A HISTORICAL PERCEPECTIVE OF UGANDA’S HEALTH SECTOR 1889-TODATE Achievements and setbacks

A HISTORICAL PERCEPECTIVE OF UGANDA’S HEALTH SECTOR 1889-TODATE Achievements and setbacks By Moses Sserwanga The health sector is primarily composed of institutions and resourcesdevoted to the healthcare of the people which include among others provision of safe water, sanitation, adequate food and diet, medical care and access to hospitals and drugs and protection of the environment. It’s important to note that while the period 1986 – 2013 has witnessed fundamental reforms and innovations in the health sector,the period 1889 – 1962 was characterized by the establishment of modern healthcare facilities under the British colonial rule; 1962 – 1970 was post-independence period which saw the consolidation and expansion of healthcare infrastructure and improvement to cater for a growing population, while the 1971 – 1986 period was a bloody scene of civil conflict, mismanagement and destruction of the state infrastructure and the health sector was not spared either . From 1986 to-date there has been marked economic, health sector reforms and innovations to mitigate the anarchy and destruction witnessed as a result of armed rebellions. It’s only recent that peace has been restored to western Uganda following the bloody rebellion of the Allied Democratic Forces (ADF); armed cattle rustling in Teso / Karamoja and Jospeh Kony’s two decades of brutality in northern Uganda. A Historical Health Sector Analysis 1889-1962 Advancedmedical care was first introduced in Uganda in 1889 by the Imperial British East Africa Company (IBEAC), a trading company. The IBEAC brought doctors and nurses to look after its own staff and not for the native population. But owing to successive epidemics of plague, syphilis, sleeping sickness and small-pox, IBEAC was forced to extend medical services to native Africans. These services were eventually taken over by the colonial government. It was the missionaries who started medical services devoted to Africans. Dr Albert Cook opened the first hospital at Mengo in 1897. By 1909, three health centres had been established at Mulago, Mityana and Masaka, devoted to the treatment of venereal diseases (VD), a new epidemic brought to Uganda by Europeans and Indians. Mulago became a hospital for treatment of VDs in 1913, and later a general hospital in 1923. More hospitals and dispensaries were established in provincial and district headquarters throughout Uganda. By 1961, 27 hospitals had been established with over 100 outlying health centres and staffstrength of 1,288 for a population of seven million. Basking in the independence glory 1962-1970 After independence in 1962, twenty-two new hospitals were built bringing the total number in the country to 49 by 1970. The period saw the development of one of the most outstanding networks of health services on the continent. It consisted of hospitals, health centres, a medical school for training doctors, and training schools for nursing, medical assistants and health inspectors. The network of health facilities supported by roads and railways, plus public health nurses and health inspectors ensured easy access to healthcare and improved nutrition, food security, and hygiene. Infant mortality rate (IMR), which is a general indicator of health status of a population, declined from about 350 to 120 per 1000 live births between 1900 and 1970. A period marked with total destruction of health infrastructure 1971 – 1985 After the 1971 military coup which led to political upheavals culminating in three decades of devastating civil wars,the country lost many trained personnel who left the country for personal safety abroad , witnessed decline in economic activity that characterized rising inflation, mismanagement, neglect, and wanton destruction of physical health infrastructure that reduced the hitherto excellent health services to an appalling state by 1975. Public outcry about the deterioration of health services led Idi Amin’s government to institute a commission of inquiry in 1977. But the commission’s recommendations were never implemented. In the meantime, NGOs and church missions continued to increase the intensity and scope of their services, contributing up to 40% of the national health services. The private sector, which was small in 1960s, increased rapidly in response to the gaps left by the deteriorating public health services. The breakdown of law and order, however, made it impossible to enforce statutory controls over private practice. This led to an explosion of illegal private clinics with indiscriminate peddling of drugs by quack medical workers. The painful reforms that turned around an ailing health sector: 1986-2013 When the National Resistance Movement (NRM) assumed power in 1986, it inherited a broken down health system. The new government put in place a Health Policy Review Commission in 1987. The commission came up with a two-pronged strategy: rehabilitation of existing health infrastructure and development of primary Healthcare services. Based on this report, the Ministry of Health prepared a ten-year National Health Plan 1990-2000 outlining 8 critical areas to be addressed namely : recommit to Primary Healthcare; promote community participation through health committees; decentralise health care; promote inter-sectoral collaboration and coordination between ministries, NGOs and donors; promote private practice and its regulation and control; integrate traditional medicine into the national health system; reorganise the health system into first, secondary, tertiary and apex levels; promote alternative methods of financing health starting with user-fees and community financing, and later explore the feasibility for health insurance. Innovations reversed by donor interventions Following the prouncement of the new government’s interventions to revap a sick health sector the donor community expressed concern that that the health budget far exceeded available resources . Donors argued that a much smaller “minimal package of services”should be the basis of the national health plan. The World Bank andother donors thusincreased their involvement in the redefinition of Uganda health sector priorities and in 1992; a three-year plan 1992 -1995 was developed. This health sector framework came up with five policy recommendations which included interalia: • No further expansion of health care infrastructure • Restore the functioning of existing health facilities • Reorient the health system to Primary Healthcare • Use a basic health care package approach based on needs and available resources; and promote user-fees as a way of health financing Around the same time $110m grant was extended to the government of Uganda to deal with the HIV/Aids pandemic (1988 to 2002) to promote awareness, the ABC strategy (Abstain, Be faithful and use Condom) of reducing HIV transmission, and to mitigate social and economic impact of AIDS. The same resources were applied to make anti-retroviral treatment to take off. Under the health system, a few selected hospitals and health centres were renovated but not enough to improve the overall health care. Therefore another loan of $75m was subsequently secured in 1995 to reform the health system. Another reform was decentralisation of health servicesto encourage community participation, promote local self-reliance and accountability, overcome administrative obstacles, and promote coordination. But this reform had down side to it, decentralised administrative units began to be created as rewards for political loyalty and not because they were rationally assessed to be viable for effective health service delivery. The health functions of districts and sub-county local governments far outstripped available resources at their disposal. Health statutory bodies born Several other reforms were undertaken and these saw the establishment of the National Medical Stores (NMS) and National Drug Authority (NDA). While the NDA was created to ensure good quality of medicines and promote rational drug use based on an essential drug list, the NMS was created to procure, store and distribute essential drugs to public sector health facilities. Public-private-partnership (PPP) is one of the recent reforms to be introduced. Based on the belief that the private sector is inherently efficient, and the public sector cannot provide all the services people need, a partnership between the two was to be established and promoted. However, although the policy is not yet fully approved, its implementation has been in progress for at least 15 years with the partnership between the government and missionary health services. The latest reform, since 2005, has been to bring in the for-profit private sector on board. Indeed, small scale partnerships with the private sector have been ongoing. But as yet there are no concrete benefits of such partnerships. The Sector-wide approach (SWAP)SWAP has also since been adopted to address the multiplicity of actors and funding channels in the health sector. It was defined as a partnership among donors, the government and other stakeholders for “a negotiated programme of work”. In Uganda, Swap started in 1999, and by 2005 funding in the health sector had increased substantially. Under the SWAParrangement, achievements were made in national programmes such as immunisation, HIV/AIDS, TB management. Writer is a communications, media and legal consultant msserwanga@gmail.com