Providing affordable healthcare to the population of low- and middle-income countries is a persistent development issue.

In 2016, the government of Uganda developed a health financing strategy to facilitate the attainment of sustainable development goal three (SDG3) of ensuring Universal Health Coverage.

This can be achieved by making the required resources for delivery of essential health services for Ugandans available, in an efficient and equitable manner. Revenue collection and risk pooling mechanisms such as insurance are one way of doing this.

The dream is that no one should face the risk of impoverishment when accessing healthcare, nor should anyone forgo medical services because of the financial cost of accessing health services.
Currently, the principal mechanism for funding health services in Uganda is through government revenue tax financing.

Out of pocket payments and contributions by health development partners constitute a substantial amount of health financing. Due to the poor quality of health service delivery, many households are compelled to seek services from private medical facilities, which are very expensive.

The cost of access to health services in private places is a huge burden on most families in Uganda, leading to financial hardships for many patients and their caretakers, and often to long-term indebtedness.

It is currently estimated that the total annual health expenditure is 7.5 trillion. Of this, 15 per cent is from government funding, with 42 per cent from donors and 41 per cent from individuals (out of pocket).

These statistics should be worrying because the government has abandoned its responsibility of providing healthcare in this country to donors and families.

The World Health Organisation (WHO) recommends that out of pocket expenditure on health should not exceed 20 per cent of a country’s total health expenditure, otherwise citizens will stand the risk of impoverishment in case a family member falls ill.

In terms of per capita health expenditure on health, Uganda stands at $53, which is less than the standard $84 dollars recommended by the WHO. In comparison with other East African states, this is the lowest.
 
It is evident that public financing available for the health sector remains the single most important constraint to Universal Health Coverage and overall enjoyment of the right to health. Over the last five years, the budget for the health sector has dwindled from 8.9 per cent of the national budget in 2016/2017 to the projected 6.2 per cent in 2021/22 financial year.

In 2019/2020, the needs analysis by the National Medical Stores (NMS) showed that there was a medicines funding gap of 6 per cent in Health Centre IIs, 56 per cent in Health Centre IVs, and 32 per cent in general hospitals. This means that Health Centre IIs are running with only 39 per cent of the drugs they need while Health Centre IVs are operating with only 44 per cent of the drugs they need.
 
The passing of the National Health Insurance Scheme Bill,  2019, by Parliament provides a glimmer of hope in enhancing access to health services. As can be demonstrated by the Rwandan experience, health insurance is instrumental in increasing access to health. By 2015/16, the health insurance cover in Rwanda had a coverage of 86.1 per cent compared to Uganda’s 2 per cent.

The Bill as passed by Parliament may not be perfect, but provides the best opportunity for beginning conversations on increasing funding to the health sector and catering for the poor and vulnerable groups.

By contributing to the health scheme, their dependants will benefit from the insurance and so will the poor  who are incapable of contributing. These shall be entitled to a defined package of healthcare benefits from government contribution  based on Uganda National Minimum Health Care package.

The Health Insurance Scheme will be an addition to the government contribution to the health sector. Government will continue to invest in health promotion and education; disease surveillance and response; immunisation and any other specialised services outside the National Health Insurance Scheme benefits package and health systems investment.

Government will also continue to finance major health sector infrastructural development, specialised medicines, technology and human resources.

Peter Eceru is a Programme Specialist, Health and Human Rights Advocacy at Center for Health, Human Rights and Development (CEHURD)
A version of this article was published in the Daily Monitor Newspaper on Friday 30th 2021.

These rains can lead to flooding, which contaminates water sources and increases vegetation around homes, creating a conducive atmosphere for mosquitoes to breed.

– Katia Olaro, Strategic Litigation program, CEHURD

World Malaria Day | 25th April 2021

With all the work that has gone into fighting it, malaria still kills tons of people despite the fact that it is preventable. In an article on news.trust.org a 74 year old Rose Acayo of Gulu District narrates how she had been sleeping under a worn out inherited mosquito net which consequently exposed her to malaria infection. Just as she was recovering, her two-year-old grandchild in her care also fell ill which left her with medical bills she could not meet. How can we draw the line for zero malaria infections as this year’s World Malaria Day theme states?

According to the World Health Organisation 2019 report, Uganda was the third highest contributor to global malaria cases, at 13.7 million cases. Globally, we were the eighth highest contributor to malaria deaths at 5,610 deaths. Malaria therefore remains a high cause of death and financial constraints, considering its non-discriminatory nature in terms of age, gender, race, economic or social status. Transmission lines are very thin and so is the severity, failure to stop its spread will continue causing high levels of poverty among the poor as treatment is a financial burden which they cannot afford.

What we can do

As the world puts the spotlight on the fight against malaria, CEHURD joins the rest of the world to ensure acceptable, accessible, affordable and good quality health for all. As a country, Uganda is making efforts to reduce malaria infections and morbidity in a sustainable way through mass media awareness campaigns, and distribution of free mosquito nets, among other interventions.

In a recent press statement, Dr Joyce Kaducu, Minister of State for Health- Primary Health Care revealed that there are currently no malaria outbreaks in the country. She, however, warned that there is a risk of outbreaks due to the ongoing heavy rains in various parts of the country. These rains can lead to flooding, which contaminates water sources and increases vegetation around homes, creating a conducive atmosphere for mosquitoes to breed.  In order to prevent these outbreaks, the Ministry of Health  urges everyone to step up the implementation of preventive measures. This includes sleeping under treated mosquito nets, getting rid of stagnant water, and seeking medical assistance where symptoms present.

Call to action

It is important to improve overall health care. The government should therefore provide quality assured services for malaria prevention and treatment to all the people in Uganda. This will lead to a good standard of health, which contributes to national development. It is also important to ensure that there is sufficient stock of essential supplies and medicines to minimise possible capacity constraints, and reduce the burden on health facilities in providing services to diagnose and treat malaria.

Change also begins with each of us. Let us do our part in preventing malaria, and if diagnosed, seek medical treatment. While preventing COVID-19 is the current issue, let us not forget that “mosquitoes are not in lockdown, they are still free”, as Mr Jimmy Opigo, a programme manager of the National Malaria Control Programme said.

CEHURD today shines the light on Tuberculosis (TB) as we commemorate the World Tuberculosis day under the theme “The clock is ticking”. This is a call to action towards commitments made by government to end TB especially in the face of the ongoing COVID 19 pandemic which puts these efforts at a risk. The World TB day is commemorated to raise public awareness about the devastating health, social and economic consequences of TB and to call on government to step up efforts to end the global TB epidemic. According to the World Health Organization (WHO), TB remains one of the deadliest infectious killer diseases and each day nearly 4,000 people lose their lives to TB and close to 28,000 people fall ill with this preventable and curable disease. A total of 1,400,000 people in the world died of TB in 2019 alone.

These glaring statistic do not get any better at home as Uganda is one of the 30 WHO designated countries with a high burden of TB and HIV. In 2019 the estimated incidence was 200 per 100,000 people with a mortality rate of 35 people per 100,000.  It is indeed worrying that the cases of TB have even gone up given the little attention to the disease. According to WHO reports, in 2019 Uganda had 65,897 cases of TB notified which is an increase from 57,756 cases notified in 2018.  There have also been reports of high drug resistance which poses a real challenge to the efforts towards controlling the infection. 87% drug resistance was reported in 2019 alone and this calls for more efforts towards research and investment for new medicines. There is however a lurking risk of patents on new medicines which may make these medicines expensive and thereby becoming a barrier to access for many TB patients.

It should be noted that most TB patients in Africa suffer catastrophic treatment costs making access to quality TB treatment impossible despite the disease being curable. In Uganda it is reported that 53% of TB patients suffer catastrophic costs of treatment as indicated in the WHO factsheets on the TB situation in Uganda. Although government has made some efforts toward the control and management of TB through commitments made under the National Tuberculosis and Leprosy Control Program 2016-2020 which aligns with the WHO End TB strategy, more is needed to ensure equitable access to quality treatment for TB patients.

It is disheartening to see that Uganda’s TB financing indicates very little of Government’s political will to end TB as committed under the Control Program and WHO End TB strategy. In 2019 the national budget for TB control and management was USD 37,000, 0000 of which government only contributed 5% while 56% of the financing was by international partners and 39% of the budget was unfunded. The second health sector development plan 2015/2016-2019/2020 is designed to support  government’s commitment to achieving Sustainable Development Goals which among others seeks to “Achieve universal health coverage including financial risk protection, access to quality essential health care services and access to safe , effective quality and affordable essential medicine and vaccination for all by 2030”.

This is to therefore call upon government on this world TB day to fulfil its commitment towards the END TB strategy by;

1. Increasing domestic funding towards TB management and control to ensure equitable access to TB quality treatment
2. Investing in research and development for new and effective medicines to find lasting solutions to drug resistance
3. To utilize the flexibilities in the Trade Related Aspects of Intellectual Property Rights to ensure that Intellectual Property Rights do not pose barriers to accessing the new and more effective medicines

By Annah Kukundakwe -an advocate for Sexual and Reproductive Health and Rights Advocate and Program officer at the Center for Health, Human Rights and Development.

President Yoweri Kaguta Museveni recently noted in his Speech during the NRM Liberation day on 26th January 2021 said people should leave their religious beliefs at home and not carry them to office. I am not sure what motivated him to take this stance, but in my case, i am motivated by the fact that the morality whip that is mainly wielded by religious leaders and members of their congregation, has proven to be untenable. Those that have been the protectors of the moral fabric of society have also many times found themselves has falling victim to this moral policing.

A policy is a course or principle of action adopted by government or the executive to guide decisions and achieve rational outcome. And Policy-making is the act or process of setting and directing the course of action to be pursued by a government, business or organization. The policy making
process entails various phases including stakeholder consultations aimed at building consensus around the policy proposals and developing solutions which will work and gain acceptance in practice.
Among the stakeholders engaged in the policy development process are religious groups who continue to be given a bigger and better platform for consultative processes. Their views on any given policy is given priority and in some cases, the views have been seen to derail or stay discussions about development of policies and laws pertaining to critical issues including social, health and even human rights. A case in point is the National Sexuality Education framework, whose implementation and operationalization has been delayed since its launch in 2018, the SRHR policy guidelines and service standards, including those for addressing maternal mortality due to unsafe abortion (2015) that were recalled and disowned by the government and the continuous failure of the Marriage and Divorce Bill to move beyond the floor of Uganda’s parliament.

Over the years the fate of Ugandans especially women and young people has been left to be decided by religious groups even in cases where decisions that could impact health and life are concerned. However,
the recent happenings in the church, including where they have been rocked by scandals calls for a review of whether religious leaders’ views really ought to count in matters of health and people’s wellbeing
The 1995 constitution recognizes Uganda as a Secular state. Besides the fact that Uganda is described as a state, the desired approach of managing public affairs, should prompt us to question this unfettered authority that religious leaders and other moral groups enjoy in public policy processes.

In my view, the reason why religious groups have enjoyed unchecked reign over the different aspects of people’s lives is because these groups and the institutions have been protected by the dogma of infallibility. There is a belief that they cannot do wrong including on moral grounds. There are also other issues that have consolidated their hold and importance of their opinions on all aspects of life. These include aspects such as owning majority of private schools and health care facilities in the country in comparison to any other group in the country. Noteworthy is also the history of this country where there has been a strong interconnection between the church and state. It is this moral authority that they wield and use as a bargaining chip and in some cases even emotional blackmail in discussions where there are technical people and data that indicates a contrary approach should be adopted.

The impact of these stayed policies, laws and interventions are not an end in themselves as they have far reaching effects on the lives of Uganda’s citizens. For instance, owing to moral objections on young people’s exercise of their agency regarding their sexual reproductive health and rights via an enabling policy, legal and service environment, young people continue to grapple with challenges regarding their sexual and reproductive health because they are unable to receive information on the same.

This has had far reaching impact on their lives like school dropout and loss of lives. Women also continue to die due to preventable causes like unsafe abortion. There is no doubt that Sexual Reproductive Health and Rights (SRHR) continue to be among the most controversial and contentious topics in Uganda’s legal, policy, and social environments. This is in part due
to religious debates. SRHR issues like family planning, sexuality education, adolescent health, teenage pregnancies, unsafe abortion, maternal mortality and morbidity, gender-based violence, sexual abuse and child marriages, continue to constitute a serious public health and human rights threats to women and young people.
I implore the newly elected MPs and persons in the various key ministries to endeavor to steer clear of moral shackles when developing public policies or when passing laws to regulate public and social issues. There is no doubt that people are entitled to their moral and religious beliefs, however, given the subjective nature of these, it is unfair for these parameters to be applied across a wide spectrum of issues that affect
persons from different social, geographical, economic and even religious backgrounds. This means that from the offset, there is an unleveled playfield and an attempt to level this playing field via law and policy
based on among others on subjective moral standards is erroneous. Let us look to data and science to cure the ills that plague our country, that way our development goals will remain relevant and attainable.

A version of this article was published in the Daily Monitor Newspaper on 10th March 2021 pg 15.