29 Years of NRM and Lessons for the Youth

By Angelo Izama

When Mercy Ayiru walked into the operating room just five days after independence celebrations on October 14, health 2010, diagnosis she expected to be home before supper. She died less than 30 minutes later.

Her sister who sat on a bench outside the theater at the fertility clinic of Dr. Edward Tamale Ssali was bewildered. The whole episode unfolded very quickly and dramatically.

It would later emerge in court that Dr. Ssali had cleared his patient for a laparoscopy, a procedure where a minor incision allows for a camera to guide a surgeon’s knife more accurately. Neither patient nor doctor expected that day to turn into a life-altering event. But it did.

Specialized practices like Dr. Ssali’s are growing in Kampala. The Women’s Hospital and Fertility center he set up has worked miracles for couples struggling to raise children of their own. In starting a practice home in Uganda, the hospital has also saved patients the cost of seeking treatment abroad in places like India and South Africa. There are larger private hospitals in the city- some like Nakasero Hospital have a reputation of boutique health care providers for the rich and powerful.

When he went on trial for the death of Ms Ayiru, first by his peers, the Uganda Medical Association and then before Chief Magistrate Olive Kazaarwe, Dr. Ssali brought the spotlight on private medical services.

Unlike government run hospitals the conditions and experience at a private facility are rarely the subject of public interest.  Even if like many African countries private health care increasingly make up the bulk of clinical services, public debate on their regulation is rare.

Medical malpractice is consequently rarely reported perhaps because patients blame themselves for making bad choices. But it is likely ignorance about the rights of the patient that maintains this conspiracy of silence.


Uganda’s medical industry has many distortions. National hospitals and health centers that do the heavy lifting for majority of citizens are poorly staffed and equipped. Newspapers are filled with heart-rending stories of operations carried out with torches, amputations without painkillers, patients having to buy everything from aspirin to surgical gloves for their treatment.

The real crisis of health care however is administration.

Specialists such as Ssali are better off in private practice. This goes for most doctors who keep a government job and a private one to “make ends meet”. Young doctors, trained expensively at universities like Makerere medical school plan to work abroad at the earliest opportunity.

Recently a call for recruitment of doctors by the oil rich government of Trinidad and Tobago attracted the top specialists in the country to the embarrassment of the government. Those who work within the constraints of the hospital system perform miracles every day. But like beasts of burden they stumble from the weight of the responsibilities imposed on them.

Demand for good health care has created a growing industry that is increasingly sophisticated. A young cardiologist once narrated to this writer how a very senior financial decision-maker had “revolutionized” heart care after he collapsed. The resulting emergency was handled at Mulago.

However his condition worsened. Normally when senior government people need emergency or specialized care; they are flown abroad at taxpayer’s expense. In this particular case the patient was too delicate to transfer to the Agha Khan Hospital in Nairobi. So decision-makers decided to fly a cardiology unit to him instead. And so begun a service now available locally to other Ugandans.

In another instance- a member of the President’s extended family who had been hospitalized in the private wing of Mulago Hospital caused an instant investigation when he received his bill. It turns out that the drugs prescribed to him were embossed “Not for Sale” because the taxpayer had already paid for them.

The absence of the regulatory state in private healthcare is probably affected by the lack of interest of the senior elite. The charge of criminal negligence against Dr. Ssali and his co-accused Mr. Christopher Kirunda did not hold up.

They were acquitted because the lead surgeon Kenyan based Dr. Parker Rafique who carried out the operation left or fled the country. While no one has yet been held properly to account for her wrongful death- the evidence in court demonstrated how not just Dr. Ssali’s facility but the private care industry is badly in need of urgent attention.

Ayiru’s heart stopped because of the wrongful administration of anesthesia- which rather than being delivered through her breathing canal [trachea] was instead placed in her esophagus. It may be that she had another underlying condition but it was never an issue in court since Dr. Ssali had declared her fit for the surgery.

It turns out that Mr. Kirunda, the anesthetist was essentially trained on the job. He gave evidence in his defense that he had successfully prepared hundreds of patients for surgery before despite being a diploma holder- for a job, which globally requires two degrees, a medical degree being the first.

The Medical Council in its own investigation found the clinic was also not properly equipped for the procedure. Sure, Dr. Ssali was a pioneering medical entrepreneur who pulled himself up by his bootstraps to make a success out of his specialty; but carrying out complicated procedures does require the correct equipment. There was a suggestion that the oxygen machine was faulty.

Judge Kazaarwe also questioned the standing of the Medical Council. Their report which raised questions of preparedness of Dr. Ssali’s clinic was two years in making and not a single expert surgeon was involved in its writing. The only expert evidence they relied on was that of Dr. Parker- a suspect himself who probably rather than face charges gave written evidence from the safety of his practice in Kenya.

In court Dr. Ssali pointed claimed the Medical Council was biased and stacked with jealous colleagues envious of his success. It may be true but what is more is that outside this case, the council rarely sanctions medical professionals. It appears that the case did reveal perhaps the lack of rigorous oversight assisted the crisis or conversely that its presence may have avoided it. Ms. Ayiru’s “homicide” is now before Justice Rugadya Atwooki upon appeal.

It is probably one of the most important cases for the Judge and the Director of Public Prosecutions Mr. Mike Chibiita. Holding the private sector to account for malpractice has long been overdue. In his last ruling, also last year, Justice Rugadya set free Uganda’s so-called “HIV nurse” who was facing another serious charge of endangering the life of a young boy.

The judge found however that the real culprit was sheer incompetence. The HIV nurse simply did not follow procedures required of her.  She also did not care. There are thousands of nurses like her many working in incredibly hostile conditions. But Justice Rugadya also pointed out that the debate on the case was unhelpful in that it dwelt on her HIV status as activists sought protection against stigma.

However both these cases can be placed within a wider legal and political context. Proper administration and regulation not just of public but also private health care is how the state meets its constitutional obligations “ take all practical measures to ensure the provision of basic medical services to the population”.  That’s in the 1995 constitution.

The Ugandan state cannot do this, in fact is flailing about it, precisely because conversation about health care is about the supply of hardware; hospitals, doctors, medicine and equipment. The state fails or is allowed to fail when it cannot account for standards of care both in the public and private sector. The difference must be made up by public pressure, which also depends on public awareness- something to which the Ssali case has contributed immensely.

Modern Africa

The failure of the regulatory state is one of the greatest tragedies of modern Africa. Standards such as appropriate signage on roads that could save thousands from a horrible end- or in the case of Ms. Ayiru and others that practitioners have valid licenses ensure that the massive health dollars are not washed away through a porous system. Countries with far less resources are known to offer more through better regulation.

If DPP Chibita were to attempt to hold a public inquiry into complaints over medical malpractice as he should; a flood of complaints many worse than what happened to Ms. Ayiru would follow. Enlightened publics however do not just happen. They are the result of active citizens.

Perhaps it is well that this October will be the 5th anniversary of Mercy Ayiru’s death as well as the 20th anniversary of the 1995 constitution. Rather than chain the constitution to a shouting match over power-sharing perhaps a conversation about the 1995 Constitution as a social contract can help deepen the importance of an efficient state and government – as an embodiment of ideas of progress, 20 years on.

The 1962 post-independence founding documents, including the constitutions of Uganda and Buganda would have been 53 years this year. Neither lasted, consumed as they were in the social, political and economic upheaval that followed self-government.

It is the 95’ constitution by lasting this long that allows for self-examination. As a social contract how has it performed?  What does that say about Uganda’s governing institutions and those who lead them?

There are no doubt other more emotional reasons to debate the legacy of the 95’ constitution. Yoweri Museveni, the patron of the 95’ constitution will be running in his truly last meaningful election next year. This has meant that the legacy of the constitution has been hinged on whether it will survive in a peaceful transition or perish like the rest.

However constitutions are not just about revolution but also evolution. Neither should they be reduced to a proscription on elected leadership but also what elected leaders do. Reducing government into a ritual of competition for power, violent or not, has dominated the debates about government and governance- to the detriment of ideas of progress.

That is not to say that these struggles are idea-less. It is to say that they are mostly about the exercise of power not the reasons for it. They don’t have to be mutually exclusive in the same way that the mind that contracts a Chinese company to build presidential offices must be the same mind that provides for the maintenance of lifts in that building. Both minds do not take away the business of the building, – which is to get leaders into rooms with a view as they make decisions.

Unfortunately African leadership often stops at the ribbon cutting for the building. Many have not even changed the furniture they inherited with independence from the colonial master. After claiming the state often violently they find themselves stuck at making speeches about retaining the state- against external aggression. Far less debate is dedicated to the workings of internal progress and far less internal progress is the main basis of determining who runs a country.

This appears far worse in countries that were little more than geography before they were administered by colonialist. Without the deeper traditions and ideas of state of territories like India and China- when they encountered Western mapmakers, African and particularly sub-Saharan states have struggled to domesticate the ideas of self-rule.

Constitutions provide that framework.

Recently some African leaders have become energized with the idea of modernizing the state and its services as a form of ideological re-birth a source of pride in modernity. There is no denying providing better services add on to a sense of community and common purpose. It certainly helps for countries to fend for themselves with the highest standards that modern knowledge and industry allow.

However the real debt owed many times over by African elites is servicing high standards. Efficient government is an instrument of the social contract. A mature state that meets its obligations reveals how deep that contract runs- and with it how the society has managed to find a common purpose. That some would put it – defines ideology and is worth debating.

Finally, put this way perhaps one can emphasize with the ideological crisis of the party of the 95’ constitution, the National Resistance Movement. No matter how frequently its supporters refer to its ideological sufficiency- often by comparison to other mass political organizations like the Communist Party of China, the Africa National Congress or even Tanzania’s ailing Chama Cha Mapinduzi- it’s evident that articulating clearly what social, political and economic ideas define the social compact is a headache inducing activity better dressed with platitudes and pontifications about history and struggle.

Even Lee Kuan Yew, the founder of the People’s Action Party of Singapore adopted as a patron saint of state-managed progress particularly NRM’s ideologically starved young members- was not just a nationalist but an administrator of the colonial mold whose vision for Singapore was hinged on aiming for the highest standards as a consequence of independence.

Surely ideology can be measured- in action? Like other African political organisations, save a few, ideology weighs on the logic of political power- essentially that it maintains itself. The rest descends in importance.

While this can lead to longevity- and some types of growth, it does not translate readily into widespread social transformation. Opposition movements too are obsessed with the tools of power and less with the tools of organizing society. The malady extends to social movements supply criticism to the kind of contract any elected government, now and in the future, has with the Ugandan people.

The 20 years of the 95’ constitution- the operating system of government is a good place to invite constructive debate. Two decades ago it made ambitious promises to Ms. Ayiru and the rest of us.
By Duncan Abigaba

The NRM will on Monday 26th January, abortion 2015 celebrate 29 years since they came into power. The national celebrations will be in Soroti district.

The NRM actually inherited remnants of power from the undisciplined UNLA soldiers who had deposed their commander-in-chief six months earlier but had completely failed to manage the state.

For purposes of preserving our history, sales according to President Museveni’s book; Sowing the Mustard Seed, treat the NRA’s (NRM’s military wing) victory had been shaped by the battle at Kembogo in Singo.

John Ogole (now deceased), the commander of UNLA’s special force had on 21st June, 1985 tried to attack the mobile brigade of NRA commanded by Salim Saleh.

In the battle, the mobile brigade inflicted a major defeat on the remnants of Ogole forces bringing to an end of his military efforts in the central sector. According to the book, President Museveni called the opening of the second front in western Uganda under the command of the late Rwigyema as the additional nail in the coffin of UNLA.

The two defeats sparked off the mutiny in the army. It became clear that UNLA was defeated and couldn’t cope up with the assault from NRA offensive. Obote was overthrown on 27th July in a military coup d’etat.

Quoting the great Martinique philosopher, Frantz Omar Fanon, every generation must out of its relative obscurity discover its mission, either realize it or betray it. The President Museveni generation realized the needs of the time; need to end extra judicial killings, impunity by the undisciplined army, gross corruption, shallow sectarianism based on tribalism and gender chauvinism, as well as lack of fundamental human rights and democracy in Uganda. All these have been achieved by high measure.

To highlight but a few of the NRM achievements, the tarmac road mileage has increased from 1,000 Km in 1986 to 4,200 Km now. The primary school enrollment has increased from 2,203,824 to 8,437,069 pupils, secondary school enrollment from 123,479 to 1,247,437 students, university enrollment from 5,390 to 150,000 students, graduates from higher institutions of learning rose from 3,000 to 400,000 apparently.

There has been increased access to clean water from 10% to 95% in urban areas and to 71% in rural areas. Gross Domestic Product has grown from $1.5 billion to $24 billion; exports have risen from $411 million to $5.4 billion while revenue collection has grown from 5 billion shillings to 12 trillion shillings last year.

Power generation has also risen from 60 MW to 856 MW with a target of 3,080 MW by close of 2016 at the completion of Karuma Dam and other power generating projects.

However, the current generation has a great task of upholding and consolidating these achievements. It should be noted that the current generation is of trials and tribulations.

There is rampant youth unemployment leading to civil disobedience, the education system is partly to blame for failing to provide adequate and relevant skills to the youth. The youth also need finance to start income generating projects to carter for the loss of jobs.

But majorly, the youth suffer great ideological disorientation driven usually by selfish interests and have in turn failed to discover a mission of their generation.

Comparatively, there is a lot to celebrate under the NRM government and I wish to congratulate President Museveni, the NRM fraternity and all Ugandans on this auspicious occasion.

Duncan Abigaba is a member of the NRM Youth League

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