Why a rotten health care system is good politics for the Kampala regime

 

 

Patients wait to be attended to at Naguru hospital as health workers went on strike last week over non-payment. The workers also complained of high patient turn up. PHOTO BY STEPHEN WANDERA.

By Charles Onyango-Obbo0

In Summary

The custodians of wetlands would be allowed to charge all people who draw water to grow rice, for example, a few thousand shillings a year – but only if they ensure that there is no encroachment beyond a certain point.

I will start with a disclaimer; feel free to dismiss the statement I am going to make after this on the basis that I am not impartial.

So, here we go: I think the most lively and informed debate about Uganda today, and where the country is going is taking place on Daily Monitor online. Debates take place on the websites of other Uganda media, blogs, and community sites of course, but none of it equals the Monitor’s.

The value of the debates on Monitor online comes from their broad range, seriousness, and political balance. Pro-government, anti-government, neutral, cynical, and anarchist views thrive in equal measure.

One of the most informative ones followed the recent tantrum President Museveni allegedly threw when he stormed out of a ruling NRM Caucus meeting, because rebellious MPs wouldn’t pass the bloated Defence budget when Uganda’s health system had collapsed, yet it had comparatively been allocated “peanuts”.

One calm debater noted that it was true, as President Museveni argued, that Uganda’s national security was paramount, but he said you can only defend a country that exists. If the country “dies off” from diseases because its health system is a shambles, there will be nothing for the Army and intelligence services to defend.

But that scuffle over Defence vs. Health revealed many other things. First, the continuing shifts in NRM (and Ugandan) politics brought by the election of increasingly younger MPs. Struggling parents brought many of them up and relatives who were “Aids survivors“ after the disease ravaged Uganda in the 1980s and 1990s, and have a stronger sense of supporting their communities.

But it also pointed to the multilayered and murky role the Defence budget plays in Uganda’s politics. The critics, and some donor and international financial institutions, have always argued that a percentage of the Uganda defence is used as a war chest to finance NRM politics, and some of it is stolen – through payment to “ghost” soldiers and substandard military supplies. Thus the Defence budget is one of the many patronage funds available to Ugandan kleptocrats.

Whatever the truth, I think that contrary to its public policy statements, the Kampala government does not want a functioning health system.

Health is one way the government dispenses patronage. In May, the Daily Monitor reported that the government spent $150m (Shs375 billion then) on evacuating top government officials and military officers abroad for treatment.

The government ensured that Uganda’s health care system collapsed, by choosing the worst possible way of making it affordable – free. Neighbours Kenya and Rwanda chose an insurance system. In other words, when you go to a hospital, you pay.

If you are poor, you get “free” insurance to pay for the medicine, not free medicine. Rwanda’s Mutuelle de Sant’e, based on a means system, works better than Kenya’s National Health Insurance Fund (NHIF). The success of Mutuelle de Sant’e is that it was a perfect innovation for a tiny country with a small population like Rwanda – in other words, besides the lower levels of corruption, geography makes it work.

Kenya’s NHIF is paid in various ways, the most common being payroll deductions. I pay the equivalent of UShs40,000 a month. However, like all employees in the state institutions and the corporate sector, I also have private health insurance – worth UShs20 million for outpatient care a year, and several times that amount for in-patient, etc.

Because of this, I will never use my NHIF, so it goes to benefit the people who really need it. Because Uganda has neither of this, you need to have cash to pay at the pharmacy, and the doctor’s secretary before you get attention. And you need cash too for evacuation abroad.

Very few Ugandans can pay for this from their salaries and businesses, and this is where the state comes in. If you have connections, you get it to pay for you either directly, or through corrupt payments to your company by way of inflated contracts.


Thus treatment abroad at taxpayers’ cost, or through lucrative earnings for your company via corrupt state contracts, is a form of patronage used by the regime to buy loyalty. In the security sector, these health “gifts” are paid through the Defence budget, and thus give the president ever greater control over the armed security services.

If Uganda had a functioning health system, through which everyone who was ill had access, the Establishment would lose this leverage. So while on the face of it the shambolic state of Uganda’s health care seems like bad politics for the Museveni government, it actually gives the regime more power, because those whom it helps to exit this horrible system and get treatment abroad, become extremely grateful.