Saturday, 11 November 2017


The passing on of Dr. Lawrence Kaggwa Nakaana is sad. The Doctor was at St. Mary’s College Kisubi for his HSC from 1967 to 1968.  He then joined Makerere Medical School where he graduated in 1974.

Dr. Kaggwa passed on Friday morning, 10th November at 9.25am at Uganda Heart Institute – Mulago where he was admitted on 16th October over heart related complications. The Doctor was among the visiting Doctors who would call at the Sick Bay at the school.  We thank God so much for his roles as an Old Boy.
The Doctor has been a retired Senior Consultant Surgeon.  He was Executive Director of Mulago Referral Hospital from 1993 to 2005. He practiced surgery at Makerere University Medical School for a long time.  

Dr. Lawrence Kaggwa’s last communication to me was on September 2, 2017
Thank you for the brilliant updates on the developments of St Mary's.
Lawrence Kaggwa.


Doctor Kaggwa communicated as below:  
“The initiative is welcome but the methods and processes have not been spelt out.  We promise to participate when the project proposal comes out with clear
Architectural drawings, rooms and Bills of Quantity”.
Lawrence Kaggwa.

On July 29, the communication was as below:
Thank you so much for the drawings which now bring about the picture better.
I have not counted the rooms but I hope they have catered for lecture rooms.
I also expect that this planning fits into the Master Plan of St Mary's College,” Lawrence Kaggwa.


3rd April 2013
While this prestigious award is principally for the alma mater, it definitely gos to Alex Coutinho for unlocking his inherent qualities of passion, commitment, empathy and sense of purpose to mix with his brilliance leading to a high level of competencies that have seen him register this rare achievement. I wish to sincerely congratulate him on the outstanding milestone in his life. This is like putting one's foot on the moon or Mars! May the name of St Mary's continue to shine and the products to remain the beacons of development in the region and globally. Thank you for making us so proud and May the Lord lead you to yet loftier heights.
Dr Lawrence Kaggwa, Senior Consultant Surgeon and Consultant in Health Systems

“It is a shock the untimely death of a brilliant and philanthropic Financial Manager! May his soul rest in eternal peace.”
Lawrence kaggwa.

When death claimed a Senior Doctor, Brig (Dr) Samuel Lwanga

“ It is quite sad the loss of this young Brigadier ! He was an accomplished surgeon who quickly rose through the military ranks albeit being a medical Professional.
The last I saw of him was about two years ago when he was exchanging marriage vows at Namirembe Cathedral. He was soft-spoken, dutiful, conscientious and target-driven. The country has lost a proficient professional and leader at that young age. May his soul res in eternal peace and may the Lord support his young family and widow through this difficult time and future in growth and development”.
Dr Lawrence Kaggwa. 

What Dr. Alex Coutihno said about Dr. Lawrence Kaggwa

"We mourn Dr. Lawrence Kaggwa. He was my teacher in Surgery and my mentor in life. He taught me how to lead with humility and he was instrumental in encouraging me to come back to Uganda in 2001 to serve my people. A man of the people always, Dr. Lawrence will be remembered by all walks of life. It was an honour for our lives to intersect.," Dr Alex Coutihno.


Dr. Lawrence Kaggwa on the National Health Insurance
Today medical expenses for elucidative procedures, sophisticated surgeries, cancer and other treatment protocols are extremely high, and to pay for them entirely out- of- pocket has been found to be catastrophic to the families and individuals. Many families have lost plots of land, houses and other important assets to fund medical treatment, and benefactors have equally suffered in the process. The MRI costs SHS 850,000 per area visualized; medium surgery SHS 4.000,000 and cancer treatment is in the region of SHS 40,000,000-80,000,000. Admission for a week in a Private Hospital may cost SHS 7,000,000 for medical treatment.
Those on kidney dialysis may incur SHS 1,000,000 weekly during the period they are looking for kidney transplants (what if this is to be 5 years?).
In Britain, the National Insurance Act 1911, marked the first steps towards national health insurance, covering most employed persons and their financial dependents and all persons who had been continuous contributors to the scheme for at least five years whether they were working or not.
Elsewhere it did not become important for most people until advances in modern technology produced many expensive procedures and drugs required for efficient and effective cure of injury and disease.
Health insurance is a type of insurance that covers costs incurred for unexpected medical expenses. By estimating the overall risk of health care expenses among a targeted group, an insurer develops a routine finance structure, such as a monthly premium, to ensure that money is available whenever need arises to pay for the health care benefits specified in the insurance agreement. While the benefit is administered by a central organization such as a government agency, private business, or not-for-profit entity, the insurance health providers have to be accredited after complying with the documented quality standards.
Historical background of Health Insurance in Uganda:
In Uganda, health insurance was traditionally seen in the non-monetary scheme of Engozi of Kabale, Munno mu Kabi of Buganda (but which required consideration of backward/upstream integration) and other forms of social support extended to the sick relatives and neighbours as deemed most suitable for each tribe and region.
These approaches are still encouraged to grow and partly convert into monetary systems to meet the hospital expenses.
For over 15 years, the Ministry of Health started exploring possibilities of alternative funding mechanisms as the national budget remained small in the midst of a sea of competing national priorities. So the tax base then and now has failed to fully fund health care. There has been consistent failure, for it is only 8.5-9.5% of the National budget instead of the 15% of the Abuja declaration many years ago.
Ten years ago Harvard University was contracted to design the Social Health Insurance scheme, around which further consultations were made with other Academic Institutions in Belgium and elsewhere. Key partners like WHO, World Bank, ILO and GTZ were consulted.
Countries with the young health insurance schemes (about 10 years), such as Tanzania, Rwanda, Ghana, Nigeria, Kenya, Burundi; those with about 50 years like Thailand, South Korea and India and those with over 100 years like Germany and Belgium were visited to compare experiences. At the moment the Draft Bill, prepared by the National Task Force and Inter ministerial Committee, is ready for enactment by Parliament.
Nature of the Uganda National Health Insurance:
The National Health Insurance Scheme will be an umbrella organization accommodating all sectors in Uganda- the public, private and communities in the form of: 1. Social Health Insurance, 2. Community Health Insurance (like Kisiizi, Kitovu, Bushenyi), 3. Private Health Insurance (like ICEA and SANLAM) and 4. Third Party Health Administrators (to link up individuals and organizations to health services). Thus the doors are open for the private sector to freely join the social scheme and the Private Insurance for products such as evacuation that may not easily be provided by the National Scheme.
Preparation has taken into account the economic and actuarial analysis; provider accreditation and quality (public, private and PNFP); quantity, complexity and scope of health services to be provided at the beginning and nascent phase; the legal and regulatory aspects by the Insurance Regulatory Authority of Uganda (IRAU); and the administrative structure of NHIS. This has been largely supported by the wide plethora of consultations with key stakeholders and technical experts.
i Management of the scheme:
The scheme is to be a body corporate with perpetual succession, with powers to sue or be sued, governed by a Board of Directors and responsible for the development, management and coordination of health insurance activities in the country, now and in the future. The Managing Director and the NHIS team will be carrying out planning and managerial functions through a widely spread out National and Sub-National Coordinating Mechanism, which will be charged, inter alia, with collecting, depositing and investing premiums. They will also negotiate and enter into contracts with the accredited health care providers about the scope of health services and payment mechanisms- capitation or after-service payment. Some of the departments will include the financial, legal, accreditation and quality, health care packages and verification.
The Board of Directors is to be made up of 11 members - from Government, workers’ organizations, employers, accredited health providers, community insurance scheme, the Private health insurance scheme and the Chairperson. They will be responsible for overall governance, direction, development and growth of NHIS.
ii. Health care package:
The package has inclusions and exclusions, the relationship of which will change as the scheme matures with more reserves and better control of moral hazard. Initially the inclusions will be all outpatient services, most inpatient services, drugs (generic rather than brands), maternal deliveries and neonatal care, preventive services, referrals and moderate surgeries and early cancers. Exclusions are plastic surgery for beauty and not reconstruction; dentures, eye glasses, accidents following high risk sports like motor rallying, organ transplant etc.
Health service will be provided by accredited providers (public, private and PNFPs), selected on the basis of quality, nature of service, clinic or hospital and showing compliance with the agreed rates per medical condition and intervention. The selection of theses providers will be jointly done by the policy holder, the employer and the Insurance. Identification of the policy holders and their beneficiaries at the time of accessing the service at the clinic or hospital will be done by special identity cards and later on electronic SMART cards, to be utilized in all parts of the country where the policy holder happens to be at the time of the illness episode.
iii .Financing and financial management:
Actuarial analysis recommended the formal public employee to contribute 4% of the salary on which the employer adds 4% to make it 8% per month. The risk is pooled together irrespective of the pre-recruitment health status; and the fact that not everyone falls sick at the same time, this fund will be able to provide health care to 4 other members of the family of the policy holder. The formal private sector will be persuaded to join but those who prefer the Private Insurance will be free to do so. With time, the informal sector, after developing some reliable and predictable fund management structure and books of accounts, will be recruited to increase the volumes of subscribers who will then share and support each other for the health risks.
Out-of-pocket payment for health services is catastrophic to the individuals and families in asset and financial loss, and is responsible for high morbidity and mortality. This is borne out by stories of transactions at the critical moment of illness which resulted in grisly complications and untimely death especially due to cancers. A robust and transparent health insurance scheme with water tight controls will improve health financing, provide more efficacious and accessible health care and ensure financial stability for households.

I contracted Marburg in 1977and lived – Dr Lawrence Kaggwa.

By Henry Lubega
Survivor. Former Mulago National Referral Hospital director Lawrence Kaggwa Nakaana told Sunday Monitor’s Henry Lubega how he turned down an opportunity to move to America and stayed in Uganda to fill the gap left by expelled Asian and white doctors.
I was born in April 1948 in Kiryasaka village, Masaka District, to Dominic Njala and Dorottia Nalubwama.
I started school aged seven at Buyoga Primary School because I could read the Luganda newspapers and do the multiplication tables well. I skipped Primary Two and went to Primary Three. When I joined Primary Four, I changed school and joined Bukalasa Seminary where I completed my primary and proceeded to Junior Level until Senior Two when I joined St Henry’s Kitovu where I completed Senior Four in 1966.
From Kitovu, I went to St Mary’s College Kisubi for my A-Level before joining Makerere University Medical School in 1969 and completing in 1974. Doing medicine was a second thought on the advice of my father. It took me three months to change from my early ambition of being a mathematician.
After medical school, I did internship at Mulago hospital from 1974 to 1975 before being posted to Kitagata Hospital as a medical superintendent. At the same time I was the Bushenyi District medical officer and the only doctor in the whole district. I did not stay in Bushenyi for long as I was transferred to Bugiri as the medical superintendent in mid-1976.
Marburg outbreak 
Around February 1977, there was an outbreak of a strange disease that we didn’t know at first. The patients were being tested for meningitis, typhus, and typhoid and all the tests were negative. This outbreak was confined to Nakibembe Sub-county and it lasted three months, claiming eight medical staff and many locals.
By the time of the outbreak, former minister Shaban Nkutu had just died and then president Idi Amin said Allah was revenging on the community Nkutu came from for his alleged evil deeds. It took us three weeks to get any form of help. The Ministry of Health intervened and the World Health Organisation gave us safety gear.
By the time the safety gear arrived, I had over exposed myself while carrying out different tests like throat swabs, blood sampling and urine collection. But when all the tests turned out negative, we realised that this could be a strange virus. I had done a post-mortem on one of the dead bodies and this could have over exposed me to the risk of contracting the virus.
One morning, I woke up with a rash all over my body. I asked my elder sister, who was staying with me, to leave for fear of infecting her. She left knowing that I’m going to die. I decided to stay, knowing that if I went to Kampala I would spread the virus.
After two days, the rash cleared and I went back to work. Together with my medical staff, we put up a quarantine around Nakibembe, not allowing people to come in or leave the sub-county. That was the only way we could curb the spread of the strange virus. The quarantine lasted for three months.
During the quarantine, medical staff from Bugiri Hospital went out to villages every after one day to treat the sick from their homes other than them coming to the hospital.
We got to know the disease was Marburg as the outbreak cleared. When the outbreak first happened, I sent specimen to Jinja hospital but was told they were thrown away by a lab attendant because they were dangerous samples.
When I sent other specimen, they were taken to Germany for tests and that’s when we got to know it was Marburg.
Back to school
I left Bugiri in 1977 to do a master’s degree in surgery. When I completed the masters in 1980, I started teaching surgery for the next seven years until when I became a consultant surgeon at Mulago and went on to become a senior surgeon in 1995. But in 1993 I had been appointed the hospital’s executive director.
Working under Amin
Life during Amin’s time was not easy for the medics as was the case with other professionals. I would have been among the many that fled the country, but when chance came, I was in Bugiri and felt it was not ideal for me to turn my back on the people at the moment they needed doctors most.
All Asian and white doctors, including some Ugandan medics, had left the country, creating a vacuum. I had been given a chance to go to America, having passed their ECFMG (External Commission for Foreign Medical Graduate) exams which would have enabled me practice medicine in America.
At the time, it was not only the number of doctors going down, but medical basics like drugs were also steadily declining, while the number of gunshot victims was on the rise. Besides the lack of drugs, there was the safety issue which made many Ugandans flee into exile.
Being in hospital did not make patients safe either. One incident happened at Mulago hospital, a Nubian lady had come with a gynaecology complication. As doctors prepared to put her on drip, some Nubian soldiers walked into the ward, threatening to shoot the doctors. They accused the doctors of wanting to kill the lady. They took away the woman, who was shortly returned dead.
The other involved the Israel woman, Dorah Bloch, who had been transferred from Entebbe airport to Mulago hospital from the hijacked plane. After the Entebbe raid, Amin was told of the woman on the 6th floor of the hospital. Army men dragged her by the hands from the top floor of the hospital, down to a waiting car and took her to her death.
There was an attempted coup said to have been engineered by his former chief of staff Charles Arube, but it failed. After Arube’s arrest, he was killed and his body brought to the mortuary. Amin came and asked to see the dead body in the mortuary. He told the dead man: “You wanted to kill me, now draw your gun and I draw mine.”
Neither were the doctors safe. While in the emergency ward, we had to keep disguised by not putting on the white coats and carrying our stethoscope in the open. We could not even put on ties; we had to blend in with the patients.
During the 1978-79 war, many victims of shrapnel wounds and gunshots were flocking to the hospital. The security situation was very bad and I decided to relocate my family out of town, knowing that once Kampala fell insecurity will stop. I took my wife and children to Kasangati and came back to Mulago.
The last two weeks of the war were the worst. I pitched camp at the main theatre of Mulago hospital, operating on wounded people. The theatre is on the first floor and the lifts in the hospital were not working.
We had to convert ward 1A and 1C into special wards for those waiting to be operated and those we had operated on. Fortunately, we had enough basic supplies to take us through those terrible two weeks.
Post Amin
After the war, I saw more deaths than during the war. Lt Gen Bazilio Okello’s men would randomly shoot at gatherings of people around the suburbs of Kampala. In Mulago alone, we lost a number of senior doctors like Bagenda, Barlow, and Obache. I understand Obache, a Langi, was killed because he was believed to be Amin’s ally. This was because Amin killed many Langis but Obache had survived.
Heading the national hospital 
Before being appointed the executive director of Mulago hospital in 1993, I was running a successful private clinic on Wilson Street in Kampala called Allied Medical Consultants as well as being a consultant surgeon at Mulago.
I had on three different occasions been approached by officials from the Ministry of Health with the job offer but I had turned them down. One evening, I returned home only to find an appointment letter signed by the Permanent Secretary Ministry of Health, appointing me the executive director of Mulago hospital.
I did not know what to do because I did not see how I could reconcile the two; being a director of the national hospital and running a private clinic. With my wife’s support, I agreed to take the offer and the next day I closed the clinic on Wilson Street to avoid the conflict of interest.
This I did painfully because I was going to lose income, what I was to be paid as the executive director was no way near what I was earning from the private clinic or what I earned as a senior surgeon in Mulago.
Unfortunately for the 12 years I was the executive director, I never got a single penny as the executive director of the hospital. After a year as the director, I resigned from being a senior surgeon and concentrated on the work of the executive director.
When I got there, I found a labyrinth of challenges awaiting my attention. They would have been overcome had the hospital been getting enough funding. By the time I was in Mulago, the annual funding was only 30 per cent of the total required budget.
Equipment at the intensive care and the main laboratory had broken down, the water and sewerage system was faulty, the roof of the hospital was leaking. Old Mulago and New Mulago were detached from each other, the staff at the hospital needed to upgrade their medical skills and knowledge.
To face all these challenges, I put in place a strategic plan, the first of this kind in the 80 years of Mulago’s existence. This saw me going to Nairobi to meet with the Japanese ambassador to solicit for some funding. Within three months of our meeting, I got $2.2m (about Shs5.8 billion today) for equipment for the intensive care unit and laboratory.
With the machines acquired, I needed training. I made contact with Pro Meme, the director Nairobi University, who agreed to train six of my staff in the use of the intensive care unit and laboratory machines.
All we were to do at Mulago was provide transport and meals. By the time they came back, the machines were being installed. The laboratory got equipment for haematology (blood), bio-chemistry (chemicals in blood), hespatology (tissue) and micro biology (microorganisms, bacteria, viruses etc.) tests. All these had broken down by the time I joined the hospital.
To refurbish the hospital structures, African Development Bank extended us a loan of $40m (about shs106 billion) to do the roofing, sewerage system, replacing electrical wires in the whole complex, creating a covered walkway connecting the old and new Mulago, leading to the rebranding of upper and lower Mulago instead of new and old Mulago.
I also managed to send people to India and America for training in open heart surgery and cancer treatment respectively.
High and low moment
During my career, there have been a number of high moments, these include when I was appointed the Pope’s surgeon in 1993 when Pope John Paul visited Uganda. I was the head of the medical team during US presidents Bill Clinton and George Bush’s visit to Uganda. I was also in charge of medical services during Kabaka Mutebi’s coronation and wedding.
During the visit of the two American presidents, I had to assemble a team at all the major hospitals to be on standby at Kisubi, Rubaga, Mulago, Mengo and Nsambya. During the Pope’s visit, I had an ambulance I was using to follow him everywhere he went, the ambulance had a full sterilised theatre for the entire week the Pope was here.
My lowest moment was when I contracted Marburg in Bugiri district.
Opinion on the health standards
Health standards started to fall during Amin’s time when the Asians and white doctors left the country. These people left with their research projects which were being done at Mulago. Mulago and Makerere were centres of research for different cancers. Among them was penile cancer (cancer of the penis). Mulago was carrying out research on Burkitts Lymphomas; all these stopped when the doctors were chased.
The cancer institute was under Prof Ziegler, an American, and Prof Charles Oweny, a Ugandan, who also had to flee the country. These people had made centre an international cancer research institute but with their departure the research there also stopped.
But I blame the fall of the system to all of us Ugandans as a people we have lost our values. We take everything we are given without asking why. Health workers have been emasculated with low pay, making them do things they used not to do professionally because they want to survive.
The ministry has also lost its oversight role; it’s no longer as sharp and effective as it used to be.

Dr. Lawrence Kaggwa is a board member:
He previously worked as the executive director of Mulago Hospital; Uganda’s National Referral Hospital for 12 years. He left Mulago to work as the Director Planning in the Ministry of Health in Uganda. He is a retired senior Consultant Surgeon a specialty he practised and taught for a long time. He currently works with AMREF (African Medical Research Foundation) as  a Consultant and has served on the board for many years. Dr. Kaggwa is the Vice chairman of the Board and the Chairman Human Resources Committee of the Board.

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