Learning from failed health reform in Uganda
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《英国医生杂志》
1 National Council for Children, PO Box 21456, Kampala, Uganda sokuonzi@infocom.co.ug
Evaluation of health care in developing countries from a Western perspective is masking the failures of market based reforms
Introduction
User fees were introduced as one of the key methods to finance the health reforms. The first formal attempt to introduce user fees failed in 1990, which led to fees being charged illegally on an ad hoc basis by health workers. In 1993, user fees were universally introduced as a condition for getting a World Bank loan.
User fees were expected to generate resources, promote efficient use of these resources, and improve the quality and equity of health services. Unfortunately, this did not materialise. The funds generated were typically less than 5% of total expenditure for most hospitals and health districts and they had little or no effect on the quality or efficiency of services. Furthermore, their introduction was associated with a dramatic drop in take up of health services.5 User fees were abolished in 2001, largely in response to the findings of the World Bank's first Participatory Poverty Assessment Report (1999), which sparked an outcry about lack of access to health care and deteriorating standards of care.6 A definitive study that proved fees had not achieved their aim was published in 2004.7
The government set an unrealistically low ceiling on health and social welfare expenditure. For example, a realistic annual budget for a large teaching hospital in 1996 was 30bn shillings (￡10m, $17m, 13m) but the ceiling was set at 12.26bn in 1996, 8.87bn in 1997, and 13.28bn in 1999. Given the rise in inflation over this time, expenditure on health services (particularly on hospitals) was effectively held constant8 and yet the population was growing at a rate of 3% a year.8
Introducing "user fees" in Uganda adversely affected uptake of health services
Credit: SEAN SPRAGUE/PANOS
Effect of the reforms
The World Bank and other institutions that advocate market style healthcare reforms typically emphasise the success of the organisational change and understate their adverse effects on health and social welfare. For example, increasing global life expectancy is cited as evidence of improved global health and welfare.14 15 Poverty, it is claimed, has been reducing, and inequity does not exist (if equity is the same as equal opportunity).15 16 When inequity is acknowledged, it is portrayed as necessary for economic growth and social mobility.17
In Uganda, both the justification for, and the effect of, market based health reform has been questionable. Poverty, which should include lack of access to basic social services, has become synonymous with income poverty, which is said to have reduced.11 Yet access to basic health care and the quality of services have largely remained low or even worsened (table 1).
Ministry staff and expatriate technical advisers have cited the reduced prevalence of HIV and AIDS (from 30% in 1990s to 4.1% 2004)18 and the increased use of outpatient services as evidence for the effectiveness of health sector reforms. Yet the reduction in HIV and AIDS was due to a political strategy of openness and massive public education; it had little to do with health sector reforms. The doubling of outpatient attendance was due to the abolition of user fees not their inception.
Increasingly, donor governments in the West demand to see clear benefits from the external aid they provide. To meet this demand technical advisers now use short term surrogate output indicators such as the number of health related radio messages broadcast, the number of health workers trained, the level of the budget funded, and the availability of district health plans. This effectively hides the reality of massive failures in health and social welfare.
Some would like to blame the poor health and social welfare status of the majority of the population in Uganda on AIDS and the war. But arguably these cannot account for the evident failure of individual health reform strategies. Besides, the effect of AIDS on infant mortality is not significant.19 Furthermore, other countries that are also experiencing a protracted civil war, such as Sri Lanka, have maintained good social welfare through a non-market based health system.20
What can be learnt from the market reform experience?
World Bank. World development report: investing in health. Oxford: Oxford University Press, 1993.
World Bank. Staff appraisal report: district health services pilot and demonstration project. Washington, DC: World Bank, 1994.
Government of Uganda. Status of emergency obstetric care (EMOC) in Uganda. A national needs assessment of EMOC indicators. Kampala: Ministry of Health, 2003.
Okuonzi SA, Birungi H. Are lessons from the education sector applicable to health sector reforms? The case of Uganda. Int Health Planning Manage 2000;15: 201-19.
Government of Uganda. Mid-term review report of the health sector strategic plan. Kampala: Ministry of Health, 2003.
Kiyonga C. Policy statement: abolition of user-charges and introduction of a dual system. Uganda Health Bull 2001;7:No 2.
Deininger K, Mpuga P. Economic and welfare impact of the abolition of health user fees: evidence from Uganda. Washington, DC: World Bank, 2004.
Brownbridge M. Financing the millennium development goals: is more public spending the best way to meet poverty reduction targets? Health Policy Dev 2004;2:40-7. http://bij.hosting.kun.nl/umu/faculty/bam/dhs/healthpolicy/vol2.html
Uganda Bureau of Statistics, Macro International. Uganda demographic and health survey 2000-2001. Claverton, MD: UBOS, ORC Macro, 2001.
Government of Uganda. Poverty eradication action plan: draft. Kampala: Ministry of Finance, Planning and Economic Development, 2004.
Government of Uganda. Background to the budget for financial year 2004/2005. Kampala: Ministry of Finance, Planning and Economic Development, 2004.
Ocom F. Quality of care in Mukono district—Uganda . Kampala: Makerere University, 1997.
Jitta J. Quality of care in Uganda health services in health care systems in Africa. Copenhagen: University of Copenhagen, Enreca Health Network, 1998: 35-47.
Chen S, Ravalllion M. How have the poorest fared since the early 1980s? Washington DC: World Bank, 2004.
Ravallion M. Competing concepts of inequity in the globalization debate. Washington DC: World Bank, 2004.
Lindelow M. Sometimes more equal than others: How health inequalities depend on the choice of welfare indicators. Washington, DC: World Bank, Centre for Study of African Economies, Oxford University, 2004.
Stigliz J. Globalization and its discontents. London: Penguin Books, 2002.
Government of Uganda. Uganda national HIV and AIDS policy: draft. Kampala: Uganda AIDS Commission, 2004.
Adetunji J. Trends in child mortality rates and the HIV/AIDS epidemic. Bull World Health Organ 2000;78: 1002-6.
Abel-Smith B. An introduction to health: policy, planning and financing. London: Longman, 1994.(Sam Agatre Okuonzi, secre)
Evaluation of health care in developing countries from a Western perspective is masking the failures of market based reforms
Introduction
User fees were introduced as one of the key methods to finance the health reforms. The first formal attempt to introduce user fees failed in 1990, which led to fees being charged illegally on an ad hoc basis by health workers. In 1993, user fees were universally introduced as a condition for getting a World Bank loan.
User fees were expected to generate resources, promote efficient use of these resources, and improve the quality and equity of health services. Unfortunately, this did not materialise. The funds generated were typically less than 5% of total expenditure for most hospitals and health districts and they had little or no effect on the quality or efficiency of services. Furthermore, their introduction was associated with a dramatic drop in take up of health services.5 User fees were abolished in 2001, largely in response to the findings of the World Bank's first Participatory Poverty Assessment Report (1999), which sparked an outcry about lack of access to health care and deteriorating standards of care.6 A definitive study that proved fees had not achieved their aim was published in 2004.7
The government set an unrealistically low ceiling on health and social welfare expenditure. For example, a realistic annual budget for a large teaching hospital in 1996 was 30bn shillings (￡10m, $17m, 13m) but the ceiling was set at 12.26bn in 1996, 8.87bn in 1997, and 13.28bn in 1999. Given the rise in inflation over this time, expenditure on health services (particularly on hospitals) was effectively held constant8 and yet the population was growing at a rate of 3% a year.8
Introducing "user fees" in Uganda adversely affected uptake of health services
Credit: SEAN SPRAGUE/PANOS
Effect of the reforms
The World Bank and other institutions that advocate market style healthcare reforms typically emphasise the success of the organisational change and understate their adverse effects on health and social welfare. For example, increasing global life expectancy is cited as evidence of improved global health and welfare.14 15 Poverty, it is claimed, has been reducing, and inequity does not exist (if equity is the same as equal opportunity).15 16 When inequity is acknowledged, it is portrayed as necessary for economic growth and social mobility.17
In Uganda, both the justification for, and the effect of, market based health reform has been questionable. Poverty, which should include lack of access to basic social services, has become synonymous with income poverty, which is said to have reduced.11 Yet access to basic health care and the quality of services have largely remained low or even worsened (table 1).
Ministry staff and expatriate technical advisers have cited the reduced prevalence of HIV and AIDS (from 30% in 1990s to 4.1% 2004)18 and the increased use of outpatient services as evidence for the effectiveness of health sector reforms. Yet the reduction in HIV and AIDS was due to a political strategy of openness and massive public education; it had little to do with health sector reforms. The doubling of outpatient attendance was due to the abolition of user fees not their inception.
Increasingly, donor governments in the West demand to see clear benefits from the external aid they provide. To meet this demand technical advisers now use short term surrogate output indicators such as the number of health related radio messages broadcast, the number of health workers trained, the level of the budget funded, and the availability of district health plans. This effectively hides the reality of massive failures in health and social welfare.
Some would like to blame the poor health and social welfare status of the majority of the population in Uganda on AIDS and the war. But arguably these cannot account for the evident failure of individual health reform strategies. Besides, the effect of AIDS on infant mortality is not significant.19 Furthermore, other countries that are also experiencing a protracted civil war, such as Sri Lanka, have maintained good social welfare through a non-market based health system.20
What can be learnt from the market reform experience?
World Bank. World development report: investing in health. Oxford: Oxford University Press, 1993.
World Bank. Staff appraisal report: district health services pilot and demonstration project. Washington, DC: World Bank, 1994.
Government of Uganda. Status of emergency obstetric care (EMOC) in Uganda. A national needs assessment of EMOC indicators. Kampala: Ministry of Health, 2003.
Okuonzi SA, Birungi H. Are lessons from the education sector applicable to health sector reforms? The case of Uganda. Int Health Planning Manage 2000;15: 201-19.
Government of Uganda. Mid-term review report of the health sector strategic plan. Kampala: Ministry of Health, 2003.
Kiyonga C. Policy statement: abolition of user-charges and introduction of a dual system. Uganda Health Bull 2001;7:No 2.
Deininger K, Mpuga P. Economic and welfare impact of the abolition of health user fees: evidence from Uganda. Washington, DC: World Bank, 2004.
Brownbridge M. Financing the millennium development goals: is more public spending the best way to meet poverty reduction targets? Health Policy Dev 2004;2:40-7. http://bij.hosting.kun.nl/umu/faculty/bam/dhs/healthpolicy/vol2.html
Uganda Bureau of Statistics, Macro International. Uganda demographic and health survey 2000-2001. Claverton, MD: UBOS, ORC Macro, 2001.
Government of Uganda. Poverty eradication action plan: draft. Kampala: Ministry of Finance, Planning and Economic Development, 2004.
Government of Uganda. Background to the budget for financial year 2004/2005. Kampala: Ministry of Finance, Planning and Economic Development, 2004.
Ocom F. Quality of care in Mukono district—Uganda . Kampala: Makerere University, 1997.
Jitta J. Quality of care in Uganda health services in health care systems in Africa. Copenhagen: University of Copenhagen, Enreca Health Network, 1998: 35-47.
Chen S, Ravalllion M. How have the poorest fared since the early 1980s? Washington DC: World Bank, 2004.
Ravallion M. Competing concepts of inequity in the globalization debate. Washington DC: World Bank, 2004.
Lindelow M. Sometimes more equal than others: How health inequalities depend on the choice of welfare indicators. Washington, DC: World Bank, Centre for Study of African Economies, Oxford University, 2004.
Stigliz J. Globalization and its discontents. London: Penguin Books, 2002.
Government of Uganda. Uganda national HIV and AIDS policy: draft. Kampala: Uganda AIDS Commission, 2004.
Adetunji J. Trends in child mortality rates and the HIV/AIDS epidemic. Bull World Health Organ 2000;78: 1002-6.
Abel-Smith B. An introduction to health: policy, planning and financing. London: Longman, 1994.(Sam Agatre Okuonzi, secre)