Category: Health

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Who Cares About Cancer?

Cancer is not captivating. Or, at least, in sub-Saharan Africa it doesn’t seem to be when compared with, say HIV/AIDS or malaria. Why is that? Is it the sheer numbers? The assumption that you are more likely to die of a communicable disease before you will ever develop cancer in this region? Or maybe, like global warming, it’s a scary topic that it is easier to put off thinking about until tomorrow. Or the next day…Or the next day…

It seems like a lot of friends of friends are dying or have died from cancer recently in Kampala. On Sanyu FM this morning, a caller asked for advice on how to handle his relationship with a girl who had terminal cancer. While I have long been interested in health and healthcare in Uganda, I have never looked much into cancer prevalence or treatment. I assumed, at any rate, that treatment was prohibitively expensive for most people when available at all. But do we even have accurate figures on who has cancer and where? I went circles around the WHO Uganda site to find any figures. At best they have projections for 2005, based on 2002 burden of disease estimates. Not exactly what you might call up-to-date or very accurate.

I next went to Uganda’s most recent Demographic and Health Survey, from 2006. I was shocked to find that in searching “cancer”, there was a SINGLE result, out of 501 pages! It was a note on reproductive organ cancer made in reference to the Sexual and Reproductive Health Policy Guidelines that had been developed in 1994.

According to WHO’s stats, cervical cancer is the most common form of cancer in women, followed by breast cancer. In men, the most common is prostate cancer, followed by esophageal cancer. Lung cancer is surprisingly low on the list (9th for men, not even ranked for women), given the number of people I see smoking around Kampala (of course this is not indicative of the rest of the country, but still, Kampala-ites are more likely to be diagnosed anyway I would imagine).

Uganda does have a Cancer Institute, which is almost definitely underfunded, understaffed and ill-equipped, though I haven’t done much in-depth investigation of the place. While cancer may not yet be killing as many Ugandans as malaria or diarrheal disease (which primarily affects children), I have a strong suspicion that it is much more prevalent and pernicious than meets the eye. It may not be captivating, but it is killing. More on this to come…

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Why?

This weekend should have been a time of celebration for Uganda’s best performing secondary school students. Instead, the family of Isaac Bunkedeko, the best A level candidate of Namilyango Secondary School according to the New Vision, was in mourning.

The young man had planned to study law at Makerere University and become a lawyer, according to today’s article in New Vision. But last week he got a headache, and was subsequently taken to a clinic on Thursday. When his condition did not improve he was taken to the (infamous) Mulago hospital, where he died at 1am on Friday morning. The medical report stated that he had died of “sinuses”.

All I can wonder is WHY?? While it is possible to die of sinusitis, it is very rare, and usually due to the condition going untreated or undiagnosed, or complicated by another more pernicious illness. In any case, I do not understand how or why this happened. In the absence of contradictory evidence, I can only conclude that Uganda’s deplorable public health system has let down yet another bright star.

RIP Isaac Bunkedeko.

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McCain’s Worst Ideas — Gag me


Foreign Policy magazine has recently published what they consider to be each of the presidential nominees’ 10 worst policy ideas. Among them was McCain’s support of the Global Gag Rule (excerpt from the FP article below).

Supporting Abstinence-Only Education and the Global Gag Rule

What he said: Asked on the campaign trail if he thought grants for sex education should include instruction on contraception, McCain turned to an aide for help, saying, “Brian, would you find out what my position is on contraception—I’m sure I’m opposed to government spending on it, I’m sure I support the president’s policies on it.” The reporter asked, “Do you think contraceptives help stop the spread of HIV?” After a long pause, McCain replied, “You’ve stumped me.” —Town hall meeting, Iowa, Mar. 16, 2007

Why it’s a bad idea: A landmark, 10-year study sponsored by Congress found in 2007 that students in sexual-abstinence programs “were just as likely to have sex as those who did not, reported having similar numbers of sexual partners, and first had sex at about the same age,” the Chicago Tribune reported. Abstinence-only education is one of the core principles guiding the so-called global gag rule, an executive order passed by President George W. Bush in 2001 that prohibits giving foreign aid to NGOs that offer any kind of counseling on abortion as family planning. McCain voted against repealing the measure in 2005. Critics of the gag rule point to reports showing a shortage of contraceptives, clinic closings, loss of funds for HIV/AIDS education, and a rise in unsafe abortions since it was instituted.

Now, I have many issues with foreign aid and the global aid industry, including bilateral donors like the US, and am highly skeptical of the effectiveness of the President’s Emergency Fund for AIDS Relief (PEPFAR). HIV/AIDS has become an obsession of the aid community and has hijacked or otherwise derailed domestic health priorities. While the global gag rule should not be the biggest of our concerns regarding foreign aid, it just goes to show you the hubris of aid policy makers. Abortion is illegal in Uganda — but whether or not NGOs in the country offer any kind of counseling on abortion should be the concern of Ugandans, not Americans who have themselves legalized the practice.

I am not at all confident Barack Obama will help make critical changes to the aid industry — there has been little evidence that he is thinking differently about foreign aid than his party typically has. But I am certain that a President McCain would make the same self-righteous and arrogant blunders as his predecessor. Which experience shows will do little to help those on the receiving end of aid, and which will burn a lot of taxpayers’ dollars on the way.

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1.3 trillion

In the coming year, approximately 1.3 trillion shillings, close to US $780 million, will be spent on the health sector in Uganda. The official budget weighs in at about Ush 630 billion (including both domestic and external funding), and off-budget support is approximately Ush 700 billion. Yet, awash in cash, the health sector is drowning.

Infant mortality stands at 76 per 1000, and under-five mortality is even worse – 137 out of every 1000 children will die before their fifth birthday, according to the 2006 Uganda Demographic and Health Survey (UDHS). Life expectancy at birth is 49 years for men and 51 years for women. The Ministry of Health (MoH) reports that there is only 1 health worker for every 1236 people. Even this figure distorts reality as an estimated 70% of doctors and 40% of nurses serve only 12% of the population, according to the MoH’s Master Plan for Accelerating Performance in the Health Sector. And it gets even worse – absenteeism in health facilities has been estimated to be as high as 47% on average, according to recent studies.

Though it is difficult to capture off-budget expenditures, it is likely that the health sector will receive more money than any other sector this year – surpassing even the budget for works, which will receive approximately 1.1 trillion shillings in 2008/09. Where is all this money coming from? More importantly, where is it going?

According to the June 2008 budget speech and the Medium Term Expenditure Framework (MTEF), the Ministry of Finance has allocated approximately Ush 375 billion from the domestic budget this year to health, split fairly evenly between the Ministry of Health and District Primary Health Care, with a smattering of funding toward Mulago Hospital Complex and District Referral Hospitals. On-budget, donors will contribute Ush 253 billion, 250 billion of which will go directly to the Ministry of health. Off-budget, the U.S. President’s Emergency Fund for AIDS Relief (PEPFAR) alone will this year contribute US$283 million for HIV/AIDS screening, prevention and treatment. Additionally, another Ush 300 billion will be spent on the health sector off-budget by donors such as USAID, DFID, and the governments of Italy, Ireland, Norway, and Sweden, among others. Altogether – domestic and external, on and off-budget – the health sector is thus set to receive over 1 trillion shillings.

Despite this flood of money, even the president has begun to feel the pain of the ailing health sector – and not just because he is forced to fly his daughter abroad on a private jet to deliver her baby. In April 2008 he wrote a letter in frustration to Minister of Health, Stephen Malinga, titled, “Alleged Gross Mismanagement of the Health Sector.” He lamented, “Whenever I travel up-country, I am accosted with complaints of lack of drugs and absenteeism of health workers in health units.” If it is gross mismanagement and not lack of funding that is resulting in a decrepit health sector, where is all the money going?

There are two major issues at play – allocation of resources and management of those resources. It is not an exaggeration to describe the global community’s interest in HIV/AIDS as an obsession, and this obsession has serious implications for the allocation of money in countries like Uganda, where HIV/AIDS has at times reached epidemic levels. Looking at a breakdown of the budget, US$ 283 million (around Ush 467 billion) from PEPFAR will go toward HIV/AIDS, US$139 million (around Ush 230 billion) from the Global Fund will go toward HIV/AIDS, TB and malaria and Ush 60 billion will go toward the purchase of Anti-retroviral drugs (ARVs) and malaria treatment from the Uganda based pharmaceutical plant Quality Chemicals. Additionally, in their most recent grant proposal from the Global Fund, the MoH estimated that “other AIDS development partners” (not including Global Fund) would contribute between US$22 million and $27 million this year, or approximately between Ush 36 billion and Ush 45 billion. While the aforementioned funds include money earmarked for malaria and TB, the majority will go to HIV/AIDS. Altogether, the sum of funding dedicated to HIV/AIDS, malaria and TB is at least Ush 790 billion, according to sources from the MoH, Ministry of Finance, the Global Fund, and the U.S. government.

The MoH, in its Round 7 proposal to the Global Fund stated that the “overall disease specific needs costing including essential disease specific health systems needs” for HIV/AIDS in 2008 would be Ush 309 billion and in 2009 Ush 329 billion. Even if only half of the Ush 790 calculated above went toward HIV/AIDS programs (an extremely conservative estimate given donor priorities), this should still be enough money to cover the MoH’s self-reported needs for HIV/AIDS. Even if this admittedly back-of-the-envelope calculation was incorrect, the same Global Fund grant proposal specifically states: “Based on the national strategic plan [NSP] prioritized goals and objectives, a resource needs model was applied to estimate the resources needed to meet the coverage costs of the plan. The estimate of the overall HIV/AIDS national response needs costing indicated a requirement of US$ 263 million for the first year of the NSP [2007/8] increasing to US$ 362 million in the financial year 2011/12.” According to this assessment, PEPFAR alone will cover the entire HIV/AIDS national response this year.

Nevertheless, of the Ush 98 billion in additional allocation to the health sector from the Ministry of Finance this year, Ush 60 billion will go toward HIV/AIDS and malaria drugs, the vast majority of which will go toward ARVs. Why? MoH officials say that there remains a large funding gap, in spite of donor contribution, and that an estimated 200,000 people are approved for ARVs but are not as yet receiving treatment. Additionally, in 2005, as an “investment incentive” the government of Uganda signed a memorandum of understanding with Quality Chemicals committing to purchase US$40 million worth of HIV/AIDS and malaria drugs per year. Thus, other sector priorities notwithstanding, US$40 million will be pumped into primarily into funding ARVs. While the idea of the plant was to enable Uganda to become self-sufficient and independent, donors such as the Global Fund and PEPFAR are not buying their drugs from Quality Chemicals – the plant has not yet met the required standards.

However well meaning, donor priorities have hijacked the health sector, pumping it full of money earmarked for specific health issues that do not always align with domestic health priorities. This dependence on donor funding is neither sustainable nor beneficial to Uganda. Already the country has run into serious issues with the Global Fund that has resulted in the suspension of grants. Most recently, the Inspector General for the Global Fund, on a visit to Uganda, warned that if progress had not been made on the recovery of money and prosecution of individuals named in the 2006 Ogoola Report, Uganda’s grant would again be suspended.

Donor funding for Uganda’s health sector on the whole has been “volatile and unpredictable” according to the World Bank’s Uganda Public Expenditure Review (PER) 2008, presented to the budget division of the Ministry of Finance on July 7. It was also noted that “funds are not always aligned with domestic priorities,” and donor commitments were almost always higher than the disbursement of funds. Given the challenges associated with relying upon donor funds, Uganda should strive to become independent of external funding and donor-set priorities.

The PER made several recommendations for Uganda’s health sector. Despite the seemingly staggering budget that the sector will receive this year, the PER concluded that Uganda should increase health spending. It specifically noted that “rapid population growth, increasing unit costs and unsustainably high donor funding create risks,” and that “efficiency gains are clearly possible.”

Many of these efficiency gains can be made in the area of human resources, which was a major area of concern that Malinga noted in his May 2008 letter to the President. Addressing human resource deficiencies and inefficiencies has been a sector priority for some time, but budget allocations have not reflected this prioritization, largely because Uganda has not been setting the agenda for the health sector – donors have. There is much information available on Uganda’s health sector and there has been considerable analysis examining health sector reform.

In April 2008, the Ministry of Health released its Master Plan for Accelerating Performance in the Health Sector, which highlights “areas of strategic concern that require immediate attention,” including Human Resources, Infrastructure, Essential Medicines and Health Supplies, and Operational Budget. Given this strategic plan, it would seem unwise to allow the donor community, however well intentioned, to dictate Uganda’s health budget allocations or distort its priorities. Pumping the sector full of money allocated by donor priorities has led it to burst, with wasted resources leaking out on all sides. The health sector is being trampled in the stampede of donor goodwill and while the Ministry lines its pockets, the greater population of Uganda is suffering.

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Preventing child deaths in Uganda

Dr. Addy Kekitiinwa’s phone will not stop ringing. And as the executive director of Baylor College Medicine Children’s Foundation in Uganda and seated at the Paediatric Infectious Disease Institute at Mulago, it is no wonder. Five minutes and as many interruptions into our interview she gets up to close the door to her office, takes her desk phone off the hook, silences her mobile phone, and sits down again with a smile and at full attention. “Now which study did you want to talk about?” she asks. Her question is indicative of the scale and scope of her work. She is an author of a study recently published by the World Health Organization (WHO) that found the Hib bacteria (Haemophilis influenzae type b) has been virtually eliminated in Uganda thanks to the introduction of the Hib vaccine in 2002. But the study was completed in 2006 and Dr. Kekitiinwa now has numerous other projects on her plate, all devoted to improving the health of children in Uganda.
Though now relatively old news, the findings from the WHO report are impressive. Widespread use of the Hib vaccine in Uganda now prevents over 30,000 cases of severe meningitis and pneumonia and over 5,000 child deaths each year. The study also found that the Hib vaccine, added to the standard DPT (diphtheria, pertussis, and tetanus) vaccine recommended for all children in 2002, is over 90 per cent effective after just two of the required three injections. Uganda’s successful immunization campaign is a promising sign for other countries hoping to reduce the prevalence of this deadly bacterium.
The elimination of Hib is good news, but bacterial meningitis and pneumonia are just two of the many preventable diseases children face in Uganda, explains Dr. Kekitiinwa. Other major threats include malaria, pneumonia, diarrhoeal disease, and malnutrition — the leading causes of morbidity and mortality in Ugandan children. Vaccine coverage for common childhood illnesses in Uganda is generally high, but there is room for improvement. According to the Uganda Bureau of Statistic’s 2006 Demographic and Health Survey (DHS), approximately 90 percent of children in Uganda receive the tuberculosis (BCG), DPT (which now includes Hib), and polio vaccines. However, only about 70 percent of children receive the measles vaccine, and only about 46 percent receive and complete all four of the recommended vaccinations.
What accounts for lack of immunization in these cases? “It is not about access,” says Dr. Adeodata Kekitiinwa, as all vaccines are free of charge and paid for by the government of Uganda. “I think people don’t see the immediate incentive even when the vaccines are readily available.” Therefore, she says, “It is upon us health workers to really show them, to really educate them to appreciate that it is an investment – look at it as an investment to health.” Dr. Kekitiinwa also hopes to educate the government on the benefits of preventative care. One of the goals of the WHO surveillance study, she says, was to provide evidence-based facts to the government of Uganda that it is actually cheaper to invest in preventative care of diseases like meningitis than to pay for treatment after the disease has spread.
Diarrhoeal disease is another major threat to children’s health that can often be prevented. Rotavirus, for which there now exists a vaccine, is the most common cause of severe diarrhoea in children and is responsible for around 600,000 child deaths worldwide each year. According to the 2006 DHS, the incidence of diarrhoea in children is lowest in Kampala (approximately 17 percent) and highest in IDP camps in the north (approximately 44 percent). Rotavirus vaccines have been developed and tested in the west and have been found to provide 90 to 100 percent protection against severe rotavirus disease. Current research in Africa and Asia is being used to determine the vaccines’ efficacy in these regions and results are expected by 2009, according to a recent report by the Rotavirus Vaccine Program. Dr Kekitiinwa is hopeful that the rotavirus vaccine will be readily available in Uganda in less than two years.
In the meantime her phone is unlikely to stop ringing. Her most recent research has shown the positive effects on growth of antiretroviral treatment in paediatric HIV/AIDS patients and the decrease in incidence of malaria for HIV/AIDS patients who use insecticide-treated bed nets. While she is keeping busy, Dr. Kekitiinwa says the government of Uganda should keep up the good work in the area of vaccine coverage and provision. “They are doing well,” she says, “and they need to be encouraged to do even better.” Parents, who are ultimately responsible for their children’s health, must also recognize the value of preventative care. It will take the resolve and coordination of all players – researchers, doctors, government and parents – to reduce the childhood morbidity and mortality from the preventable diseases that claim thousands of lives each year.

Melina Platas
The Independent