Richard Smith: Ugandan health—what should be the priorities?

richard_smith_2014Uganda, like all low income countries, has formidable health problems and limited resources. If you were the health minister in Uganda what would be your priorities? This question was in the back of my mind as I listened to the presentations at the Uganda Health Summit held in BMA House and organised by the Uganda Diaspora Health Foundation and supported by the BMJ, BMA, and others.

The challenges

Total fertility per woman in Uganda is 5.7, and so, as under 5 mortality fell from 187 per 1000 live births in 1990 to 55 in 2015, the population is growing by 3.2% a year. It is currently around 39 million with 52% of the population under 15. Uganda met its Millennium Development Goal (MDG) for under 5 mortality, but there are still 85 000 deaths a year—14% from pneumonia, 8% from diarrhoea, 7% from malaria, 7% from injuries, 6% from HIV/AIDS, and 23% from “other causes,” showing how only so much can be achieved by targeting particular causes.

But Uganda is a long way short with the MDG for maternal mortality—as its stands at 360 per 100 000 live births when the target was 200. About a fifth of maternal deaths occurred in woman who didn’t want to be pregnant but didn’t have access to contraception. Less than half of the demand for family planning is satisfied.

Some 32% of children under 5 in Uganda are stunted, and yet 7% of adolescents are obese or overweight, illustrating how Uganda suffers from the “double nutritional burden.” Joyce Kikafunda, the Ugandan High Commissioner to London and who is probably the only high commissioner or ambassador in the world with a PhD in nutrition, said at the meeting how the United Nations has declared that to live a life free from malnutrition is a human right. Despite agriculture, health, and nutrition sharing a common aim of a healthy population, the links among the three, she said, are weak. Agriculture and health are strong, but nutrition is weak; yet, she said, nutrition is the link between the other two.

Like all low and middle income countries, Uganda has a rising tide of WHO’s four main NCD (non-communicable disease: cardiovascular disease, diabetes, cancer, and chronic obstructive pulmonary disease) in addition to “the long tail of NCD”—asthma, injuries, epilepsy, musculoskeletal problems, congenital defects, and many other conditions.

Across the whole world, including the rich world, only about a third of people with mental health problems receive any treatment, said Graham Thornicroft, a professor at King’s College London; and in low income countries it’s usually less than 10%. Stigma is one reason for this, and Thornicroft described how he had heard health workers refuse to have anything to do with the mentally ill for fear of the effects on them. Uganda does now have one mental hospital, but provision of care across the country is inadequate.


Most expenditure on health in Uganda, as in most low and middle income countries, is out of pocket, and government expenditure on health care is about $24 per capita a year. But the shortage of staff is probably a bigger problem: Uganda has around 3500 doctors and 20 000 nurses and midwives, while for a population less than twice the size England has 107 000 doctors and 317 000 nurses and midwives; and 70% of the doctors in Uganda are in the cities, while most of the population is in rural areas. John Sekabira, a paediatric surgeon from Mulago National Referral Hospital in Uganda, told the meeting how Uganda has four paediatric surgeons for 20 million children.

What should be the priorities?

So what should your priority be if you are the health minister? Or, a related question, how might you best spend £100 000? The second question arose at the meeting because Lord Dolar Popat, the UK’s prime ministerial trade envoy to Uganda and Rwanda who was born in Uganda, promised £100 000 of his own money to the country.

If the minister were a strict utilitarian unaffected by political pressures or uninfected with aspirations then the question would be easier. You start with sanitation and clean water. Uganda has done well with this, although in rural areas some quarter of people still don’t have a clean water supply and 8% defaecate in the open.

What does the utilitarian minister do next? Invest in the education of girls, try to improve the food supply, or concentrate on vaccination of children (where Uganda also does well)? It might well be that the minister would spend nothing on health care and certainly not on hospitals, which, if working well (and they often aren’t), provide good care to some at the expense of the many who have no access to hospitals.

But clearly this is impossible for the minister even if he or she were a strict utilitarian. Somehow hospitals have come to seem like necessities. If there is no hospital what happens to children with acute malaria or life-threatening congenital heart defects? The children with the heart defects will almost certainly die—unless they happen to be the children of rich families or senior ministers, when they might be flown to a hospital in a high income country. If the government pays, then others will be denied basic care. There is no escaping this dilemma, but we see the pictures of the smiling child who is treated while those denied, of whom there will be many, are never seen.

The child with malaria—or the child at risk of malaria—might be luckier than children with other problems because their condition was highlighted in the MDGs, giving rise to the Global Fund for AIDS, TB, and malaria. These “vertical programmes,” which concentrate on particular conditions, are discomforting for a utilitarian minister. It would not make sense for the minister to turn down the generous funding offered by international donors for particular conditions, but the minister knows that the overall effect may even be negative—because the resources (money and people) poured into the vertical programme may undermine the health system, denying care to those with the many other conditions.

The minister may also fear that the vertical programmes will capture future resources. For example, patients with HIV currently require lifelong treatment with ever more expensive drugs as the virus develops immunity. If the international donors pull out at some point then the government may be left with the bill, a bill it would be very hard to refuse to pay.

Accepting the political necessity of having to spend something on health care, the utilitarian minister will concentrate on primary care. It should be integrated care covering all major problems, including mental health problems, driven by the population’s needs; and the care should be provided by teams of health workers who will stay in the rural areas and slums where they are needed. This requirement usually precludes doctors—because they have skills that are marketable not just in cities, where at least some people can pay, but also in high income countries. Particularly noble doctors might be willing to stay in rural areas, but that might well mean being separated from their families because they will be reluctant to deny good education to their children—and that education is probably available only in the cities.

Good primary care will inevitably identify people—perhaps the children with congenital heart disease—who need care that can’t be provided in primary care. They thus generate political pressure for specialist hospital services, and the tragedy—seen today in Britain—is that the expensive specialist services divert resources from the cost effective primary care.

What is the long term aim?

As I listened to the talks at the meeting, I wondered if the implicit assumption is that Uganda would eventually build a health system like that in high income countries—with a wide range of specialist services covering every condition and an emphasis on treatment? That does generally seem to be the assumption, but it makes little sense when the costs of health services in high income countries are increasingly unaffordable and crowding out other items like housing, education, the environment, and social care, which might well have a bigger impact on health than health care. And as we sat in the opulence of BMA House I thought too of the junior doctors’ strike, which surely is sending a signal that something is badly wrong with health care in England.

So, strange as it might seem, the health minister might want to spend some resources on envisioning a different kind of health system. Money should also be spent on research because while a rich country like the US can afford to waste money on the ineffective, excessive, and even harmful a country like Uganda cannot. It might be that Lord Dolar Popat’s £100 000 might best be spent on envisioning or research rather than on hospital care, where it might be consumed in days having created expectations that can no longer be delivered.

I left the meeting full of admiration for those working with passion to improve health care in Uganda but more aware of the great complexity of the exercise.

Richard Smith was the editor of The BMJ until 2004.