The Independent (Kampala)

Uganda: Healthcare for the Rich

On Monday, April 23, Daily Monitor reported that the government of Uganda spends US$150 million per year (Approx. Shs 375 billion) on medical treatment of its top officials abroad. When I was still young and intelligent, I would have been angry and denounced Uganda's ruling elites as heartless. I would have widened the argument to claim that such abuses are symptomatic of a broader elite crisis in Africa; and that it is lack of democratic accountability that perpetuates such abuses. Today, I have grown old and stupid; I carry a sobering awareness that such actions are actually predictable human behaviour.

The day the story was published, I was in Rwanda with a team of 21 journalism students from Makerere University and Uganda Christian University visiting King Faisal Hospital, a highly specialised medical facility in Kigali. There, we saw five poor illiterate peasants on dialysis machines. Doctors told us that two of them were about to be flown to India for kidney transplants. In Rwanda, it is standard operating procedure for ordinary people with severe medical problems that cannot be treated in the country to be flown to India or South Africa for specialised medical attention. Because the costs of such international medical evacuations are high, it has forced the government of Rwanda to invest in highly specialised services like brain surgery which is now a routine service at King Faisal Hospital. Indeed, we saw a poor illiterate peasant who had just had one.

The students asked enthusiastically how such ordinary citizens get such extraordinary medical attention. The doctors answered that it is because every Rwandan has medical insurance. How does the hospital select those to go for specialised medical attention abroad? Doctors answered that there is a medical board that does so. But how do they protect its independence so that it makes recommendations on the basis of medical need as opposed to political influence? What if a powerful army general or politician wanted to get his wife with a minor problem unto the list as opposed to a poor peasant; can the board resist? The doctors answered that such abuses don't happen in Rwanda because such powerful individuals would be held to account. By who, students asked. The answer was unanimous: by the president. This is a blessing and a challenge; a subject I will return to another time.

To revert to Uganda's US$ 150 million expenditure on the powerful, I suspect, it is what happens in democracies like Kenya, Zambia, Ghana, Malawi and Senegal. It is also what happens in the United States, United Kingdom, France and other democracies. We saw the speed and ease with which the US government released US$ 750 billion in 2008 to bail out Wall Street banks (a record four days) whereas the country had spent decades debating whether 40 million of its poor citizens can get medical insurance and had failed to do so. The benefits from the mistakes by these banks had gone to individuals as bonuses, dividends and capital-gains while the costs of the bailouts were incurred by the taxpayer. That is how human society works most of the time. Elites in positions of power and influence serve their own interests first, the rest later.

I see this inversion of things with charities: often, their administrative and fundraising costs take nearly 70 percent of their revenues; the beneficiaries of their work, 30 percent. It is also what happens with aid projects. Many "pro-poor" programs across the world - in rich and poor countries, in democracies and dictatorships - benefit the elites who work in them than the poor who are supposed to benefit from them. Indeed, it is better for one to be an employee of an aid project (or a charity) than a beneficiary of its work. It is also the reason I prefer free markets to state welfare.

Rwanda therefore is an exceptional case. Norway, Sweden, Canada and other rich countries do provide their poor citizens with world class medical care. But I suspect that may be largely because these countries are very rich. Every elite has the best medical care they need; so they can afford to be generous to their poor citizens. I suspect that if Canada or Norway had a similar level of income and its distribution as Rwanda, elite behaviour would be closer to what we are seeing in Uganda. In our poor countries, the rich compete with the poor for the same resources. Since the distribution of power favours the rich, elites in control of public resources serve their interests first.

President Yoweri Museveni was the leading critique of such elite behaviour when he was not yet president. Now, it is the government he presides over that has indulged in the worst excesses of elite privilege. I have watched over the years politicians denounce him for such abuses. Immediately he has won them over, they are the first to get themselves and their families such international medical evacuations and State House scholarships. Often those complaining do so because they don't have access to such benefits. The fact that most of the elites in Uganda do not provide medical insurance for their workers (including domestic house-helps) or even adjust their salaries to inflation tells a lot about what they would do if they had state power.

Last year, police unleashed unprecedented brutality against opposition leader, Dr. Kizza Besigye. In one of the most macabre episodes in Uganda's history, we were treated to a gruesome television torture-show featuring Besigye and starring one police officer Gilbert Arinaitwe. The heroes of that day were the bodyguards of Besigye who tenaciously held unto defending him, risking everything to protect their leader. So they suffered almost as much beatings and pepper spray as Besigye.

There was a lot of concern about Besigye's health in the press. A few days later, I saw him being flown to Nairobi for specialised medical treatment. I did not hear anyone talk about the fate of those bodyguards and their medical needs. When I raised this issue, I was told I hate Besigye. And each time I have raised issues with expenditure at State House, I am told I hate Museveni. In politics, as in history, the names and dates change but the arguments and events remain the same.

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