Following his much publicised but unannounced visits to two hospitals in the capital Kampala earlier this month, whose outcomes remain unknown, President Yoweri Museveni is reported to have of late been the recipient of information about what a local daily termed the “dilapidated state of government health facilities in the country.”

Unlike the impromptu visits, which some commentators have been quick to dismiss as political stunts, the reports have catalysed an interesting reaction.

Apparently the president has now directed the Ministry of Health to upgrade all public health facilities in the country and to ensure that all districts, 117 of them, have hospitals and mortuaries.

Reacting to the “order,” the Minister of Health, Dr Elioda Tumwesigye, has emphasised the importance of the upgrading because it will “ensure that Ugandans get access to quality service delivery.” He went as far as promising to include the necessary financial resources in next year’s budget.

For anyone who takes developments such as these at face value, the president’s directive and the minister’s response are truly heart-warming. There are probably large numbers of simple folk out there who are celebrating the pronouncements.

Perceptive observers and the more experienced consumers of whatever services the public sector provides, however, must be asking themselves all sorts of questions.

For me, the most immediate question is this: Why on earth does the upgrading or repair or even expansion of health facilities wait for the president to issue directives before it happens, in a country that, like any normal country, has a minister of health and other officials whose job should be to think of such things and do them as part of their mandate?

Now let us assume that indeed the Ministry of Health will include the requisite financial resources in its next budget, that the Ministry of Finance will make them available, and that the president’s specific directive will be implemented. Perhaps it will take another directive, whenever it may come, before other necessary steps are taken to “ensure that Ugandans get access to quality service delivery”?

These may sound like idle questions. They are not. Uganda’s health sector is riddled with problems that, if their solution had to await presidential directives, one may as well give up on ever solving. Besides dilapidated buildings, there is the shortage of qualified personnel.

There is probably no country with enough health professionals. Even developed countries with excellent training facilities and good working conditions experience shortages. Shortages in Uganda, however, can be severe, with some health facilities barely able to fill 50 per cent of open vacancies.

Health personnel may be far fewer than needed, but even the few that are available do not have access to all the inputs they need to provide a decent service.

Nor are they compensated for their time and effort and or even managed in ways that ensure consistent commitment beyond the call of duty that elsewhere is taken for granted. If absenteeism and dereliction of duty are notable features of the health sector, culminating in avoidable calamities every now and then, it ought not to surprise.

Research points to a significant increase in the availability of essential medicines following recent improvements in delivery and accountability mechanisms. There are, however, severe shortages of essential equipment, including in referral facilities, although ironically where equipment is available, it may lie unused for years as a result of lack of skilled personnel to operate it, or even electricity to power it.

Elsewhere, hospital stores and yards are full of equipment with minor defects, whose repair must await the completion of longwinded bureaucratic procedures for sourcing service providers, or the recruitment of in-house technicians, which rarely happens.

It is hardly unusual to arrive at a hospital and find several vehicles, including ambulances, rusting away in yards when all it would take to get them working again with positive implications for service quality, is flexibility in procedures and greater autonomy in facility-level decision-making.

Nor is it unusual to find health units with more broken beds in their stores, some with only a leg or wheel missing, than useable ones in their wards, with several patients lying on the floor.

Clearly, none of these problems lends itself to resolution via simple issuing of directives to upgrade, renovate, or expand infrastructure. But even if all it took to resolve complex managerial and governance problems were improvements in infrastructure, the measure would amount to little more than a temporary fix.

Dilapidation of infrastructure in Uganda’s health facilities manifests itself by way of collapsed ceilings, leaking roofs, broken windows, non-functional sanitary facilities, and unpainted buildings. There is no denying that shortage of financial resources is a key factor in all this.

There is, equally, a heavy dose of something that, while not uniquely Ugandan by any stretch of the imagination, is common wherever one looks: Lack of a maintenance culture.

For some reason we seem to believe that nothing should be attended to or fixed until it has broken down completely. Besides our health units, one need not look farther than our roads, which are famous for enormous potholes; pedestrian sidewalks on major roads that are littered with gaping manholes; dingy police stations and army barracks, and even residential hostels and lecture rooms at universities.

Frederick Golooba-Mutebi is a Kampala- and Kigali-based researcher and writer on politics and public affairs. E-mail: [email protected]