Special Report: Ugandans Battle New Health Challenges As They Become Wealthier

Health, as defined by the World Health Organization (WHO), is “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” This definition has been subject to controversy, as it may have limited value for implementation.

Health may also be defined as the ability to adapt and manage physical, mental and social challenges throughout life.

As such, the meaning of health has evolved over time. In keeping with the biomedical perspective, early definitions of health focused on the theme of the body’s ability to function; health was seen as a state of normal function that could be disrupted from time to time by disease.

An example of such a definition of health is: “a state characterized by anatomic, physiologic, and psychological integrity; ability to perform personally valued family work, and community roles; ability to deal with physical, biological, psychological, and social stress”. Then in 1948, in a radical departure from previous definitions, the World Health Organization (WHO) proposed a definition that aimed higher linking health to well-being as stated above.

Although this definition was welcomed by some as being innovative, it was also criticized as being vague, excessively broad and was not construed as measurable. For a long time, it was set aside as an impractical ideal and most discussions of health returned to the practicality of the biomedical model.

Just as there was a shift from viewing disease as a state to thinking of it as a process, the same shift happened in definitions of health. Again, the WHO played a leading role when it fostered the development of the health promotion movement in the 1980s. This brought in a new conception of health, not as a state, but in dynamic terms of resiliency, in other words, as “a resource for living”. In 1984, WHO revised the definition of health and defined it as “the extent to which an individual or group is able to realize aspirations and satisfy needs and to change or cope with the environment. Health is a resource for everyday life, not the objective of living; it is a positive concept, emphasizing social and personal resources, as well as physical capacities”.

Thus, health referred to the ability to maintain homeostasis and recover from insults. Mental, intellectual, emotional and social health referred to a person’s ability to handle stress, to acquire skills, to maintain relationships, all of which form resources for resiliency and independent living. This opens up many possibilities for health to be taught, strengthened and learned.

Systematic activities to prevent or cure health problems and promote good health in humans are undertaken by healthcare providers. Applications with regard to animal health are covered by the veterinary sciences. The term “healthy” is also widely used in the context of many types of non-living organizations and their impacts for the benefit of humans, such as in the sense of healthy communities, healthy cities or healthy environments. In addition to healthcare interventions and a person’s surroundings, a number of other factors are known to influence the health status of individuals, including their background, lifestyle, and economic, social conditions and spirituality; these are referred to as “determinants of health.” Studies have shown that high levels of stress can affect human health.

In the first decade of the 21st century, the conceptualization of health as an ability opened the door for self-assessments to become the main indicators to judge the performance of efforts aimed at improving human health. It also created the opportunity for every person to feel healthy, even in the presence of multiple chronic diseases, or a terminal condition, and for the re-examination of determinants of health, away from the traditional approach that focuses on the reduction of the prevalence of diseases.

The case for Uganda

Health in Uganda refers to the health of the population of Uganda. In the 1980s and 1990s, Uganda had one of the worst healthcare systems in the world. But that story is different today. For example, HIV infection rates reached 30% of the population then and has since fallen to less than 5.5% today. The maternal mortality rate has dropped by more than 40%, from 561 deaths per 100,000 live births to less than 343 today.

The table below shows how Uganda compares to Africa, USA and the World, on key public health measures, according to World Health Organization data.

1.  Maternal mortality ratio per 100,000 live births
2. Neonatal mortality rate per 1000 live births
3. Skilled health professional per 10,000 population
4. Malaria incidence per 1000 at risk population
5. Suicides per 100,000 population

Uganda outperforming Africa

Uganda is now outperforming Africa on these 5 metrics, although the country under-performs the global average or the U.S. Progress in public health is inevitably slow, with always one more hill to climb—like the topography of Uganda.

The steady progress reflects the leadership that the government of Uganda has provided in setting ambitious goals and putting programs in place to achieve the same. Uganda was ahead of most African countries in providing free universal access to state health facilities beginning in 2001. This resulted in an 80% increase in hospital visits, with over half coming from the poorest 20% of the population, but serious access and delivery problems remain. To that end, Uganda’s government is now open to collaborating with different organizations, which is why many are forging such a strong partnership to provide healthcare to rural Ugandans.

New Challenges

Nevertheless, the success in addressing the above health situation has ushered in a new wave of health related issues and the government is struggling with what to do to avert this situation termed as Non Communicable Diseases (NCDs).

According to prof. Anthony Mbonye, this growth in NCDs is a big issue for Uganda and its health system and he had this to say: “When most of us were young, many people in Kampala walked or cycled to work. There were a few Matatus and very few cars. It didn’t make us very productive but, we now know, it fended off many of the diseases that are so common across Europe and North America”.

In the past 25 years, the population of Kampala has more than doubled. Traffic gridlocks the roads for much of the day. People laugh at the idea of cycling to work – in any case, it would be far too dangerous.

Growth of wealth

The growth of African cities is driving the growth of African wealth. But urbanization and economic development are unfortunately driving the growth of NCDs. These chronic diseases, like hypertension, cancer and diabetes, are associated with the passive lifestyles many people adopt when moving to the city. The population is increasingly eating unhealthy (junk), lacking exercise, smoking tobacco and abusing alcohol. Many are unaware that this type of new life is storing up future health problems for them.

This growth in NCDs is a big issue for Uganda and its health system. Today, 25% of Ugandans die from an NCD, and the proportion is increasing every year. However, we are still fighting the battle against some infectious diseases –such as malaria, meningitis and HIV –which are still the biggest killers of people in Uganda. Alongside these well-known diseases, we are seeing the emergence of chronic illnesses which are silent killers – often people don’t know they have high blood pressure until they have a stroke or a heart attack. Nearly a quarter of Uganda’s adult population has raised blood pressure. More than 75% of these people don’t know they have a problem, and are not on a medication to control their hypertension.

The Ministry of Health has already established an NCD program to coordinate efforts around prevention and control.

The country is working with partners and other stakeholders to draft policies and guidelines geared to prevent and control NCDs. The Minister of Health, Dr Jane Ruth Acheng, is very supportive of these efforts, as is President Yoweri Museveni. But more partnerships to fight NCDs is needed.

Uganda has just signed a memorandum of understanding with the multinational healthcare company, Novartis, to help the country improve its capacity to diagnose and care for people with NCDs. It will also increase the availability of affordable treatment.

The agreement with Novartis means that Uganda will become the fourth country in Africa to roll out Novartis Access. The program offers a basket of 15 generic and patented medicines to address cardiovascular diseases, diabetes, respiratory illnesses, and breast cancer. The medicines in the portfolio have been selected based on their medical relevance: they are either included in the WHO Model List of Essential Medicines, or belong to the most frequently prescribed medicines in these disease areas. All 15 treatments in the basket will cost the public sector only $1 (Sh3,700) per treatment per month.

Fortunately, the government of Uganda is committed to making these medicines available free of charge to patients in public health facilities. Products will also be available through the Uganda Muslim, Protestant and Catholic Medical Bureaux where patients are expected to pay no more than USD 1.60 per treatment per month – just under 6,000 Ugandan Shillings. We expect to receive the first shipment of treatments at the end of this year. Novartis Access will also support capacity-building activities on the ground toward NCD prevention, diagnosis and treatment.

One of Uganda’s key strategic priorities is to strengthen a multi-sectoral approach to prevent and control NCDs and their risk factors. We hope our new partnership with Novartis will help to accelerate and scale up the national response to the NCD epidemic in Uganda. But we know we will need many more public-private partnerships to eventually tip the situation.

More Ugandans Embrace Jogging

Have you noticed that these days more and more Ugandans go jogging and do other forms of exercise?

Is it because they think it is a cool thing to do? Just a decade ago, the number of joggers in this country was nearly a handful but it has steadily grown. Our eyes have seen a lot of jogging on TV and more organizations have sponsored marathons, I even don’t care if the marathons are a PR (public relations) gimmick because they have managed to have more Ugandans embrace regular exercise. I am also grateful to the different series and films Ugandans enjoy, which have characters that exercise routinely. These stars are seen making time for jogging, yoga or whatever form of exercise that best suits the script. Such is what people see and it is now bearing fruit in Uganda.

On my way to work every other day, I see many Ugandans jogging along the road. Many joggers are closed to the world with earphones plugged in their ears, exuding the concentration of a soldier at war. I even got a new hobby of sorts: counting joggers. I have noticed that the number grows every week.

In the first week, the number was averaging seven to ten joggers every evening. The last time I counted, the number had grown to thirty. You have to agree, that is a lot of Ugandans jogging in one evening. You couldn’t see that in the year 2000. Weight loss, doctor’s orders, job requirement, peer pressure… whatever their reasons may be, I am glad to see more people exercising because it only means they really care for their health.

This is true for a friend of mine who achieved her New Year’s resolution. Pam [not real name] has lost weight after trying everything – jogging, yoga and hitting the gym. After only four months, she is the person she set out to be last December (Michael Apire, May 16, 2013).

Uganda Most Active Nation in the world

And perhaps because of this, Uganda has been voted among other reason the most physically active nation in the world, by the recent report by the WHO (15 Sep 2018).

The WHO report on physical activity, which categorizes Uganda as one of the most active countries in the world, and also tracks the level of physical activity around the world, found that only 5.5% of Ugandans had an insufficient level of activity while the report shows that about a quarter of the world’s population don’t get enough exercise.

The research findings note that, generally, people in low-income countries seem to integrate a sufficient amount of physical activity in their lifestyles, unlike those in wealthier countries, because the poorer people are, the more likely they are to use modes of transport, or be in an occupation, that involve physical work.

However, the study, an analysis of self-reported national data, doesn’t explain why Ugandans are more active than other countries with a similar level of income, and this can only be explained by the following observation that in low-income countries, like Uganda more people are getting into formal employment, spending long hours at the office, buying cars and eating more fast food, meaning Uganda might become less healthy as they become wealthier.

Many Ugandans are involved in either moderate aerobic activity like walking fast, water aerobics, riding a bike on level ground or with a few hills, table tennis, pushing a lawn mower, hiking, skateboarding, rollerblading, volleyball, basketball or in vigorous activity such as jogging or running, swimming fast, riding a bike fast or on hills, football, rugby, skipping a rope, hockey, aerobics, gymnastics, martial arts and also in activities that strengthen muscles like lifting weights, working with resistance bands, doing exercises that use your own body weight, such as push-ups and sit-ups, heavy gardening, such as digging and shoveling, yoga and activities that are both aerobic and muscle-strengthening such as circuit training, or netball.

Changing lifestyle

But it is also not easy for those Ugandans trying to stay fit as their lifestyles change.

Kampala is not a fitness-friendly city. There are hardly any green parks, most roads have no pavements, and many cars emit the same amount of fumes as a grass hut on fire.

Walking or jogging demands some bravery. If you are lucky to find a walkway, you have to watch out for open manholes, and boda bodas (motorcycle taxis), which will push you off the pavement and top it off with insults.

Motorists will not be shy to drive you into the storm-drain, in which you have to jump over plastic bags that look very suspiciously like “flying toilets”.

Still, over the last couple of years, joggers, mostly the urban elite, have increasingly appeared on the streets.

There is also a growing trend of fitness groups around the city. It is common to find three different groups working out in the parking lot of Mandela National Stadium, Namboole.

From people in their 60s to a nine-year old girl, they go through their jumps, squats and stretches.

Encouraging physical activity

On 7 July, President Yoweri Museveni launched the National Day of Physical Activity, which will be marked annually. But it will take more than a presidential gesture to keep Ugandans active.

The country may be celebrating the WHO study, but Uganda is rapidly urbanizing and in the next couple of decades, there are likely to be fewer 67-year-olds still fit to till the land, and more people behind the wheel in traffic snarl-ups.

Roy William Mayega of the Makerere School of Public Health conducted a study in the peri-urban areas of Iganga district, east of the capital, in 2013. He found that the lifestyles of Ugandans are changing, and the study found that 85% of the participants were physically active, and when blood sugars and weight as well of these were assessed, all seemed well. However, the 15% who were not sufficiently active were twice as likely to have diabetes and high blood pressure than those who were active,” he says.

The study also noticed a shift in the food environment. In every small roadside town, young people were cooking high-calorie, processed-flour foods, and people were coming from the villages for a taste.

“Physical activity is becoming less of a lifestyle, and we have started to eat things we didn’t in the past, but the people’s perceptions of recreational activity are still negative. One man in the study told me: ‘Playing is for children’,” he adds.

For now, though, most Ugandans are keeping fit without fancy gadgets to count their daily steps and monitor their calorie count. But the country will need a national consciousness and the right infrastructure, to retain its top-shape position. Thus the Ministry of Health must put lots of emphasis on NCD program to coordinate efforts around prevention and control.