Uganda attempts to treat the malignant disease of inequality

Daudi Luganga Musisi can hardly remember when his family last had breakfast. “We care more about lunch and supper,” says the father of six. “Having breakfast means we won’t have enough money for lunch and supper.”

Musisi, 52, lives in Kibbe zone, a sprawling slum in the Kalerwe suburb in Uganda’s capital, Kampala. His home, which he rents for 60 000 shillings (about $17,83) a month, squats beside pools of stagnant rainwater – a world away from the well-watered, emerald-green lawns of the upmarket suburb of Kololo, just across town. Stones hold down the corrugated roof, and the walls are cracked. A sack of sand sits in the doorway to keep any running water out.

Like tens of thousands of others in Kampala, Musisi, a casual worker, has not benefited from Uganda’s steady economic growth, which has averaged above 6% since 2002 (pdf). He has no piped water, or sanitation. His family share a pit latrine with five other households.

Across Uganda, at least 13.8 million people (pdf) use unsanitary or shared latrines. More than 3.2 million people have no toilet at all. Open defecation contaminates drinking water sources and can spread cholera, diarrhoea, dysentery and typhoid. Those living in rural areas are most at risk – eight out of 10 people in villages live without improved drinking water sources.

For Musisi, poor sanitation has a real, and costly, impact on his life. Every month, he spends 80 000 shillings ($23,77) on medicines, which sometimes pushes him into debt – his average monthly income is 120 000 shillings ($35,66).

“Every month, we have a [family] member who has malaria or another infection. That’s what disturbs us here.”

Impoverished by out-of-pocket expenses
Nearly 23% of households spend more than 10% of their total household income on healthcare. About 4.3% of Ugandans are impoverished annually due to out-of-pocket health payments.

Parliament is due to debate a bill to pave the way for legislation to introduce national social health insurance , as a first step towards universal healthcare. The bill has been around since 2007 but has been held up by disagreements between government and employers on how to fund it. Fewer than 1% of Ugandans (pdf) have insurance cover.

Achieving universal healthcare is a specific target in the sustainable development goals , a blueprint for development for the next 15 years that was adopted by United Nations member states in September. However, for millions of people like Musisi, economic and social inequalities are fundamental threats to health that must be tackled as well.

Michael Marmot, director of the Institute of Health Equity at University College London and winner of the Prince Mahidol award in public health last year, researches social and economic disadvantages and how they create health inequalities between and within countries.

He says: “Inequality brings with it other social evils like ill health and crime. It damages health. Absolute inequality means disempowerment of a severe kind and not being able to afford food and shelter. Our response to this inequality in health is working towards universal health coverage.

“Why treat people and send them back to the same conditions that made them sick? We need action on the social determinants of ill health.”

Healthcare essential for development 
Last September, 267 leading economists signed a declaration calling for universal healthcare as an essential pillar of development.

For Marmot, this is just one part of the puzzle. Conditions for good health must also exist at home. “Increasingly, the lower you are in the social hierarchy, the [more the] health of the poor suffers,” he says.

His words find a ready echo among some health professionals in Uganda.

“Addressing conditions at home is the way to go,” says Julius Bamwine, health officer for the western district of Ibanda. “We still need [working] health facilities. But a sizeable public budget should go into prevention. People must know that drinking contaminated water makes them sick.”

Robinah Kaitiritimba, director of the Uganda National Health Consumers’ Organisation, says primary healthcare should be the main focus.

“Even when we don’t have a lot of money, we can use information [and] education to tell people how to avoid some diseases. Prevention is the best and cheapest,” she says. “At least 70% of hospital admissions in Uganda are related to malaria but if people slept under treated mosquito nets, these would be drastically cut.”

Others argue that a functioning, affordable health system is just as crucial as improving conditions at home.

For Musisi, improving living conditions is a critical first step. “If government can help us and build for us better houses, it would be the start of a new life for me. You can see the life we live here.” – The Guardian