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Wrong thinking on health services

THE LAST WORD: Why expecting a Ugandan peasant to have the same quality of healthcare as an American is madness

THE LAST WORD | ANDREW M. MWENDA | Last week, I attended the Advocates Coalition for Development and Environment (ACODE)’s monthly State of the Nation seminar on public spending and governance on the health sector in Uganda. Like all such conferences on African issues, context is always missing. So we discuss the state’s ability to deliver public goods and services as if poor countries have the same resources – both human and financial – as rich nations.

To understand our frustrations with our governments, one has to first appreciate the mind-set. For most of the educated elites in Africa, we have been indoctrinated with the ideology of a welfare state i.e. that government should provide a large basket of public goods and services to all her citizens for free – health (especially medical), clean water, education, electricity and roads. When these services are poorly provided or not provided at all, we assume that it is because of lack of “political will”, or corruption, or greed and selfishness of our leaders.

This explanation for poor delivery is even found in the works of the most sophisticated academics and intellectuals in Africa and the Western world. Yet the problem is very simple: poor countries simply do not have the resources – both financial and human – to provide a large (or even small) basket of public goods and services to all their citizens and for free in the quantity and quality they demand and desire.

Corruption, absenteeism, incompetence, etc. are consequences of the state trying to do too much for everyone, everywhere, all the time on a string budget, not a result of “cruel, selfish and greedy African leaders who don’t care about their people” as the common narrative in the media and academia, both in Africa and the West, has postulated. Put simply, the state in most of Africa is over-developed in functions but underdeveloped in capacity, so its reach goes far beyond its grasp. That is the main source of all our continent’s frustrations and recriminations.

Let me illustrate. This financial year, Uganda’s total revenue is Shs16.2 trillion ($4.3 billion). Divided by a population of 40 million people, you have per capita revenue of Shs405,000 ($107) – in Purchasing Power Parity (PPP) it is $353. That is not enough to provide us with all the public goods and services in the quantities and quality we demand. So government goes to international creditors and the domestic market to borrow where it raises an extra Shs10 trillion. So this gives us a budget of Shs 26 trillion ($7.1 billion or $22.7 billion in PPP). This brings public spending per person to Shs 650,000 ($173 or $567 in PPP).

Compare Uganda with the USA. This year, its budget is $7.56 trillion for a population of 328 million people, giving it public spending per person of $23,000. It matters very little how wasteful the USA can be. This money is enough to provide a large basket of public goods and services in large quantities and of high quality. Even with all the best intentions and efficiencies, Uganda simply cannot match this level of providing for her people. Yet Uganda’s ideology of a welfare state and its policies on social service provision to its citizens is modelled on that of rich nations like the USA.

Coming to health specifically, look at what our most elites expect and what the government of Uganda promises: to provide every citizen, everywhere in the country, every time they are ill with all the treatment they need – for free. Anyone looking at Uganda’s resources and not burdened with the ideology of a welfare state and not blinded by the mind-set that the state has to do this would consider our government insane in making such a promise given the resources at its disposal.

Let us look at the numbers. This financial year the USA will spend $1.7 trillion on health, Uganda Shs2.3 trillion ($612m or $2.0 billion in PPP). This gives the USA per capita health spending of $5,200 while Uganda’s is Shs57,000 ($15.3 or 50.2 in PPP). I have constantly adjusted figures to PPP because it tells us better the number of hospitals, medicines, equipment, nurses, doctors etc. that Uganda has to procure and the prices it has to pay in her own national currency.

I have used the USA here because her budget and its distribution are easily available online – but it represents a typical rich country. In fact her peers in Europe do much better with slightly less spending. The point is that we are expecting Tadeo Mukasa, a peasant in Masaka, to provide his children the same quality of healthcare and education like Bill Gates does his. Its madness!

The solution for poor countries in fixing their healthcare problems has to begin by identifying important priority areas where they can have the highest impact with their meagre resources i.e. prioritisation. Prioritising everything means you have prioritised nothing. And they can begin with what we know. The biggest cause of low life expectancy is high infant and child mortality rates. Too many kids die before their first and fifth birthday. This is where we need to have the most effort.

The founder of social medicine, Thomas McKoewn, drew a series of famous diagrams (on Europe) showing, for a whole series of diseases, that mortality rates were falling before the introduction of effective treatment and continued to fall almost at the same rate after its introduction. McKoewn found that medicine was not very useful in improving health. This led him to conclude that the root of health improvement lay in economic and social progress; especially better nutrition and living conditions.

The Nobel laureate in economics, Angus Deaton, in his book: `The Great Escape’ shows that improvement in health is best realised by improvements in public health interventions such as sanitation, access to clean water, vector control and primary health interventions such as immunisation and vaccination. These interventions are effective and cheap yet positively impact the vast majority of the people. They are also the only affordable interventions by governments of poor countries.



  1. Well researched. If Mwenda was a woman, we could be talking about “mood swings” but we suspect that he’s a man so we should be talking about “momentum shifts.” Nice article though we cannot talk of “governments being over developed in function but under developed in capacity” when it is the capacity that brings about development. In other wards, we are putting the cart before the horse. How much of our realised budget do we put to good use. Even the $151 is not reflected on the ground. To me, we should go back to the basics of 1 + 1. We can benefit from the 16trillion economy if we embarked on efficiency.

  2. 1. “McKoewn found that MEDICINE was not very useful in IMPROVING health. This led him to conclude that the root of health improvement lay in ECONOMIC and SOCIAL progress; especially better NUTRITION and living conditions” This was Uganda’s post-independence priority right from elementary school, we were taught ‘preventive health’ and truly there was no congestion in Hospitals, Health centres and dispensaries. Why? Ugandans fed well, worked well and rested well.
    2. ” This financial year, Uganda’s total revenue is Shs16.2 trillion ($4.3 billion).” If the total revenue was 100 times ($430 billion) the fortune would still not reach the ‘Tadeo Matovus’ for the simple fact that GREED (as is displayed by leaders) knows no magnitude. They (the powers-that-man the mulembeko) would criss-cross the world buying oil wells and islands and all other vain toys to use in molesting people and high-tech equipment to calm the poor….only the chinese and other foreign contractors would gain.
    3. These people(at the helm of leadership) look like they are irreversibly corrupted and are incorrigible.
    The only medicine to the status-quo is found in Jeremiah 6:16 …..Thus says the Lord: “Stand in the ways and see, And ask for the old paths, where the good way is, And walk in it; Then you will find rest for your souls. But they said, ‘We will not walk in it.’ To Muslims, there must be a similar exhortation in the Quran.
    4. Ejakait will agree with me that the system requires complete overhaul for things to start and proceed well.

    • “4. Ejakait will agree with me that the system requires complete overhaul for things to start and proceed well.”
      Completely in agreement my dear brother.

      For one, anyone who thinks that in our current state that we can provide the “basket of goods” that the developed nations can provide their citizens , is mad. So where MWENDA finds these people who think thus beats me.

      Which on the other hand is not to say that our nations, with our meager resources, can not do better.

      Here the big YELLOW elephant in the room is LEADERSHIP as he himself MWENDA has given examples of firstly RWANDA under KAGAME and then KOREA , who as he rightly says are able to provide a reasonable basket of goods , as well as make advances along the development path, with a small resource pocket, which countries with bigger pockets have not been able to do.

  3. The mindset of expecting all free services I think is brought from colonialism who did better in terms of health. The incapacity of the state to provide these services is clear as evidenced by the math. But the question is why the state does not clearly articulate this to the masses so that they know the limit of what to expect? Our president once advised Ugandans to have many children and he was promising to educate them.

  4. M7 has over performed as CEO of Uganda he knows that his job is not ordinary and bears a lot of responsibility.

    Social welfare is the only link between governments and its citizens. In Uganda for example, 90% of the sick seek for medical services in government owned facilities.The British would say A nod is as good as a wink to a blind horse.((There is no need to emphasis gov’t’s role in the social instructure development of Uganda).

    Journalists have now become drug dealers.Tell me how much money did Solomon Sserwanja spend in his alleged undercover investigation on drug theft in Uganda to make us believe that the drugs recovered at his home were for investigation purposes and not for making a quick buck?secondly Serwanja has about 4 jobs in Uganda isn’t that a sign of greed for money?What was the worth of drugs found in serwanja’s house?since his wife works with MOH dont you think she is one of the drug thieves Ugandans talk about?

  5. Dr Eng Kant Ateenyi

    From the standpoint of Western-‘indoctrinational’ economics, this Mwenda article gets an ‘A’. For even his usual critics now seem to be in line. Unfortunately friends, I am not near 100% alignment! I quite agree on the obvious issue of ‘Preventive’ health care. For is that not what in my world, we have always emphasised – after creating assets?
    But there also lies one of my points of departure: The assets MUST HAVE BEEN CREATED before they are ‘preventatively’ maintained! And even that Preventive maintenance works best if there is a clearer understanding of, and ABILITY to effect or modify, the creative processes that made the assets.
    Back to preventive health care now: Good nutrition of a young, unemployed, under-educated population of 40 Million still growing at 1.2+ million a year in a country as small as it was in my (and Ejakait’s + Rwasubutare’s) youth when we, the then youth were about 10% of the present numbers, needs relatively massive production of nutritious food, which in turn, needs ABILITY on part of the better educated to do so.

    Vector control today could in theory be easier than in the pre-1986 days: for we have irreversibly damaged the ecology of the country. However, the control still needs knowledge and ABILITY to act before anything else. So does good Hygiene; so does good sanitation; so does good water supply & treatment (eh you good friends, when am I getting your 1st order of solar water purifiers?), so does ——.

    Now my second point of departure: What is this ABILITY? My good brother Rajab – might quickly jump to ‘Money’ (sorry Rajab if I am wrong). Even Mwenda expresses this in monetary terms in this article. But mine is a big NO, NO, NO. It is the taking of initiative to act. That courage to clear mental laziness first, and follow it by physical action as guided by the mental plans. We need thoughtful doers, not mere planners or counters, or statisticians, which ‘indoctrinational’ economics of the west (and now China) wants us to be hoodwinked into.

    Money is often looked at as a medium of exchange. But more realistically, it is a way of saying ‘my creative effort is worth so much of yours’. Thus, countries and societies with less imaginative and creative talent are doomed at this alter of money. Imagination and creativity are nature’s endowments for every human being to explore and exploit to sustain her/himself in this universe. Those who do it better than others, will always dominate, in a competitive environment for resources.

    Ah, time to attend to other things comrades ———.
    Dr. Eng. Kant Ateenyi

  6. “…………we have irreversibly damaged the ecology of the country…….” much nearer home is the fact that the river thatused to flow through the School (there are only 2 Schools in Uganda) land has dried up because of people laying bare the cover upstream…..consequently the Nyakasura (sorry School) swimming pool cannot be filled as was before ‘liberation’ war. Ecological damage is a sin to everyone including the damager. It really pains me. I wish they would be stealing,embezzling and misusing what was set up by man but leave what nature gave us.

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