On Saturday, November 22nd, 2014 around 4:00 pm Kampala time, nearly 100 people who are passionate about global health met at Fairway hotel, Kampala to celebrate Global Health Corps’ (GHC) fifth birth day. This was one of a series of events, commemorating GHC’s fifth year of existence, which began on November 16th – in the USA, Zambia, Rwanda, Malawi, Burundi, and ending in Uganda.

Unlike other common birthday parties, this was exceptional, in the sense that emerging leaders who share a common goal but with “uncommon roles” gathered not only to celebrate the birth of the organization that is nurturing them to leverage their potential but also to share insights on how to confront global health challenges. At the party in Uganda, a number of exciting, yet inspiring speeches – from the current GHC fellows to the United States Ambassador to Uganda, Mr. Scott H. Delisi – were made. I must say, however, that all these speeches had one common denominator: that exclusion and disparities in health sector around the world in general and Uganda in particular are, in every sense of the word, unacceptable.

Granted, inequalities in global health are unacceptable! However, as I heeded to these speeches and shared ideas with friends; I, rather, contemplated on a different question: what can be done to make Uganda’s health outcomes desirable?

Uganda’s Health sector disparities in numbers

Needless to say, Uganda has had its own share of health inequalities: the maternal mortality ratio has almost remained stagnant since 2000 – currently at 438 per 100,000 live births, too high above the Millennium Development Goals (MDGs) target of 131 per 100,000 live births by 2015; HIV/AIDS prevalence increased from 6. 7 percent in 2006 to 7.3 percent in 2011; and access to reproductive health services is at trial. These statistics are just the tip of an iceberg; by and large, Uganda’s health challenges are really much greater than this.

Due to inequalities in Uganda’s socio-economic structures, there is a section of people that is even more susceptible and therefore bears a disproportionate burden of disease. For instance, HIV/AIDS prevalence among the fisher folks is at 22 percent, 33 percent among female sex workers, and their partners at 18 percent. Malnutrition, too, remains Uganda’s health challenge and costs the country over 5 percent of her GDP, every year. In Kisoro – my home district, for example, more than 51 percent of children below 5 years are stunted. It is to be seen that, failure to intervene in timely manner, will render a significant portion of the next generation of young people in Kisoro unproductive (God forbid), given the consequences of malnutrition.

The neglected challenge

While the Government of Uganda and donors such as USAID have committed significant amount of financial resources in Uganda’s health sector, health outcomes are, by far, incommensurate to this unwavering expenditure.

What has led to this discrepancy, however, remains a more complex yet decipherable syndrome that more often than not attracts less attention. This syndrome is the lack of inclusive institutions and poor accountability relationships that define Uganda’s health sector.

In early 1990s the government of Uganda adopted a decentralized system of government where planning, expenditure and monitoring in health sector was delegated to the district local governments, but, in my view, this has neither abolished social exclusion nor instituted inclusiveness, fully.

Decentralization as a “supply-driven” approach to public accountability has been met with limited success, and at worst, remained a mere work on paper. Thus, it suffices to say that ordinary peoples’ participation in designing, monitoring and evaluation of health interventions is not, ideally, vigorous leading to a mismatch between planned health care interventions and actual community health care needs. This, I must say, is the breeding ground for Uganda’s health challenge. And, incidentally, it cuts across in all public sectors.

Ordinary people who are disproportionately affected by the disease burden do not “own” the health care system. There are no demand-driven accountability mechanisms that would, essentially, allow these vulnerable people to participate meaningful in health planning and budgeting. In such scenario, regardless of the amount of financial resources invested, health outcomes remain detrimental.

Make no mistake! Lack of people “ownership” of the health system neutralizes peoples’ demand for health services. And, this illustrates, partly, why, in many Ugandan communities, health seeking behavior is poor.

Access to information and budget advocacy skills matter

At the risk of knowing that I am not proposing anything new, I will go ahead to say that Uganda’s health statistics will read better if, and only if, health sector institutions are more inclusive, cohesive and accountable to all Ugandans, particularly the poor and vulnerable women and men. Ordinary and vulnerable communities should take a center-stage in Uganda’s health care systems –from health policy designs to monitoring and evaluation of health care packages, at all levels.

But this participation will only be possible where there is access to health budget and expenditure information. Then, these ordinary people must have the minimum health budget advocacy skills to participate, meaningfully, in health sector planning and budgeting. And if such participatory budgeting is institutionalized, then health interventions will be more rationalized, prioritized, and equitable and at the same time accessible to all.

Conventional wisdom suggests that participation shifts health systems “ownership” from the hands of health care providers to those of the ordinary people – the health care recipients. This does not only build trust but also strengthens accountability relationships among government institutions, health care providers and care recipients – ultimately leading to better health outcomes, good governance and empowerment.

 Everyone’s duty

“The only thing necessary for the triumph [of evil] is for good men to do nothing,” said Edmund Burke, an English philosopher. That GHC nurtures a critical mass of emerging leaders capable of eliminating inequalities in global health creates a window of opportunity for young people like me to contribute, meaningfully, towards achieving health equity in their communities.

However, given the complexity of health challenges and the interconnectedness of the social economic determinants of health, I can only say that no single intervention can address Uganda’s health challenges. It will take concerted efforts, combination of interventions – and more or less a holistic approach with high precision – to improve Uganda’s health indicators. Nevertheless, people must remain at the heart of these interventions, if desirable health outcomes are to be seen.

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