The news from around the country is not good; in some places
we are hearing of people with access to anti-retroviral
treatment succumbing to the Aids condition because
they do not have food to eat (healthy eating is an essential
factor in managing the condition), while in other places
HIV/Aids sufferers with food do not have access
to therapy partly because the high incidence of
infection, has outstripped the financial resources
currently available to make ARVs available.
However, in a few weeks, an agreement between
the Uganda government and a local drugs producer,
Quality Chemicals (QC) will be complete.
The agreement will specify what nature of life-saving
HIV/Aids drugs the company will provide for
the 300,000 or so Ugandans infected with
the HIV virus and require treatment.
It is what health managers and experts in
Uganda's checkered fight against the pandemic
hope the future will look like.
Locally procured medicines with Ugandan
taxpayer's money to replace a long, and some
say dangerous addiction to donor-funded procurement.
The government has set aside some
Shs60 billion to procure locally manufactured
ARV's from QC - a business with suspected
strong connections to the higher-ups of
the ruling National Resistance Movement party.
Until this point, the country's HIV/Aids response
plan has been "rented house" for donor countries
and NGO's providing virtually all Anti-Retroviral
This has bred a situation which some say
has made Uganda a hostage to the agenda set
by big Western-based pharmaceuticals who
benefit from the millions of dollars spent by
Western countries supporting
the treatment of Ugandan patients.
Regardless of the truth or not of such views- what
is factual is that there are major contradictions
in strategy - led by the concern that the national
response is tied too tightly to the rules
governing the money outsiders provide.
That's the part that the Ugandan authorities
have no control over.
A glance at the plethora of organisations
involved in HIV/Aids management and
the mangled distribution network for drugs
cannot qualify the success of treatment
It's to the broken health care system that
some point for most of the problems that
Uganda is facing.
One observer pointed out that in one district
like Kabale there are multiple organisations
all providing ARV's including The Aids Support
Organisation (TASO), the Joint Clinical Research
Centre and the Ministry of Health itself.
There could be more.
And this scenario is replicated around the country.
Ideally information about all patients and their
needs are tracked and fed into a nationally
coordinated plan but experts say
far from it – and despite the hype about
Uganda's successes in the past - there
are huge gaps in information – HIV/Aids treatment
is in a mess.
It's a statistical nightmare as many varied
figures are churned out and no consensus
exists on the correct number of patients,
infections and trends.
The Aids Information Centre (AIC) should know
but says it does not.
"MoH does not have a complete list or
general number of patients (although it claims
it does)" says Dr Raymond Byaruhanga
of the AIC who says most organisations
report centrally to the Ministry of Health.
With a reported rise in new infections, confirmed
two months ago with much alarm
by Uganda Aids Commission chief,
Dr Kihumuro Apuuli, there is also a moral and
medical dilemma as patients old and fresh
are suddenly left without drugs for months.
And it goes something like this.
In light of the financial crisis, accusations
of corruption such as the Global Fund saga,
money for Aids treatment is dwindling
leaving patients reeling as stock-outs are reported.
There are unconfirmed reports of deaths of patients
unable to get their regular dose at
government-mandated clinics, says Dr Byaruhanga.
"There are too many players and little coordination
between them," he says, adding that in fact
Uganda has no reliable numbers of
HIV-infected persons or those on treatment.
"We have poor statistics which means
we plan badly," he adds.
Fortunately, despite that poor planning
there are pockets TASO where patients
are guaranteed regular supply because
unlike other players it is in charge of its
entire chain including procurement of drugs.
"The solution is twofold.
Uganda can produce its own drugs and supply
to its patients or pay for treatment
of patients directly [as opposed to donor funds.]
I pay taxes why should I not get treated
by the government?" asks TASO director
Robert Ochai, who recognises the dependency
but says patients must come first.
TASO and other organisations reflect
the schisms in the patchwork of HIV/Aids treatment.
"The donors run a parallel process,"
explains a senior Ministry of Finance official
who tracks health care spending.
"Government has little control over what they do".
The official who could not be named because
they were not authorised to speak to the media
on the matter told Sunday Monitor that
the National Medical Stores – the official
drug repository - only distributes donor drugs
to accredited distribution centres.
This means that NMS can only distribute
what has been delivered to it and to whom
it is instructed to.
Currently, the body has Aids drugs to last
five months (this is matched to pre-existing
programmes not new ones) in stock.
"We receive ARVs on behalf of the government
and distribute them according to instructions
from the Ministry of Health.
Currently there are two Ministry of Health staff
at NMS helping in translating orders from
treatment centres and drawing up
allocation lists" said NMS publicist Hamis Kaheru
in an emailed response to Sunday Monitor.
"It is against those orders and allocation lists
that ARVs are picked and packed in our stores
and then delivered to treatment clinics.
Therefore it is true that we don't control
how much ARVs we stock and distribute.
However there are indications that this will
change soon because we have been informed
that NMS may start handling supplies from
Quality Chemical Industries Limited (QCIL)
for which government pays QCIL directly.
Therefore we shall be dealing with
QCIL directly" he adds.
The involvement of the Ministry of Health
suggests that the government has some say
in procurement and distribution but according
to Dr Byaruhanga there remains an unequal
relationship between the state and donors.
He argues that this explains the bizarre situation
where tonnes of drugs are procured
for non-existing patients which then expire
on NMS shelves.
He adds that donors still have a bigger say on
where to procure the drugs leading to delays
especially when there is disagreement
"For example PEPFAR (the American-funded Aids
support and treatment programme) objected
to procurement of drugs before including
from Quality Chemicals.
Where the donor pays,
he calls the tune" he said.
The head of planning at the MoH, Dr Francis Runumi,
in a phone interview on the sidelines of
a health conference in Kigali however
said the relationship between the ministry
and donors is governed by a Procurement
and Supply Plan (PSP) which acts as
an agreement of sorts as well as a roadmap.
It details the quantity and type of HIV/Aids drugs
that are required.
It's based upon this agreement
that procurement on a competitive basis is initiated.
Health officials say that a lot of Uganda's Aids
drugs are procured this way and suppliers
of both generic drugs like India's Cipla (a partner
in QC) and well known global pharmaceuticals
compete on even ground.
However, the PSP governs mainly procurement
out of the Global Fund for HIV/Aids,
Tuberculosis and Malaria.
Other organisations that procure for themselves
including PEPFAR which runs one of the biggest
budgets determine their own suppliers.
According to Lynne McDermott, the PEPFAR
communications officer based at
the American Embassy in Kampala - the programme
will continue to spend $280 million annually
on HIV/Aids through 2013.
"There are indeed problems with the supply
of ARV's in the national programme"
she acknowledges and adds that even
with PEPFAR's funding
"there is a gap between national treatment
needs and funds available to provide treatment".
PEPFAR funding accounts for the largest
percentage [61%] of off budget money
for health care in Uganda according
to an August 2008 study.
The US embassy notes that American money
alone is two thirds of HIV/Aids response in Uganda.
A major distortion in Ugandan government
spending on health care is precisely because
it is a minority stakeholder.
Of the close to $800 million planned for spending
on healthcare in the financial year 2009/10 half
is donor money.
It is however unclear if the government would
be better organised had its own funds
Organisational weaknesses clearly
exacerbate the problem of making the best
use of the money available.
A study by the World Bank for example
found that nearly 90% of all drugs at NMS
did not reach their intended recipients - let alone
the leakages in the public health sector
blamed for the waste that goes on.
Former health minister Mike Mukula says
inconsistencies in the fight against HIV/Aids
is entrenching the disease.
"The way you make babies is the way
you get HIV.
Uganda's population is rising and the politics
of procurement must be put aside.
No single African country can meet
the bill of costs for treatment.
Aids should be de-politicised nationally
and internationally so that all hands
are on deck in this fight," he said.
After two decades in the trenches it will
take more than speeches to turn the page.
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