6,172 Health Workers to be Recruited

It seems that the Government of Uganda has agreed the need to recruit more healthcare workers. That’s really good news and something that should be positively received. The Ministry of Health will need to make sure that matters affecting morale are also tackled; salaries are too low, health centres are often in a poor state of repair lacking equipment and medical supplies. These issues all contribute to poor morale and staff seeking alternative opportunities. These extra six thousand will not be sufficient to bring the numbers of healthcare workers to the levels that WHO suggest are required, or even to the average in the Africa region. If all 6,172 new recruits are doctors (very unlikely), Uganda would have 1.8 per 10,000 citizens; the average in the Africa region is 2.2.

Toward an AIDS-Free Generation

U.S. Chargé d’Affaires, Virginia Blaser made a statement recently about the on-going support by the USA for healthcare in Uganda and for the fight against HIV/AIDS in particular. You can read the statement in full here.

This statement of support comes at an interesting point in time. The Uganda Ministry of Health has just recently announced that a recent survey shows the prevalence of HIV has increased to 7.3% of adults, that’s about 1.2m people, more than double the number estimated 7 years ago.

In Uganda, with the support of Target TB, Touch Namuwongo (IMF) has improved access to health education and HIV testing in the community through outreach work. Here a fully trained community healthworker undertakes blood tests at a mobile clinic.

In June the Government of Uganda announced that the allocation of national budget to the Healthcare sector would be reduced from 9.8% in 2011/12 to just 7.6% this year. Depending on the exchange rate this is equivalent to about $307m.

In her statement, Blaser starts by reminding us that since 2004, the American people have invested over $1.7 billion in support of the national HIV response in Uganda. Most of this has been channelled through PEPFAR, for which we should always give a note of thanks to former President George W. Bush.

In 2003, Bush launched the President’s Emergency Plan for AIDS Relief (PEPFAR), pledging $15 billion to end the suffering and save lives threatened by the AIDS epidemic. In 2008, Congress agreed to provide $38 billion more.

In Uganda an estimated 600,000 people living with HIV need to be treated with ARVs but only 330,000 are currently receiving these life-saving drugs and of those the USA directly supports funding for 314,000. Antiretroviral treatment, ART, means that a person living with HIV can expect to live as long as their fellow countrymen who are HIV infection free.

We know that ensuring early and sustained access to ART for all those that need it will be a very significant intervention in the fight to reduce the growing numbers of new infections. So it is good to hear Blaser state:

the PEPFAR program in Uganda will review its programs to ensure that we prioritise treatment expansion to ensure all who need ART receive it

On July 5th Blaser stated that $425m will be given in Aid to boost Uganda’s health sector. This is more than 60% of the total Aid being given by USA to Uganda and is some 40% more than the GoU budget allocation.

That budget allocation is coming under increasing scrutiny. Blaser urges the GoU to increase the allocation to the 15% committed in the Abuja Declaration. Whether or not the country can afford to reach that target, it should perhaps be a little more circumspect before revealing that it spends some $150m to send VIPs overseas for healthcare treatment.

It is clear to me that fighting HIV is more than just about GoU budget or Aid from USA. That budget and Aid need to be used more effectively, we need to focus our attention on proven interventions that we know will work. Implementation will involve many different partners from all parts of the health sector and as Blaser says:

By working together, we can free Uganda from this terrible epidemic.  Let us all fight together for an “AIDS-free generation.”

Uganda Aids Indicator Survey 2011–Preliminary Report

Uganda MoH has released a preliminary report of its findings from the Aids Indicator survey. Data were collected between February and September 2011.

This survey was designed to enable data to be compared with those collected during the previous survey in 2004-5.

Male Circumcision

The prevalence of male circumcision, 23%, has not changed since the last survey and there are only small variations in the data by age groups. This indicates that there is little change in the practice of MC over time. The prevalence of MC for reasons of faith, culture or tradition continues as before.

There are wide variances of MC prevalence across the country and across wealth quintiles, men in the higher wealth quintiles are more likely to be circumcised. About 35% of men in Kampala are circumcised whereas prevalence is less than 6% of men living in the north of Uganda.

Knowledge of HIV Transmission

About 75% of adults are able to say that remaining faithful to one uninfected partner and always using a condom are ways of reducing the risk of becoming infected with the AIDS virus, HIV.

The survey also identified the numbers of those with misconceptions about how HIV is transmitted. Just less than 50% of adults think that HIV can be transmitted by mosquito bites and up to a quarter think that you might become infected by sharing food with a person living with HIV.

Comprehensive knowledge measures those that can state the two means of reducing HIV infection, know that a health-looking person can have HIV and can also reject the two most common misconceptions. Interestingly the survey shows that less than 40% can be counted as having comprehensive knowledge; so there is still room for improvement in the way in which we are delivering the prevention message.

Stigma and Discrimination

There is a section in the survey which attempts to uncover attitudes towards people living with HIV. Stigma and discrimination are still issues that will need to be addressed. These can lead people to stay in denial and refuse to come forward for counselling and testing, an essential first step in the prevention campaign. Others may keep their infection secret from others, which in turn may lead to further transmission.

Sexual Behaviour

The most likely mechanism for transmission of HIV in Uganda is through unprotected sexual intercourse with an infected partner (heterosexual). There are growing concerns about the increasing prevalence of those with multiple concurrent partners, MCP.

The survey asks a number of different questions related to this. I think the most interesting result is that less than 16% reported using a condom during their last sexual intercourse, which when combined with the admitted numbers of multiple partners is a worrying trend. This presents an interesting dichotomy between what people state as knowledge (be faithful and use a condom) and actual behaviour.

HIV Prevalence

Prevalence rates might be increasing, this survey indicates the overall rate to be 6.7%, which is higher than the previous 6.4% but this movement may not be statistically significant. Prevalence among women is higher, 7.7%, than in men, 5.5%.

A later press release by the MoH stated the prevalence rate as 7.3%, which means as many as 1 in every 13 adults in Uganda are HIV positive.

You can access the survey report here: http://t.co/98S1RkUe

Healthcare Funding in UK and Uganda

Healthcare Funding is one of those polarising topics that generates a lot of debate; people tend to feel quite strongly about their particular view on how this should be done. Just consider the debates raging today in the USA about Obamacare, in the UK about NHS reforms and in Uganda about the recent cut in the share of government budget allocated to the healthcare sector (down to 7.6% from 9.8% last year).

The Guardian recently presented data showing the spend on healthcare for 193 countries. Now we may have seen these data before but this time I noticed that the UK and Uganda spend almost the same when measured as a percentage of GDP.

Health spending as a % of GDP

Such a measure or that showing the comparative per capita spend will of course highlight just parts of a complex whole. These are measures of Input and do not tell us about the resulting Outcomes.

One of the problems in measuring just the spend is that we cannot easily tell how such spend is shared across the whole population. We know that the rich tend to access more than a fair share of the healthcare services and we can also see that in each country there are many who cannot always afford necessary care.

UK Uganda
Healthcare spending,
% of GDP
                  9.6                   9.0
Government spending on health as % of all health spending                    84                    22
Private spending on health as % of all health spending                    16                    78
Per capita total spending on health
(PPP int. $)
              3,480                  124
Nurses and midwives per 10,000 population                  101                    13
Doctors per 10,000 population                    27                      1

The Guardian says that it intends to add indicators of Outcomes that may help to make useful comparisons and give some sense of which country is doing best or which approach to healthcare funding is most effective.

In the meantime it has published the number of doctors, nurses and midwives per 10,000 population. Now this is not a direct measure of outcome but one would hope that it is a significant driver of good outcomes?

What I don’t understand is how these two countries can be spending similar percentages of GDP and yet the numbers of clinical staff being provided are very different.

It must mean that the budget is being allocated across various costs in very different ways. Perhaps the cost of drugs and treatments requires a higher percentage allocation in Uganda? Perhaps more of the budget is spent on central administration or on capital developments? Perhaps there is just a general lack of cost efficiencies or insufficient management and accountability of the monies being allocated.

In September 2011, in response to the UN General Assembly held in New York, the Uganda Ministry of Health stated that the country had a gap of more than 2,000 midwives, needed to help improve maternal and child health. Adding such a number would simply move the number of nurses and midwives per 10,000 population to 14.

If you would like to access the WHO data for Healthcare Funding in 193 countries and the comparative indicators discussed above then please use this link: http://bit.ly/LpJJMd

The BBC has a good explanation of what GDP is and how it is measured.

Cost of Providing Universal Coverage

The Uganda Ministry of Health has set an overall goal to achieve Universal Coverage. If achieved this would enable all of its population to seek care without financial constraint or any concern of financial hardship as a result of accessing health services. It would also imply that required health services were easily accessible and available to all, at their time of need.

In 2001 the WHO “Report of the Commission on Macroeconomics and Health” suggested that on average it would cost $34 per person per year to provide the full set of essential heath interventions. These are broadly those covered by Uganda’s National Minimum Health Care package, UNMHCP.

The equivalent in 2008 allowing for an average of 6% pa inflation is $51.

WHO data show that in 2008, in Uganda, the total health expenditure (THE) per person was just $33. So a shortfall of $18, about 35%.

The Government of Uganda contributes about 23% of this total, $7.59.

Donors, NGOs and charitable giving contributes 38% of the total, $12.54.

That means the sick and their families are paying on average 39% out-of-pocket (OOP), $12.87.

There is general acceptance, which we will explore another time, that this OOP expenditure is too much for the majority of the population and perhaps a major barrier preventing the most needy from seeking and accessing basic health services.

Donor funding is generally not deemed to be a sustainable means of funding health care.

So the GoU will need to increase its share. As mentioned before, Government spending on health care is capped at 10% of the overall government budget. So unless this approach is changed we will need to see a significant increase in the overall national budget, which would imply either greater taxation or a much higher national GDP. The 10% of budget allocated to health care is equivalent to 1.4% of GDP. The CIA World Factbook shows Uganda’s GDP as $17b.

GDP in Uganda has been growing strongly at more than 6% per annum, but this is largely negated by both inflation and the growth in population which is the second highest in the world at 3.5% pa.

A recent report in the Sunday Monitor indicated that Uganda may be able to produce up to 120,000 barrels of oil per day (it currently imports all of the 13,000 barrels/day it consumes; source CIA). This new local production could result in up to $3b additional annual income, about 17% of GDP. So in future years oil could be a significant contributor to the country’s economy.

How might this impact the GoU health care budget allocation?

If we use current budget policy (10% to health care) and the same 1.4% of GDP as above, oil production will only add about $1.35 per person per year for health services.

If we take a more optimistic view (one not likely without a shift in GoU policy) and increase the allocation of national budget to health care from 10% to the 15% agreed in the 2001 Abuja pledge, this would be equivalent to 2.1% of GDP. GoU would be contributing an extra $3.80 per capita and oil would contribute an additional $2.03. This total extra of $5.83, whilst very welcome, is still small compared to the estimated gap in funding, $18, that contributed from overseas, $12.54 or OOP, $12.87.

So not even the promise of wealth from national oil production or a change in GoU economic policy will be enough to significantly, or materially, reduce the financial burden on the sick paying out-of-pocket or reduce the country’s reliance on necessary funding from overseas.

In order to defray the full contribution to health care from overseas, the GoU would need to spend up to 13% of the estimated revenue generated by oil production. Such an approach would certainly be possible, but I wonder how likely it might be; still it’s something worth pushing towards.