By Suzanne Kiwanuka
Almost three centuries ago, Benjamin Franklin said, an ounce of prevention is worth a pound of cure. This makes even more sense today as we embark on Universal Health Coverage where cost-effective interventions and strategies are the best buys for a low income country like Uganda. After all, why spend more for less when you can spend less for more? And why does the average African government continue to spend the bulk of its resources treating the sick, while battling a mostly preventable disease burden?
In Uganda crowd funding for overseas care has increasingly become a popular but alarming solution to the flaws in our health care system. Again one wonders why it is acceptable to ship patients (money) abroad for treatment, while our own system ails? At the global level, the failure to attain set targets is addressed by renaming and setting even more ambiguous targets. Challenges in the public sector have pushed people from the formal providers of health care to the even more costly private and informal sectors. Can we honestly continue doing things the way we have always done them but have the optimism to expect different results?
Dr. Margaret Mungherera (former President of the World Medical Association), once said that; “to achieve our health sector targets in Uganda, a paradigm shift is what we need.” This shift requires a radical change from investing in treating disease to investing more in preventing it. Disease prevention encompasses all efforts to anticipate the causes of disease and its progression to clinical manifestations. Although disease prevention has always been a central tenet of the health care reform in Uganda, most efforts to expand prevention have been continuously thwarted by a system biased towards treating disease. Since the colonial days the health system has prioritized treating the sick thereby marginalizing illness prevention and the wellbeing of the public. Moreover, this medical model is characterized by high costs of technology (equipment, drugs and supplies) and economic interests. This paradigm shift needs to overcome these obstacles by changing approaches to medical education, re-organising service delivery. But how can we do this?
Hippocrates said, “the greatest medicine of all is to teach people how NOT to need it”. Medical schools need to emphasize prevention strategies alongside treatment approaches, and educate communities with a focus on lifestyle modification in addition to prescribing medications to the sick. Medical school curricula should emphasize health, in addition to disease and diagnosis, provide training in the science and practice of cost-effective health promotion. Incentives should be provided for medical schools to provide more training in community settings to emphasize health-enhancing behaviors, and not in hospitals – filled with the sick and dying. We have to educate our communities on the many factors that generate health and well-being. Tackling the causes of ill-health including poverty, sanitation, malnutrition, lack of education and poor environment will require a well- coordinated multi-disciplinary team approach, a “health in all policies” approach.
More investments need to target activities for promoting health and wellbeing. The US and several European countries already have bike-to-work schemes, with incentives such as tax breaks and financial support for buying bicycles. As people exercise by biking-to-work, health care costs go down, quality of life improves, and they are generally more productive. In Uganda, one could get arrested for “walking to work” and this would actually be a considerate action compared to the hazards one faces as a pedestrian, with limited provisions for walking, compounded by errant boda-boda riders.
Attaining the ambitious goal of universal health coverage will require equally ambitious reordering of our investment priorities. Admittedly the need for medical care will remain, but focusing our meager resources on prevention is the best way to contend with the infectious disease burden while forestalling the emerging pandemic of chronic disease. Ultimately, embedding prevention in the national development plans, training of health workers, organization of social systems like roads, and the delivery of health care will stem the economic burden of treating the illnesses of an ever-increasing population.
Dr. Suzanne Kiwanuka is Senior Lecturer in health policy at Makerere University School of Public Health and Co-Principal Investigator for the SPEED Project