Uganda: Inside Candidates' Plans to Revamp Healthcare System

1 December 2020

Uganda's healthcare system is convulsing in a volley of problems, suggesting injection of fresh ideas is urgent to revamp it to better serve the estimated 41.6 million citizens.

From inadequate personal hygiene causing preventable diseases and deaths, to systemic operational and management hurdles and curative care capacity constraints, the problem list is long.

It is, therefore, unsurprising that each presidential candidate is making the most sweetening of offers to overhaul the sector as they traverse the country to canvass support for the January 14, 2021 election.

Good health determines citizens' productivity and lifespan but, as the varying promises by the presidential flag bearers show, the best pathway to achieve this goal is mined with competing political ideas and interests.

Our analysis of the manifestos, which detail the presidential candidates' governance agenda for the country if elected, reveals as much commonality as differences in their approaches to matters of health.

The different documents more generally provide broad-stroke proposals, and are scant on details and resourcing in ways that make their evaluation for feasibility difficult.

Just about half of the eleven presidential candidates have launched their manifestos, meaning that what the others intend to do once in office, and how, can for now only be assessed based on their verbal proclamations on the campaign trail. Some are yet to articulate any plan for the health sector.

Whereas many of the candidates appear to agree on the need for Uganda to have a national health insurance scheme, none offers precise details on financing mechanism and the package in the insurance or how it will be run.

Questions such as whether the scheme will operate as an autonomous unit or be domiciled under the Ministry of Health, whether each citizen will pay the same rate or individual contribution be staggered according to income and what happens to formal sector employees with existing health insurance, remain unanswered.

Also unresolved is whether an insured individual will be entitled to access automatic free care for all ailments, from cheaper-to-treat but most-killer malaria to cancer and other non-communicable diseases or sophisticated surgical procedures that cost much higher.

Funding Health sector

Uganda's current health financing model is problematic, imposing on healthcare seekers a higher out-of-pocket spend burden. Four in every Shs10 spent on health in the country is directly by households, donors make similar contribution to the sector's expenses while the direct financing by the government constitutes only 15 per cent of health budget, The Independent magazine reported on June 25, 2019, quoting Ms Sarah Byakika, the Health ministry's commissioner for planning, finance and policy.

These statistics reflect a fraction of the teething health sector problems which, according to the 2019/2020 Annual Health Sector Performance Report, is saddled with significant decline in the quality of healthcare and shortage of essential medicines in hospitals.

The report shows about 11,000 more patients died at health facilities in the period than the previous year, with malaria and pneumonia identified as leading causes of death.

In addition, more women died while giving birth, signalling an apparent reversal of Uganda's progress six years ago on Millennium Development Goal 5; improving maternal health.

Accountability on health

Having held power for nearly 35 years, the torch of scrutiny shines brighter on the National Resistance Movement (NRM) and its flag bearer Yoweri Museveni for these failings.

This means government officials have more accountability to give and more explaining to do, on why healthcare is facing deficits or why citizens should hope for different outcome if they renew NRM's mandate.

For instance, the government's attempt to establish a National Health Insurance Scheme (NHIS), whose version approved by the Cabinet in June 2019 imposes a 4 per cent charge on gross salaries of formal sector employees (with matching employer contribution) and monthly remittances by all Ugandans aged 18 years or older, has remained wet in the wings in Parliament due to the controversy the proposals generated.

Alive to the political headwinds, Alliance for National Transformation (ANT) candidate Maj Gen Mugisha Muntu, who is yet to launch his manifesto, told Daily Monitor that his government plans to pick some health insurance best practices from countries such as Rwanda and Ghana, with demographics and resources comparable to Uganda's.

Rwanda, for example, runs a community-based health insurance scheme where citizens contribute a health fund managed at the district level and contributors access the kitty whenever in need of healthcare.

Independent presidential candidate Joseph Kabuleta is eyeing a similar model as well as promises to increase the remuneration for health workers but by 20 per cent in the first year.

It is, however, Democrat Party's Nobert Mao, who appears to discount the urgency for pay raise for doctors and nurses, prefers instead to provide free housing, transport and pick utility bills for them.

"Once you take care of those, the salary will be for other personal expenses ... [and health workers] will have more disposable income," he said in a telephone interview.

Mr Mao, who is running for president for a second time but is yet to launch his manifesto, has proclaimed his intention to shift the focus from curative care to disease prevention. He said Uganda does not have capacity to treat a large sick population.

Thus, if elected, his government would prioritise prevention of illness through mass immunisation, distribution of mosquito nets, public health education and reintroduction of physical education in all schools.

In many respects, these mirror some of the things the Ministry of Health is doing under NRM, meaning Mr Mao's policy proposals, which in rhetoric and packaging may sound different, in reality make little difference in detail and practice.

For example, the Ministry of Health in its 2020/2021 ministerial policy statement flags a shift from curative care to public health promotion and disease prevention as well as control of epidemics and non-communicable diseases as priorities.

It also singles improvement of reproductive, maternal, neonatal, child and adolescent health services and emergency medical services as key focus areas.

That way, Mr Mao's unique offering perhaps is the promise to direct attention to specialised care through the establishment of sub-regional specialised centres and collaboration with regional neighbours to form an East African Community framework where member states invest in and provide specialised services in which each enjoys a comparative advantage. "For instance, Kenya would focus on cancer (treatment), Uganda can be a regional centre for heart disease (handling) and the other countries would take on others," Mr Moa said.

It is a proposal which appears predicated on good neighbourliness, but one fraught with danger in the event of bilateral and diplomatic tiff between member states as is the current situation between Uganda and Rwanda.

FDC plan

In a manifesto launched last week, Forum for Democratic Change (FDC) party's Patrick Oboi Amuriat committed to leverage technology to advance e-governance in the delivery of health services.

If elected, his government's aims to improve systems for, among others, better health management, referrals, medicines and other medical supplies and inter-institutional and inter-sector coordination.

The FDC's promise to automate health management and logistics compares with the promises in the NRM manifesto, although Amuriat's plan to attach a doctor and clinical officer to every family - akin to Cuba's community-based polyclinics - would be ground-breaking in the country, if implemented.

Both NRM and FDC pledge to recruit more health workers and pay them better but, but like other candidates, neither Mr Museveni nor Mr Amuriat offer specifics of numbers of new staff they intend to recruit and also do not computes the possible financial cost of the planned reforms.

Whereas NUPs Robert Kyagulanyi, Bobi Wine, commits to increase the health budget from 6 per cent to 15 per cent of the national budget, in line with Uganda's commitment under the 2001 Abuja Declaration, his manifesto is quiet about how this will affect financing of other sectors.

In addition, Mr Kyagulanyi's claims that the $45 million (Shs166.6 billion) that the government of Uganda borrowed to strengthen health service delivery in districts failed to achieve the goal.

He plans to persuade the World Bank to waive the debt so that funds earmarked for repayment of the loan can be reinvested to improve the health sector.

We could not establish the arrears due to World Bank, if any, on the loan.

But the ruling NRM and its flag bearer Mr Museveni claim they have done a lot to improve the country's health sector, except the gains are either not well publicised or remaining sector challenges are being exaggerated by critics for political reasons.

Amid renewed criticism and doubts that it can in the next five years achieve what it has failed to deliver over three decades, NRM in its re-election manifesto reports that it has built more health facilities, accessible within 5-kilometre radius to 86 per cent of the population.

The party's earlier promise to build a health centre III in every sub-county remains work in progress, yet it is committing to renovate or construct new theatres and wards in 37 health centre IVs and ramp up ongoing construction of 500 staff houses. This is besides plans to establish regional cancer centres in Arua, Gulu, Jinja and Mbarara cities.

"NRM government will ... increase access to family planning services, antenatal care, basic obstetric care services and post-natal care services [and] reduce the high maternal deaths ... ," the party manifesto reads in part.

Similarly, NUP promises to establish a maternal health facility in every sub-county while ANT is offering to match health facilities and service levels to population in order to stem future crisis.

"We have got one of the fastest growing population and we must start to build a foundation, and ensure adequate equipment and medicines ... because of the expanding population, even the facilities we have [are not sufficient]," Maj Gen Mugisha Muntu, the ANT presidential flag bearer, said.

Covid-19 challenge

There is little the candidates offer by way of policy to strengthen Uganda's institutional capacity to respond to epidemics and future health emergencies.

With Covid-19 spreading faster and killing more Ugandans now than earlier in the year, presidential flag bearers would be expected to treat the pandemic as urgent and in-tray priority crisis to tackle on assuming office next year.

This is particularly so because the infectious disease has severely disrupted economies and lives and illuminated cracks in Uganda's less-than-adequate institutional capacity and resourcing required to sustain long-term response to health security threats.

Despite differences in priorities within the health sector, and best approaches to fix the problems, the candidates are unanimous in their plan to transform the health system by improving the welfare of health workers, prevention of non-communicable-diseases, implementation of a national health insurance scheme and fighting corruption.

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