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Parliament should save our ailing health system

The Ministry of Health has made significant strides in improving access to health services with 91 percent of  Ugandans now leaving with 5km of the health facility. Reduction of budget allocation to health will roll back the achievement made this far. Investment must now be directed at functionalising these health facilities. 

By Peter Eceru

Parliament is currently scrutinising Ministerial Policy Statements for the 2023/2024 Financial Year. The statements are the equivalent to the draft Budgets for the subsequent financial year. For most people, discussions on the budget does not make sense because it is perceived not to add value to their lives. Unfortunately, for millions of Uganda, whose lives depend on access to health care, is dependent on the public health delivery system these conversations are a question of life and death.

Adequate allocation to the health sector is critical to promoting equity in health service delivery. In the next financial year, the health budget allocation is projected to drop to about 6.5 percent of total budget from 7.7 percent as provided in the current budget. The drop is worrying development and must be arrested by Parliament during the current budget scrutiny. To put this into perspective, it is important to look at some macro-economic factors that have a direct impact on the health budget. 
In Uganda, the annual population growth rate is about 3 percent per year. The increasing population calls for increased investment in public health. Also, the Uganda shilling is projected to lose value against the dollar. This implies the cost of importing a unit of drugs and other health equipment will become more expensive in the coming year than it is this year. Prudent budget allocation will, therefore, demand that the allocation of resources to health should take into consideration these macro-economic considerations.

The Ministry of Health has made significant strides in improving access to health services with 91 percent of  Ugandans now leaving with 5km of the health facility. Reduction of budget allocation to health will roll back the achievement made this far. Investment must now be directed at functionalising these health facilities. 
In Uganda, 71.6 percent of the Out-patient Department attendance is at health centres II and III. Similarly, 56 percent of deliveries take place there. To foster health equity, public health financing must ensure that the quality of service at these lower health facilities is improved because they help decongest the higher health facilities.  
Improving the quality of health service delivery means investing in essential medicines and health supplies, strengthening human resources for health, investing resources in primary health care, ensuring that there are medical equipment and that they are functional, among others.

The draft budget does not respond to the above needs and in some cases, financing has been reduced.  National Medical Stores is projected to receive about Shs537.6 billion in the next financial year with a funding shortfall at Shs245 billion. The biggest funding gap for essential medicines is in health centre IIs accounting for about Shs17 billion. At the height of the drug stockouts earlier this year, we argued that funding was one of the driving factors for drug stockouts in the public health facilities. This budget making process gives Parliament an opportunity to conclusively address stock out challenges. 

Last year, Parliament allocated Shs23 billion for Uganda Blood Transfusion Service and made a proposal for progressive increase in the budget for blood collection, processing and distribution. Unfortunately, government has instead proposed a reduction in the budget for blood from Shs23 billion to Shs21 billion.  The reduction will mean that Uganda Blood Transfusion Service will be incapable of closing the gap of 150,000 units of blood needed by patients in Uganda with the possible result being that more Ugandans will die. 
Financing for service delivery, including health is usually dependent on availability of resources and we have consistently argued that we need to tap into all available opportunities including health insurance. 
We also need to aggressively ensure that every one pays their fair share of the tax that is due to them. Uganda currently loses more than Shs7 trillion annually to tax exemptions that would be channelled to service delivery. These have a direct impact on the country’s ability to provide quality health service delivery for its citizens. Government needs to urgently review its policy on tax exemptions.

The writer is the Program Coordinator- Advocacy at Center for Health Human Rights and Development (CEHURD)

A version of this article was published in the Daily Monitor on April 24th 2023.

Saving Lives Through Contact Tracing In West Nile

Uganda is one of the 30 nations with the highest TB/HIV burden and one of the 20 countries responsible for 83% of cases of persons who do not know their TB status and accordingly do not get appropriate treatment.

By Fred Opon

In order to end Tuberculosis (TB) by 2025, Uganda has adopted one of the strategies recommended by the World Health Organization (WHO) which is the use of Tuberculosis Preventive Therapy (TPT) among people living with HIV but are TB negative, and initiation of all TB negative contacts. Active TB has been excluded regardless of their TB history and level of immunosuppression or ART status. TPT is safe for the treatment of latent TB infection (LTBI) among PLHIV (People living with HIV) and prevents progression to active TB infection in this population.

Uganda is one of the 30 nations with the highest TB/HIV burden and one of the 20 countries responsible for 83% of cases of persons who do not know their TB status and accordingly do not get appropriate treatment. The progress made in reducing the number of people who are not on appropriate treatment was negatively affected by COVID despite Uganda’s success in eradicating TB as a public health concern. The government of Uganda, with a strategy of Catch-up and (CAST) (Community Awareness, Screening, Testing, Prevention and Treatment to end the TB campaign which were implemented by the National TB and Leprosy Program (NTLP) in May 2021 and March and September 2022 respectively) substantially addressed the aforementioned challenges, with remarkable success in terms of detecting new and relapse TB cases.

Systematic testing for TB of all family members and close contacts of TB patients through contact investigations are essential for stopping the spread of TB. It is also important to identify people with TB and HIV, and have them start early treatment. This helps in locating people (contacts) who are at a high risk of developing TB, initiating them on TB preventive medication, and offering education and counseling on infection and its control. Contacts are individuals who have spent one or more nights or long stretches of time during the day with a patient confirmed with TB in the three months prior to diagnosis. 

Fred Open in the field

“TB Testing and Treatment are free of charge at all Gov’t Health Facilities.”

Contact tracing involves interviewing the confirmed person who has tested TB positive, informing him or her about the TB disease, generating a list of potential people that have been in close contact with the person, organizing and scheduling time for health professionals to perform contact tracing activity through screening during home visits. Among the contacts, people with signs and symptoms of TB (Presumptive) are further evaluated and samples of their sputum (cough) are tested for TB and initiated on TB drugs when results turn positive, whereas those without signs and symptoms of TB (Non-presumptive) are started straight away on TB preventive therapy for 12 weeks using 3HP.     

“Support people with TB to adhere to Treatment”

A community member who has TB but is unaware of it can be found through contact tracing and the infection contained as they receive treatment. Contact tracing also reveals folks who have been in contact with TB patients and after that, TB preventive medications to stop the TB from becoming active can be given to them. This also gives chances to health workers to provide information and counseling to those who may have been exposed to TB as well as to the larger community. It is important to note that contact tracing is at the heart of TB control and prevention. 

Under the Global Fund, CEHURD is implementing contact tracing for Pulmonary Bacteriologically Confirmed TB cases (PBCs) in 13 districts of West Nile in 147 Health Facilities. This project is being funded by Global Fund through UGA-C-TASO project and in the last two years CEHURD has facilitated contact tracing through Regional TB/Leprosy Supervision, District TB/Leprosy Supervision, Facility TB Focal Point Persons and lastly VHTs and TB expert clients. 

Over the implementation of this intervention, it is evident that, in order to gain entry to previously inaccessible communities for TB screening, strong community links are essential. A larger TB yield can be achieved using patient-led contact tracing as opposed to the conventional health worker-led method. With this method, healthcare providers can reach out to people who may not have known that TB patients existed. There are more TB cases in communities than in hospitals and so there is still a great need to continue taking TB services to communities rather than waiting for them to come at late stages to the hospital or health centers for testing and treatment.

While patients of TB can cure, People with tuberculosis are particularly vulnerable to being marginalized, stigmatized, and discriminated against. This stigma and discrimination have a negative impact on the country’s commitment to conduct contact tracing. More than ever, concrete steps must be taken towards a gender-responsive approach, accompanied by detailed instructions for local communities. This is especially so given the gender roles played by women as carers in our communities.

It’s masterful that these interventions are dependable on community representatives or leaders to assist in fostering relationships with the affected people and community members. Other key players could also be cultural or religious leaders, public figures, unofficial gatekeepers, educators, local business owners, taxi drivers, saloon owners and others. They can be engaged to localize homes for the TB clients for contact tracing including a focus on difficult-to-reach subgroups and to gain support for contact tracing interventions.               

“TB is curable and Drugs are free at all Gov’t Health Facilities”

It is also critical to provide a community feedback channel to guarantee that misconceptions, complains, and suggestions from the communities about contact tracing activities are reported, discussed with relevant teams and used to improve message, message delivery and methods to let them know that their voices are being heard and taken into account.                                                                   

“Yes! We Can End TB”

The writer is a TB Contact Tracing Officer at the Center for Health, Human rights and Development in the Community Empowerment Program.

We need a healthy, violence-free society

 The world would be better off with more women as leaders, entrepreneurs, and agents of change for development.

Ms fatia kiyange
We have made tremendous progress toward achieving women’s rights over the years. However, massive gender gaps persist. There are still increased cases of gender-based violence and women continue to provide the biggest percentage of unpaid, but essential care work.

Transformative change toward gender equality requires further investments, changes in law and policies, interventions to shift social and gender norms, and the audacity to change power relations. For example, we urgently need a witness protection law that ensures that witnesses and survivors of gender-based violence are protected.

We also need to invest in the establishment of gender-based violence shelters where survivors are able to access a full range of services including psychological support. Our public health system that serves most women is substantially under-resourced to guarantee the right to health for the most vulnerable women in our community. The world would be better off with more women as leaders, entrepreneurs, and agents of change for development.

Women and girls are still struggling to access health services and that women and girls are disproportionately affected by barriers to accessing and using health services. For example, women and girls experience structural barriers, including financial hardship, lack of transport (especially in rural areas) and lack of time because of a care burden or other unpaid labour. The existence of specialised sexual and reproductive services for women is essential in addressing the huge structural barriers that women and girls across the world experience in accessing health care. Much more must be done to communicate the importance of gender as a barrier to access health services.

Processes for achieving Universal Health Coverage are gender blind, and COVID-19 has shown that women and girls are still being left behind. Cases of Gender Based Violence, teenage and unplanned pregnancies skyrocketed during the pandemic. To achieve Sustainable Development Goal 3 of health and wellbeing for all, it is imperative to transform health systems so they are intersectional- and gender-responsive.

The writer is the Executive Director for Center For Health Human Rights and Development.

A version of this article was published in the New Vision Newspaper page 40, on Wednesday March 8th 2023.

Equal Division of Unpaid Care Work is The Way To Go

By Seth Nimwesiga

“So they are no longer two, but one flesh. 

… therefore, what God has put together, 

no man shall put asunder…” 

Matthew 19:6

In the verse above, the Holy Bible emphasizes union and oneness upon marriage of man and woman with crystal clarity. For the non-believers, the supreme law of the land suffices. The Constitution of Uganda is explicit on equality in marriage. It prescribes the entitlement of married people to enjoy equal rights during and at the dissolution of marriage. 

For a couple, their equal rights necessitate equal duties and responsibilities, equal obligations, and equal contribution to acquisition, development and maintenance of matrimonial property. This contribution can be direct or indirect; monetary or non-monetary.

In a recent judgement vide Ambayo v Aserua (Civil Appeal 100 of 2015), the Court of Appeal recognized unpaid care work as that form of work that is not compensated by way of wages. It includes caring for children, cooking, cleaning, doing laundry, fetching water, et cetera. Court reasoned that the non-monetary contribution or unpaid domestic care work ought to be computed at the market value of the of the services offered based on the knowledge, skills and character of the service provider labourer, a spouse in this instance, so as to determine the value of one’s contribution to matrimonial property.

The judgment followed a divorce petition filed by a wife, and a counter petition filed by her husband in the High Court of Uganda wherein they both settled by consent on all grounds bar the wife’s claim for an equal share in the matrimonial property. At the court of first instance, the judge ordered for a sale of the matrimonial home and an equal division of the proceeds. In the opinion of the husband, the High Court occasioned a miscarriage of justice when it found that the wife contributed to the acquisition and development of their matrimonial property, and ordered for a 50% share of the proceeds from the sale of that property, which prompted him to appeal. The Court of Appeal has now reversed the decision of the High Court in part and instead deemed a 20% share sufficient to compensate for the wife’s unpaid care work.

The question of compensation for unpaid care work is a reasonable one. It is good music to my ears that unpaid care work is recognized, though unfitting to put a price to it for a married person. In fact, unpaid care work in a home should be shared. That way, the men would get to appreciate how priceless such work is. In prescribing for equal rights in marriage as stated before, the Constitution also implies equal duties, such as equal division of care. This, however, is not the practice in our society, generally.

The case in discussion could not have come at a better time for the court to give the text ‘equal rights in marriage” as is in the provision of a progressive constitution, their true and natural meaning. The case came at the time when our society is progressing on affirmative action for women empowerment. According to a 2022 UN Women gender snapshot of the progress on the Sustainable Development Goals, it will take about 286 years to overcome discriminatory laws and close the gaps in the legal protections for women and girls. Through judicial activism, courts have the power to build on the current steps to achieve gender equality, especially in a society that has apportioned gender roles that set men as the providers and women as primary caregivers, which creates power imbalances and often works against the latter.

It is not uncommon that many times, women lay their hands on domestic unpaid care work to act as springboards for men to run the errands that ‘put food on the table’. By shouldering this domestic work and creating room for men to do paid work, the women are directly contributing to the economic wellbeing of the family most times at the expense of their own careers. For married people, it should neither be categorized nor valued as a business.

Equality is just that; equality. It was never the intention of our Constitution to give with one hand and take away with the other, equal rights in marriage. Courts should therefore proactively promote gender equality and steer clear of any norms, customs, beliefs and practices that promote the opposite.

There is a need for a government policy to regulate and regularize equal division of care work in families. This would go a long way in countering the gender imbalances in our society.

The writer is a Policy Advocacy Officer, Generation Gender Project, CEHURD.

A version of this article was published in the New Vision newspaper on March 8th 2023.