Why putting more money into the health sector is like putting more meat in a butchery controlled by hyenas
The recent “stand-off” between parliament and President Yoweri Museveni on whether to allocate Shs 39 billion to health or defense is one of the many false debates about the budget process in Uganda. An uninformed observer may easily think that there is a serious policy difference between the legislature and the executive. For those who have followed the budget making process in Uganda over the last 15 years, parliament is posturing, not trying to correct executive excesses.
In the financial year 1997/98, the government of Uganda allocated Shs 58 billion to the health sector. According to Uganda Revenue Authority, the dollar exchange rate for that year averaged Shs 1142.This means government allocated US$50.5 million or Shs 127 billion to health in today’s currency. (I am using the dollar to adjust the shilling to inflation). In the 2012/13 budget, the government of Uganda has allocated Shs 838 billion to health. Therefore, the real monetary value of the health budget has grown by 560 percent.
Equally, the population of Uganda at in 1997 was 20 million meaning that per capita expenditure on health was Shs 6,350 or US$2.5. Given our current population of 35 million, this financial year’s budget translates into per capital health spending of Shs 24,000 or US$ 9.6, an increase by 280 percent. Is there a noticeable improvement in the quality of healthcare delivered by the government of Uganda as a result of this budget expansion?
Anyone visiting our hospitals and health centers would be appalled at their state of disrepair, the poor equipment used and absenteeism of medical workers – not to mention their poor pay. So, public debate in Uganda needs to shift from inputs to outputs, from budget allocations to services delivered, from more money to value for money and from policy pronouncements to policy outcomes. Before we agree that any more money is allocated to health, let us first ask whether the money currently allocated is being used appropriately to maintain, renovate and build hospitals and health centers; to furnish them with medical equipment and drugs and if it pays for the services of medical workers like doctors and nurses.
These activities are not an end in themselves; they are supposed to be a means to an end i.e. produce specific healthcare outcomes like reducing infant mortality, child morbidity, incidence of diseases like malaria, etc. Do people who go to hospitals and health centers get a service commensurate with what is spent? Have these services become better as the budget has increased? I have personally visited Mulago and other hospitals like Kiryandogo in Nakasongola, Kambuga in Kanungu, Itojo in Ntungamo and been appalled by their state of disrepair, limited presence of medical workers, congestion, broken beds, malfunctioning equipment and uncollected garbage.
In her autobiography, My Life’s Journey, Mrs Janet Museveni also admits to this state of affairs. She says that during her first campaign, she went to Itojo Hospital to solicit for votes but what she saw made her feel like crying. “Every time I attempted to speak, I chocked with sadness,” she writes, “Eventually I told the staff that I was sorry that such a dejected place could be called a hospital since a hospital is a place where the sick come to be made well, but I pointed out that no one could get well in that place. It seemed to me that a patient would come with one disease and leave with another.”
Some studies suggest that there has been improvement in the health of our citizens; life expectancy has gone up, infant mortality and child morbidity have reduced etc. However, this may have more to do with private healthcare services than government ones. Therefore, let the executive account for the Shs 838 billion spent on the sector per year – not to mention what donors spend off budget which is close to Shs 700 billion – before a dollar is thrown into the health bottomless pit.
In fact, after my visit to Somalia and witnessing first hand how professional UPDF has become and how commendable the job it is doing is, I am more inclined to support a budget increase to them. There has been real reform in the army. As a result, we no longer have news about ghost soldiers, junk helicopters, junk tanks, expired food rations and undersize uniforms that had turned the army into a springboard for private profiteers and around which I built my investigative journalism career.
In November 2009, The New Vision reported that a government audit had revealed the existence of 100 ghost hospitals in Western and Central Uganda alone. If an audit was conducted on the ministry of health payroll, we would be shocked at the number of ghost medical workers and the money spent on them per year. Mid this year, Daily Monitor reported that the president had ordered an investigation that found that our country spends US$ 150 million (Shs 375 billion) on treatment of top government officials abroad. Can we first end this profligacy by our rulers?
Besides, a World Bank study in 2008 found that 80 percent of Uganda’s health budget is spent on hospitals in urban areas that serve only 20 percent of the population. The study also found that 80 percent of public sector medical workers in Uganda work in urban areas where only 20 percent of the population lives. What is clear from the above is that the democratic process in Uganda has failed to represent the interests of the ordinary citizen. Instead, it seems to reinforce the urban bias – a tendency to allocate ever more and more resources to serve a narrow urban elite.
This bias is largely because people in urban areas have voice – they form political parties, establish civil society organisations, write in newspapers and speak on radio and television to promote their interests. Elites have therefore used their access or these platforms of democratic expression to enhance their power and privileges. The standoff between Museveni and parliament is not about delivering healthcare services to our diseased citizens. It is about which group of elites gets the chance to steal the Shs 39 billion – whether it is those who work in defense or those who work in health. This is not a policy difference that Ugandans need to take seriously.