Leadership, Health & Justice (1st Dr. Margaret Mungherera Memorial Lecture 2017)
Delivered at the 2nd Grande Doctors Conference Uganda Medical Association Annual
Hotel Africana, Kampala Uganda
7th September 2017
Guest of Honour, Dr. Jane Aceng, Minister of Health, Uganda
Dr. Fred Bisso, President UMA
Distinguished colleagues, Ladies and gentlemen
It’s an honour not only for me but for Africa’s oldest and biggest International Health NGO to be invited to give this 1st Dr. Margaret Mungherera memorial lecture to honour one of us who believed in Lasting Health Change in Africa as much we do.
Amref works in over 35 countries in Africa delivering programs, research and advocacy for strengthening of health systems but more so linking communities with the health system and we are strong advocates for a bottom up health system staring from a formalized community health strategy all the way to a well distributed and staffed secondary and tertiary infrastructure with strong referral systems, good leadership, management and governance.
In Uganda specifically, we have projects across the country and in many rural areas working closely with the Ministry of Health and other partners and Amref is a household home.
Let me start with this simple poem written in 1932 by Mary Frye. Its origins and history is controversial and so was Margaret — it’s paraphrased without permission:
Do not stand at my grave and weep,
I am not there — I do not sleep.
I am the thousand winds that blow across the hills in Uganda,
I am the diamond shimmers on Lake Victoria,
I am the sunlight on ripened matooke,
I am the gentle morning rain.
As you awake with morning’s quiet
I am the quiet motion of birds in circling flight.
Do not stand at my grave and cry,
I am not there — I did not die.
I accepted the invitation to deliver this First Margaret Mungherera Memorial Lecture with enthusiastic humility but also eternal hope.
Just as Mary Frye who captured eternity in this beautiful poetry, I am one of those people who believes that great women and men don’t die.
They transition to a new form and leave behind their spirit and energy amongst us.
Margaret, as I usually called her because no school could teach me enough to pronounce her second name, is one of those people.
On February 4th 2017, on World Cancer Day, Margaret took the ultimate sacrifice through cancer; not in submission but in defiance!
Her first Memorial Lecture provides an excellent opportunity for us to celebrate her life of achievement through service and to declare our eternal gratitude to her and our enduring respect.
Secondly, it’s a time to revisit the ‘Margaret who never died’ and on whose grave we won’t weep.
Margaret dedicated her life to the provision of quality healthcare, not for her patients alone but as a global advocate for justice to patients and the health workers who take care of them.
From a small village in Jinja, she rose to be the First African woman President of the World Medical Association. Having led Uganda Medical Association for 7 terms, started the UMA SACCO and becoming the first woman vice-chair of the Uganda Medical and Dental Practitioners Council, she IS a ceiling breaker.
When I was requested to come and speak, the topic was simply ‘LEADERSHIP IN HEALTH’. But in the process of critiquing my thoughts, I asked myself what Leadership is. I concluded that you can actually look at leadership from 2 sides. One, the process of leadership which is what we are always fascinated about. Who is a good leader? What qualities does a good leader have? What does a good leader do? Is a leader born or made?
But if we look critically at Leadership, and we define it as the process of rallying people around a common vision and eliciting the passion to achieve that vision, then our view of Leadership changes.
It changes to the result rather than the process. It changes to the vision and its clarity and achievement!
On reviewing Margaret’s work locally and internationally, her vision in her leadership, in my opinion, was Justice.
It was the ‘just’ treatment of all in the quest to accessing quality healthcare.
It was the ‘just’ allocation of resources.
It was the ‘just’ distribution of health workers
It was the ‘just’ remuneration of health workers
So in honour of her work, I chose a topic to which not much has been spoken or written.
Health and justice.
What is the relationship between health and justice? Can we achieve access to quality health for all in an unjust society? How closely is justice associated with poverty? And how closely is poverty associated with health?
Is poverty really the opposite of wealth or the absence of justice?
Although it seemed an important issue to me framed in the work and life of Margaret, very few attempts have been made to ask the question or to analyze the issues involved.
This conspiracy of silence in the literature should have warned me that I may be treading on dangerous ground. Maybe good sense should have guided me to beat a hasty retreat and to steer me in the direction of more popular subjects like mental health, which was Margaret’s technical passion or maternal mortality which was the entry point for the famous and yet to be accomplished ‘Mungherera petition’ or even adequate remuneration of health workers, for which she was a great advocate and determined fighter.
However, with stubbornness bordering on stupidity, I have persisted with my choice in the hope that even if I cannot produce appropriate answers, I can at least raise some relevant questions because in my mind, what tied all the issues Margaret fought for locally and internationally, was the presence or absence of Justice.
1. What kept mental health patients unattended and loudly referred to in our markets as ‘mad men and women, is absence of justice.
2. What results in premature death of mothers and children and especially newborns is absence of justice
3. What results in an underfunded health sector with underpaid and inadequate health workers is absence of justice.
The Mungherera petition was not and is not about death of mothers and children. It is about justice for the Ugandan people. It is about achievement of access to quality health for all now under the banner of Universal Health Coverage.
It is about health as a human right and the burden lies with the duty bearer; the policy makers and the legislators!
The WHO Constitution enshrines “…the highest attainable standard of health as a fundamental right of every human being.” This includes access to timely, acceptable, and affordable health care of appropriate quality. It’s a fundamental right.
Yet, more than 150 people will die today in Uganda from only the Top 10 killer diseases and 80% of them because of preventable communicable diseases like HIV/AIDS, Malaria, respiratory infections e.t.c….not because of old age! 5 out of 10 of these will be children under 5.
And this largely in vulnerable and marginalized groups which tend to bear an undue proportion of health problems because they are the ones most likely unable to afford healthcare or even find a health worker. And yet health is a human right. Where is justice?
Margaret fought for access to quality health for all in Uganda and beyond. She fought for Universal Health Coverage.
Universal health coverage is a means to promote the right to health which includes both freedoms to control ones health as well as entitlements of health protection that gives everyone an equal opportunity to enjoy the highest attainable level of health.
So what’s Justice?
Justice is a scheme in which every person receives his or her due from the system, including all rights, both natural and legal and must neither be denied nor delayed.
Let’s explore a few truths about the effect of injustice n healthcare:
In Africa, over 50% of deaths happen in under 5s while in the developed world, 80% of deaths are beyond 60 years. Africa is the continent of premature death!
In Africa, over 70% of deaths are as a result of preventable disease while only 10% in the developed world. The top causes of death in Uganda as in many other countries in Africa are HIV (15,000), Malaria (10,500), Lower Respiratory Infections (6,125), TB (4375) Meningitis (3,500)
Most of these deaths are in marginalized communities. Is it for absence of technological advancement? Not 90 years after the discovery of Penicillin!
It’s about access and access is about resource allocation and resource allocation is about Justice.
In Africa, average health expenditure per individual is about $100 while it’s more than $3000 in Europe never mind the $8,000 spent in the unjust system in the US! Out of this $100, the government contributes only $10–14 and the rest is from Donors and Out of Pocket by the patients themselves.
Africa may not have the resources to match Europe and or to waste as North America does but even where the resources are available, they are not justly allocated.
To quote Nelson Mandela,
Overcoming poverty is not a gesture of charity, it is an act of justice.
For many years now, governments have been asked to increase their budget on health to at least 15% of National Budget. Uganda is still at 8% as are many countries in Africa. Can it be achieved? Yes. To date, only six countries (Botswana, Burkina Faso, Malawi, Niger, Rwanda and Zambia) have met this commitment.
But this is not a lone solution in itself because even governments which have allocated more may still fail to achieve necessary expenditure because of small budgets or unable to achieve necessary allocation because of corruption and misuse of funds.
Rwanda has focused its health budget on developing a community based health insurance that works. It’s about just allocation and reallocation of resources.
If a population does not have a decent level of health, it is very difficult to ensure economic prosperity, political participation, collective security and so forth.
I said earlier that this subject of Health and Justice has not been widely explored. However, one scholar, Jennifer Prah Ruger has been steadfast in defending the right to health and the imperative of reducing unconscionable health inequalities around the globe.
In her work, she argues that all people should have access to the means to avoid premature death and preventable morbidity. To achieve this, its ‘good policy for health’ that’s needed rather than ‘good health policy’.
Indeed, WHO insists that the Health Sector is not the only contributor to good health and adds that “the social conditions in which people are born, live and work are the single most important determinants of good health or ill health, of a long and productive life, or a short and miserable one”. But you cannot expect to achieve economic prosperity and achive better social conditions without a health population!
In a study done by Financial Services Deepening (FSD), on the perceived risks by households in Uganda, the most common form of risk affecting household welfare was illness of family members, which affected 48% of the adult population. It’s followed closely by crop failure and then closely by sickness of the income earner. Why are our people so worried about sickness? Because it’s also the biggest cause of selling assets like land and livestock and the second biggest reason for borrowing money after education. Why is health our peoples biggest worry yet is actually a human right?
WHO has been actively strengthening its role in providing technical, intellectual and political leadership on the right to health including strengthening the capacity of WHO and its Member States to integrate a human rights-based approach to health so that states, and other duty-bearers including the health providers are answerable for the observance of human rights.
But the question that arises is, who will hold the state, the hospitals and the health providers accountable?
Let me now introduce a thought in continuity of Margaret’s work.
It’s the citizens. But the citizens need information and leadership. The citizens must be educated to participate in budget accountability, in questioning their failure to access good quality care. In questioning the absence of the doctor or nurse from their station. It’s the patient.
I am holding here a Ministry of Health patient charter. This defines their rights but do they know? Even if they knew, do they have the courage to question inadequate services? Even if they knew, do they have the means to do so?
What if our citizens were educated and empowered to demand the right to health from their government and healthcare providers?
Premature death is justice denied. No, Margret did not die. But every time a mother dies prematurely, we kill Margaret. Every time a child dies prematurely, we kill her more.
So what can Uganda do to avoid citizen litigation for lack of access considering the limited resources? Better policies and legislation and domestic resources mobilization from taxation and citizen participation.
A World Bank report showed that Ugandans spend 22% of their income on health and a significant number of people have to sell their assets to cover medical bills. Government should invest a support policies that establish a National Health Insurance Fund and aim to make it mandatory for all in a defined period. However, this cannot succeed unless the government, as the biggest provider of healthcare to the people by numbers, improves its healthcare infrastructure.
An improved health infrastructure at all levels from community, primary to tertiary and better quality of service is the best incentive to a successful National Health Insurance Fund followed by mandatory registration and subsidy for the poor. I am glad Uganda has started on this journey. Can it be achieved? Yes! Rwanda is already on the table.
Let me end by quoting Hon Ruhakana Rugunda, Prime, Minister of Uganda, in a tribute to Margaret carried in the Daily Monitor of Thursday 16th February 2017:
In writing the story and history of Psychiatry and mental health practice in Uganda, the name of Dr Mungherera will always be remembered with gratitude.
In writing the story and history of Butabika National Referral Hospital, the name of Dr Mungherera will always shine bright.
In telling the story of breaking barriers and ceilings, Dr Mungherera will always provide an excellent example.
And I add, in seeking justice for the poor to access health as a human right, Dr Munghereras light will continue to light the way.
Ladies and gentlemen, Do not stand by Margaret’s grave and weep. Margaret did not die. It’s us who will kill her as we kill her spirit in us.