Why in spite of registering good welfare outcomes we have made little progress at structural transformation
I have just been reading the National Population and Housing Census (NHPC) report for 2014. It shows Uganda has registered many welfare improvements, but also reveals that President Yoweri Museveni’s dream of transforming Uganda from an agrarian to an industrial society has not progressed. Let us look at welfare improvements first.
Between 2002 and 2014, Infant Mortality Rate has fallen from 87 to 53 deaths per 1,000 live births (39% improvement), Under Five Mortality from 156 to 80 deaths per 1,000 kids (a 48% improvement) and life expectancy at birth has increased from 50 to 63 years. Maternal Mortality has fallen from 550 deaths per 100,000 mothers giving birth in 2000 to 360 in 2014. Malaria prevalence has fallen from 42% to 19% between 2009 and 2015.
Comparatively, only Ethiopia and Rwanda do better than Uganda on most of these health scores in Sub-Saharan Africa. Yet we think Uganda’s health services have become worse. If this perception holds any water, why are health outcomes improving? One could say that failures in public health institutions have been compensated by private healthcare providers.
I would love to embrace this interpretation because it confirms a policy bias I have always articulated i.e. that government should leave healthcare provision to the private sector and restrict itself only to financing. But I have learnt to avoid letting my biases blind me to facts revealed by scientifically generated data. We have a qualitative study by the World Bank on medical competences in Uganda. What does it show?
On vital medical tests like diagnostic accuracy, adherence to clinical guidelines and management of maternal/neonatal complications, the differences between private and public sector providers are statistically insignificant. The private sector is marginally better in drug and equipment availability and much better in infrastructure availability.
If clinical health conditions are declining in Uganda (as we commonly believe) what explains improved health outcomes? Only increasing incomes, improved maternal education and improved nutrition would explain these gains. The alternative explanation would be that it is Jesus Christ, Allah or the spirits of our ancestors who are performing the trick.
The report findings indicate improving delivery of public goods and services on the one hand and increasing household incomes on the other. Regarding public services; in 2002, only 8% of Ugandans had access to electricity. In 2014 that had increased to 20%. Access to improved water sources has grown from 24.8% in 1991 to 60.9% in 2002 and to 71.2% in 2014. School attendance and literacy rates have all dramatically improved.
Regarding household income, while 77.4% lived on rammed earth floor in 2002, only 32.4% did in 2014. Houses whose walls are built of permanent materials have increased from 12% in 1991 to 26.1% in 2002 to 43.7% in 2014. Roofs made of permanent materials were 40% in 1991, 56% in 2002 and 70% in 2014. This shows economic growth has been widely shared.
While these welfare gains are commendable, evidence in the report shows that our country has only made baby steps on the core vision that Museveni has always articulated – structural transformation. This is especially disappointing for a president who has been in power for 30 years.
The 2002 NHPC showed that 78% of Ugandans depended on agriculture for a livelihood; 73% of whom as subsistence farmers. Only 2% of the population depended on industry and 8% on services for a livelihood. The report also showed 87.6% of Ugandans lived in rural areas, 12.4% in urban areas. These are characteristic features of a backward society.