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

1 in 13 Ugandans are HIV+ and Reactions to my SMC Post

We received a number of comments after my initial posting about the Safe Male Circumcision Programme at IMG.

It’s true that SMC (MMC, VMMC) has its detractors. There are some that do not consider this procedure desirable and others who are concerned that circumcision may in fact lead to an increase in HIV infections and the spread of STIs.

Some have called into question the validity of the initial three research studies, often quoted as the reasons for these national SMC programmes. We welcome further research studies, designed to ensure that these concerns are addressed. As we embark on this programme in Uganda, we are keeping research and evaluation right at the heart of what we do.

When the BBC reported the news that in Zimbabwe MPs were coming forward for SMC, it noted these concerns:

But it is not the whole solution. Promoting safe sex, providing people with HIV testing services and encouraging the use of male and female condoms are all seen as equally important.

Some experts also say there is a danger in sending out a message that circumcision can protect against HIV because it could lead to an increase in unprotected sex.

We agree, it is essential that SMC is made an integral part of a comprehensive prevention programme. We are ensuring that both men and women understand that male circumcision does not give full protection and other preventive measures must still be taken, in particular continued use of condoms and knowing your partner’s status.

TNP ABC - Put it on like this

We are using the SMC programme as a unique opportunity to reach men who are often not present at our other community health outreaches. We are combining each of the reproductive health messages with the SMC message, covering e.g. HIV, STIs, Family Planning, PMTCT, the need for and importance of ante-natal visits and attended delivery. In that way we hope that both men and women will gain a better, more complete, understanding of all these related matters.

These programmes are hugely important in Uganda. Just this week the Ministry of Health reported new data showing that HIV/AIDS is on the increase:

The number of Ugandans infected with the HIV virus has increased by 100 per cent in the last seven years, it was announced yesterday. Results from the 2011 Uganda AIDS Indicator Survey show that one in every 13 Ugandan adults has HIV. The prevalence rate has surged from 6.4% in 2005 to 7.3%.

Joshua Businge from the AIDS control Program from the Ministry of Health attributed the incidence to multiple sexual partnerships (MCP) and failure to use condoms as one of the major reasons why the figures were going up.

You can read more about this announcement here and here.

Male Circumcision Programme in Tanzania reaches 100,000

The Maternal and Child Integrated Programme, MCHIP, announced this week that its safe male circumcision programme in Tanzania had now provided services to 100,000 clients. You can read the original press release by clicking on the image below.

MCHIP Logo

Estimations show that 16,000 future HIV infections will be averted between now and 2025 as a result of these 100,000 circumcisions. If accurate this means that for every one pound or one dollar invested in the SMC programme, about 14 will be saved in future treatment costs.

I shared this news with our own team and here’s the reply back from Francis, the in-charge at Hope Clinic Lukuli:

This is extremely very good news for East Africans. Overall, I think the success in TZ can be attributed to the immense family support for men going for VMMC as the article does note. For example, a son and his mother accompanying a father to the VMMC CENTRE and also availing himself (son) for the VMMC is extremely awesome. Also, not forgetting the hard work of the local medical team, the nurses.

For Uganda, there is a lot to learn from TZ especially how can we have full family support for men in Uganda to get the numbers we desire for VMMC? Also can we have work places support the VMMC so that men who work can benefit fully from this? Can registering, HCT and STI treatment and carrying out the procedure in one day work better than giving appointments? Lastly, why do some men register and never show up?

VMMC – voluntary medical male circumcision

SMC – safe male circumcision

These are the same, just referred to differently in different places.

HCT – this is the counselling and testing for HIV, an integral part of an SMC programme and sometimes also referred to as VCT.

Mark dies and Benton leaves

This was a traumatic week; Dr. Benton decided to leave ER to spend more time with his family and Dr. Mark died.

Pamela and I are just catching up on some ER DVDs, almost 10 years old now, but some of the issues travel far and long.

It is hard to plan and manage hospital operations when we are so reliant on good medical personnel. Uganda has a huge shortage of doctors and even in the last week we lost one of our in-house OB/GYN to a hospital in Botswana; the “Brain Drain” is very real.

This Country needs to quickly train more MOs and to explore more seriously how it can safely “task shift” to lesser credentialed, specifically trained cadres; e.g. we need Clinical Officers who can safely and legally perform C-Sections and Nurse Practitioners who can take on more clinical work. Our Clients need to be more willing to accept that some services can and should be provided by Midwives rather than Obstetricians.

Oh and the day after Dr. Mark died, the ER continued on as normal; sure his friends were sad and missed him but neither Mark nor any of us are indispensible.

K.

Communities Being Served – KCCL, HIPS and IMF

By Clodagh:

Kasese is in the West of Uganda and this programme is operating in communities on the shores of Lake George.

All three of the communities being served, which have an approximate total population of 10,000, suffer from extreme poverty. This is mainly due to their near sole dependence on small-scale fishing, the produce of which is sold in the local market. The local people are unable to afford large fish so the fishermen must catch small, immature fish. As well as being illegal, this may be putting the future sustainability of this activity at risk.

The simple fishing boats used in the area

Inhabitants of both Kahendero and Hamukungu are unable to farm the land as they are within the boundaries of Queen Elizabeth National Park. They are forbidden from growing crops by the park authorities and any cattle owned by the community members are under constant danger from predators such as lions. As a result the population survive on a diet almost solely comprising of fish.

Living conditions are poor with housing consisting almost entirely of small wattle and daub houses with one room per family. Most do not contain a bed and are only furnished with a couple of cooking utensils. Additionally, toilets are few and far between and the majority of the locals are forced to resort to the bush despite the obvious dangers from the park’s wildlife.

Typical housing in the area

Water is also a problem as many of the inhabitants of the community have no access to a fresh, clean supply and so they are forced to drink the lake water. This is the same water that is used for washing, bathing etc. and has lead to numerous outbreaks of diseases such as cholera, dysentery and typhoid.

All of the communities contain a primary school and Hamukungu has its own secondary school. Yet there is a major problem with absenteeism as many pupils go out fishing on the lake instead of attending.

The communities receive little other healthcare and any problem that can’t be dealt with by the project must be referred to Kagando or Kilembe hospitals. Yet this in itself can cause problems as the hospital can be up to 40km away from the patient’s house and many cannot afford the cost of transport. Even at these hospitals there is no access to facilities such as X-ray, scans etc.

This poor socio-economic status in the communities has lead to feelings of hopelessness. This, coupled with the boredom of small town life and lack of activity, has caused many to resort to alcohol. The resulting problem with alcohol abuse, in conjunction with the large number of sex workers in the area, has lead to an increase in HIV high-risk behaviours and therefore greater vulnerability to HIV infection. Additionally, it perpetuates the vicious cycle of poverty.

Map KCCL

Coke and Primary Healthcare

It’s a simple pleasure; ride my bike through the local communities until exhausted – which for me in this heat and with these hills doesn’t take very long. I’ll admit, at times it might have been better described as “there’s Kevin taking his bike for a walk…”

When exhausted stop at a local shop (for local people) buy an ice-cold coca-cola and drink it from the bottle.

A_simple_pleasure

It doesn’t matter where you are in Uganda, you can always find somebody selling Coca-Cola, usually from one of those red fridges and often cold. That made me think about the delivery of primary healthcare. Now I’m not about to equate the distribution and supply of a cheap commodity such as a soda with PHC, but I do think there are some principles that we could adopt.

Coca-Cola is available, accessible and affordable to all in Uganda. Those buying it can be assured of its consistent quality and the price is known to all parties before the transaction begins. Sometimes we may choose to pay more, for nicer surroundings, to have it brought to the table and served in a glass with ice – but it is just the same coke as that bought from the shop in the picture above. There is something quite equitable about this.

Healthcare planners should be seeking to ensure that primary healthcare is available, accessible and affordable to all in Uganda. It will take some effort and perhaps legislation or self-regulation to ensure a consistent quality of care. The price thing is something that should be easier to make happen. Wouldn’t it be better if there were set prices for consultation, test and treatment of the common ailments; so that those wanting to use the services know, before coming, how much they will be asked to contribute? Making it affordable, that’s the next challenge.

Isn’t it great when you get to freewheel downhill, makes all that effort seem worthwhile.