By Odongo Lango
Kampala—27, May 2020: In 2006, Professor Omaswa, a highly respected former Director General for Health Services, became famous for his “Health is made at home” radio jingles. In a seminal paper about sector-wide health services delivery system, he noted that:
“… for historical reasons and because of weaknesses in national policies and structures, development assistance had been largely organised through stand-alone projects. This modality of aid delivery was seen as an essential approach to allow flexibility to manoeuvre, quick response, and demonstrable results in key priority health concerns. However, project-based support has been criticised for causing fragmentation of the health system into several subsystems with differing capacities, delivering different health interventions to different beneficiaries.”
The current COVID-19 pandemic has exposed the weakness of the vertical programming that Professor Omaswa warned against. The pandemic has not only caused some tropical diseases to be neglected, but the whole system strengthening approach that was emblematic of the Uganda health system, has been thrown into the dustbin.
There is imminent danger in taking this route. During the recent Ebola outbreak in Eastern Democratic Republic of the Congo [DRC], for example, Medecins Sans Frontieres [MSF] International sent a team to tackle the outbreak. The population attacked and dismantled the Ebola treatment camp. It baffled the bosses of MSF. So they contracted a medical anthropologist to find out the root cause of the community hostility.
After weeks of investigations, the anthropologist one day met with an old woman and asked about MSF. She replied, “These are profiteers. Measles and malaria killed so many of my grandchildren. They were nowhere to be seen. Now, they have seen Ebola as a way of milking money!”
This was illuminating. Another system wide intervention was then designed. MSF opened clinics attending to diarrhoea, malaria, vaccinating children, providing antenatal care, to mention but four key services. It was only after they did this that the community started cooperating with the Ebola Response Team [ERT].
What this means is that responses to emergencies must be designed in a broader context of needs and evaluated on a wider range of wellness indicators. Often, communities know better what their most pressing needs are. Even in the face of a pandemic like COVID-19, perennial concerns like malaria, diarrhoea, pneumonia, anaemia, maternal mortality, remain the major causes of death and grief.
Efforts to tackle these ailments must run concurrently with the campaign against COVID-19. No Ugandan may have seen a person suffering and dying from COVID-19, and the danger remains abstract and less terrifying than malaria, diarrhoea, or HIV/AIDS.
In the face of epidemics and pandemics, we must ensure that comprehensive health care services delivery continues; we don’t focus on a single disease; and we don’t neglect the known major killers in Uganda. If we were to track Malaria cases and deaths in Uganda as meticulously as we are doing with COVID-19, we would find that it is probably the biggest cause of hospitalizations and deaths in the country.
We cannot, as a country, afford to reverse the gains we have registered simply because we must divert resources to fight COVID-19, a disease with a very low fatality rate. Experiences from Sweden and Tanzania suggest that countries that shut down completely may have overreacted.
Fourteen years ago, Professor Omaswa and his colleagues concluded that “the introduction of the sector-wide approach (SWAP) in Uganda has been motivated by concerns for government leadership, efficiency, and equity to improve sector performance by coordinating development assistance and thereby reducing administrative costs for government”.
These are insights that the crop of leaders at the Ministry of Health would do well to notice, that when you strengthen the whole health system — rather than taking a vertical, disease specific intervention — the greatest number of people in the country benefit from a limited amount of resources.
The author is a Public Health specialist with an interest in Health System Strengthening. He hails from Minakulu sub-county Oyam district.