) not provided by the state but by private agents and/or by nongovernment organisations; especially churches and other charitable bodies.

But the African elite who went to school read about or even saw what the colonial government was doing at home. So the leaders who fought for Africa’s independence argued that the colonial state denied natives these services because of racism. That was only partly true.  Even without its racism, the colonial state could not have funded the large basked of public goods and services to all its subjects in the colonies because it could not afford it. So our founding fathers promised to deliver this wide range of public goods and services to all citizens in imitation of the colonial state at home.


  1. Time to rethink and redirect our energies and resources. Yes conditions in Rwanda might be unique and difficult (did you mean unsavory?) to recreate but the guy there has demonstratec it can be done.

  2. The NRM govt cares for its citizens recently; they renovated most hospitals and most medical students are on state sponsorship.

    A Ugandan has access to 100% free medical care courtesy of the govt there is no insurance govt caters for us 100% Its just that the fairly rich opt for private services but there are free services in govt hospitals we just need to improve on service delivery. A lady delivers a child normally and pays no coin but some opt for private hospitals to pay 3 million for a normal delivery.

    Honesty how many times does a normal human being fall sick besides having colds?When you go to Mulago Hospital, most patients have more than 2 attendants its hard to tell whether they stay in hospital coz of the good food offered by govt or the patients have failed to heal.

    There are major terminal sickness like Sickle cell,cancer,diabetes,stroke,kidney and lung complications that require one to be admitted for a long time.

    95% of diseases in the world are curable but why are Africans still dying from preventable diseases like Malaria,cholera,HIV we take life for granted at times.

    In Britain, Charlie Gard a 9 months old child is fighting for his life despite doctors recommending that he should be left to die in dignity but his parents still have hope and want him to be flown to USA for special treatment just imagine that determination to save a life?

    • But Winnie, lets face it squarely. If you went to Katakwi where I come from, drug stockouts is the order of the day. So where is the free healthcare?

  3. ejakait engoraton

    Normally I let fools be because they are a waste of ones time and energy, but I’m going to make an exception of WINNIE who thinks she is GOD’S gift to this forum
    I’m taking you back to your previous postings where you think you have out reasoned all other persons on this forum.
    Bambi, that will be the day.
    Yes, it was you who brought up the G7 issue, something you knew zilch about.
    You thought roads or infrastructure had anything to do with being a G7 member and wondering why UAE, Saudi etc were not members inspite of and then saying that China and Russia were members.
    If you come up with a topic then at least be armed with the facts.
    You want a G7 to have 8,9,10 members and still call it G7?????
    G7 is a closed shop n not like a premier league where one gets demoted or promoted according to performance.
    And how is it conflict of interest if members decide who joins. Who decides who joins EAC, if not the existing members?

  4. ejakait engoraton

    My guess is you heard the term ‘conflict of interests’ and thought you would come and mesmerise people on this forum.
    You say you are a lawyer, is it Surveyors or Engineers who determine who joins the Bar Association. And I don’t mean the bar where you work as a barmaid

  5. ejakait engoraton

    The issue of providing public services is a seemingly complex issue but the bottom line is the will and desire and ones priorities.
    M7 n his government have absolutely no desire to provide the country with these services.
    Rwanda is not in any way a misplaced example. In fact it is the most applicable and relevant in showing how a poor nation with hardly no resources can provide such a wide basket of goods to its citizens.
    It all boils down to WILL n DESIRE

  6. ejakait engoraton

    Most if not all of Africa has not reached the stage of fair competitive politics, persuasive politics where one party tries to provide services and the use this to convince voters to return it to office on the basis of its performance.
    We are still involved mostly in coercive politics.
    M7 gets a better an tangible result by buying guns n teargas which he can use to forcefully keep himself I power.
    By his own admission, he can not be removed by a mere paper( ballot)

  7. ejakait engoraton

    Moreover he faces a dilemma. The areas where services are rolled out, especially the urban areas, are opposition strongholds, so why roll out services to your ENEMIES as h chooses to call the opposition

  8. ejakait engoraton

    He would rather be in control of the few privileges given out so he can be the controller of life and death and be the decider of who goes for treatment abroad and who is left to die

  9. @ Asio Veronica:When you noted that there were no drugs in Katakwi what did you do as a responsible citizen?Hope you are not the type who reports to Besigye so that he embarrasses M7 during presidential campaigns.
    1. There are free toll lines for the MOH monitoring unit you could have informed them .
    2. Every district has a public servant whose role is to implement govt policies e.g for Hospitals,there are district health officers,RDC’s,LCV did you inform them?
    3.Every district is requested to prepare a budget for items they need.
    4.Drugs expire in NMS stores yet this store is in Uganda does this mean govt over stocks drugs?
    5. Its the role of District officials to requisition drugs from NMS not M7.
    6.Govt officals are paid salary every month how can an officer fail to notice that the compound is bushy,mattresses are torn,roofs are leaking isn’t that irresponsibility on the side of health officers?
    7.Most districts have a population of between 80,000 people how many are admitted in hospitals?What diseases are Ugandans suffering from that they fill hospitals to capacity?Districts need to provide these statistics.
    8.Ugandans also need to be smart when going to hospitals at times you scare nurses on duty you find Ejakait dressed in a gomesi yet he is a man.
    9.Nurses should be trained on how to administer 1st aid as they wait for the doctor to report on duty,they can also be given air time so that they inform the doctor the state a patient is in.
    10.There is alot of sensitization programmes for the youth e.g they are told to avoid bad “touches”abstain from sex.
    11.Can medical insurance work in Ug?How do you explain to a peasant that he has medical insurance worth 200k per year yet he has no food to eat?I know how medical insurance scheme is being abused by both insurance companies and their clients you find staff x and their family are entitled to medical insurance worth 5M per year but their genuine medical bill is just 1M how do they account for the 4M they will collude with hospitals and generate fake bills.
    12.Treating terminal illnesses is quite expensive;Govt can allocate resources to cater for all Ugandans with terminal illness.

  10. @Ejakait: I feel so sad when men fail to comprehend basic issues: EAC is a regional body whose membership is determined by the geographical allocation of states and their economic goals;there is ECOWAS in West Africa,Arab league,European Union they are quite different from the G7 set up its different in that, the G7 countries are a combination of wealthy states from Asia,Europe and USA their goal is chest trump,bully, direct other states & feel nice; they decide amongest themselves who will be number one in their league no wonder all their discussions are held inhouse.

  11. ejakait engoraton

    No need to bring in all men, just goes to show your very shallow mind. If you have issues with me take it out on me , why do you bring in your father and brothers.
    You fell into quick sand or put boldly into your own S**T and now trying to wiggle your way out and the harder you are trying, the deeper you are sinking into it.
    Just do the right thing and admit your ignorance , even when an idiot accepts and acknowledges their status, you may earn the respect of a few.

  12. ejakait engoraton

    Normally you do not blame someone for being stupid , but by the looks of it you are making a conscious decision and a very big effort to be or to sound stupid.
    You just can not put it in your head. You came on the forum hardly knowing what the G7 is , save maybe for the fact that you had just heard of it. No matter how much you wish away, China and Russia are not part of it. All I am trying to tell you is that any group has the right to regulate its membership.
    The EAC started with 3 countries, other countries were subsequently brought in and if the members so wish, they can bring in other members.
    But you can not expect them to bring in Chad and still call it EAC. All this is beyond your comprehension, simply put that membership to most organisations is by invitation.
    And then you go on to say that this constitutes conflict of interest!!!!!!! Whose interests and what conflict.

  13. ejakait engoraton

    WINNIE, I think you are a pervert or like our rulers, a sadist.
    How do you even think that people overstay in Mulago because they get good food.
    You do not wish your enemies ill, but pray it doesn’t happen to you.
    You are the only idiot who thinks Mulago is a 5 star hotel.

  14. 1.Ejakait:When one resorts to name calling it means they are losing the battle how can a Briton and Lawyer not know G7 yet my country Britain is one of its members?
    2.Its normally polite to read and internalise issues before making a comment thats why lawyers read alot.
    3.Yes a simple and basic mind like yours thinks that regional groupings like ECOWAS,EAC,Arab league are the same as G7&G8; your basic mind tells you that since all this involves heads of states meeting then their goal is the same me thinks that G7 is about rankings ,domination and supremacy while the other leagues have no element of ranking other wise we would have EU 4,EAC 2,ECOWAS 3 etc
    4.The issue of conflict of interets araises in G7 coz there is no neutral state to verify that nation x indeed qualifies to be in the G7.we all know the bully in the world(USA) no one checks their workings they just make directives.
    5.When i mentioned states like UAE not being in the G7 my intension was to inform Bantu that Kenya may economically be stronger than Ug but we are realtively comfortable but the fuckard in you thought that i meant that roads leads countries to G7.
    6.How do the G7 select states to be in their league?the issue of conflict of interest still pops up coz one needs to be an ally of sorts but with other assocaitions like EAC membership is voluntary thats why Rwanda,Burundi,S.Sudan are member states.

  15. ejakait engoraton

    WINNIE, the more you try, the more you are putting your knickers (to use the pan) in a twist.
    It was you who was wondering why UAE, Saudi etc were not members of G7.
    Why would you be wondering if you knew the criteria for membership.
    To make it easier, it’s like how the NRM historicals were decided.
    No matter what your contribution after the fact, you can not become a historical.
    Some countries have achieved the credentials by which the group was formed but they can not join the group.
    That is why you have the latter G20.
    I now rest my case, me Lord!!!!

  16. @Ejakait i am done with you.You can go and hang with your G7.

    Doctors who trained from Russia in Obote’s time are not so good like those who trained from Britain.In 2012, a close family friend had a problem with her intestines she was referred to a Russian trained surgeon for surgery what does the surgeon do? he operates the poor lady and forgets to put a catheter this made the lady’s stomach swell and later bust coz of pressure all her intestines were out.At 1st her son thought it was a new medical procedure where clients who have had surgery don’t have catheter stitched on them to drain fluids;to make matters worse the nurse who was attending to her kept telling her that she had instructions from the doctor to only administer painkillers this raises the qn at what point can a nurse correct a Doctor even if the other is more technical and senior.How many people lose their lives to such careless mistakes?

    This poor lady was again rolled to the theater 4 days after the surgery fortunately she survived.

  17. very poorly informed article
    the author claims to have stumbled upon a great truth that was previously unknown, writing “We now know that the most effective health care is not clinical but preventive…”
    If the author had any knowledge of health policy he would be aware that this focus on preventive care has in fact been the mantra of all African governments for the last sixty years. He could consult any of Uganda’s five-year development plans from the 1960s, or he could consult notable scholarly works such as the report of the Makerere 1966 conference on “Medical Care in Developing countries”.
    Someone knowledgeable on Health policy would be aware that the focus on preventive care has been in fact effective, rates of preventable disease are way down in most African states, and this has contributed to the rapid growth in population which has overwhelmed all other services.
    Finally, a knowledgeable author would be aware that even with effective preventive policies people still do get sick and need treatment. The WHO has a list of “basic health services” and the list includes “curative services”.
    The article, like many from his author, is mostly unfocused generalization. Africa is many different countries. A handful have adequate services accessible to all citizens, including some with cutting edge curative services. At the other end some countries lack clean water and adequate food supplies to most of their residents. In the middle are many countries where health services of fair quality are available for much of the population even though a need for improvement is glaringly obvious. Lumping such nations together for policy purposes is meaningless.

  18. ejakait engoraton

    MWENDA uses a few scanty fact and figures/statistics laced with flowery language to make his presentations, but when you look closely most of it lacks in substance or critical analysis.
    HE would want you to believe that M7 , with the resources available to him, which according to Mwenda are very meager , has done a tremendous job and Ugandans should be eternally grateful to him.
    Just in yesterdays MONITOR were among a few articles , two articles , one by Muniini Muleera and another by none other than the Speaker, which left one in no doubt about the state of our health system which leaves one in no doubt that it is not fit for purpose.
    All this is despite Mwenda and others trumpeting the fact that revenues have increased n fold since the NRM coming to power and the much talked about astronomical development rate.
    MWENDA always conveniently forgets that statistics do not always tell the full story, sometimes they tell no story at all. This is eloquently told in an article in today’s MONITOR by KALINAKI.

  19. ejakait engoraton

    JUST in todays INDEPENDENT, the great visionary has once again come out to trumpet his long held but greatly misplaced view that a big population is a good thing.
    This is only true IF other factors are in place most notable good leadership and planning.At the moment in UGANDA we have none and what this big and uncontrolled population has done is to greatly stretch an already almost non existent system – education, health ………
    He cites the examples of other countries like Malaysia which have large populations and have somehow been able to develop.Yes , this fortune ( population) was in the hands of good leaders who were able to use it to transform their countries.
    As they say, a fortune in the hands of a fool is a big MISFORTUNE. Uganda’s fortune(large population) is the hands of fools (our rulers) and no doubt is turning out to be a misfortune

  20. If Uganda is doing so well economically and developing how do you explain the persistence of famines, suggesting it is incapable of feeding itself?

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