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350,000 abortions in Uganda are induced – experts

Article by Catherine Mwesigwa Kizza ( New Vision)

Infanticide, child abandonment and abuse — the Ugandan media is full of the stories. The missing story though is that the abused and murdered children are most probably survivors of induced abortion.

“There are over two million conceptions in Uganda every year. 200,000 to 300,000 of these miscarry or abort spontaneously but 350,000 abortions in Uganda are induced,” said Dr. Charles Kiggundu an obstetrician and gynecologist at a breakfast meeting convened by the Center for Reproductive Rights and Centre for Human Rights and Development in Kampala Wednesday, to discuss the laws and policies on abortion in Uganda.

“90,000 of the induced abortions end up with severe complications but only a half of them access post abortion services,” he added.

“Only half of the women with complications seek medical care. A few survive but many others die,” he added.

Joy Asaasira of CEHURD said of the 20 women in Uganda who die due to pregnancy and childbirth-related complications every day, four to five of these are due to induced abortion.

Dr. Kiggundu says these are needless deaths. The policy environment allows women to receive healthcare for post- abortion complications, however, studies have shown that when they seek care, it takes about 44 hours for them to get attention compared to 35 to 45 minutes other women spend in hospital before getting a service.

“Health workers do not want to treat women with abortion complications because they do not want to be seen to be accomplices to the termination of pregnancy,” he said.

He also pointed out that phrases on hospital documents like “Police notify” worry health workers and are a deterrent to provision of care for women.

‘Health workers do not want to get involved with police. They want to do their work unencumbered,” he said.

Women induce abortions due to unwanted pregnancies due to wrong timing of pregnancy or economic and social hardships.

“Some men tell their wives to abort because ‘they stopped having children’ and yet did nothing about it,” Dr. Kiggundu said.

Those who survive death end up with chronic pain, anemia, and infertility among other complications.

He said safe abortion services were available but hidden to the poor.

“You must be connected and well-oiled to access the services. Some women fly to South Africa to terminate pregnancies and return,” he revealed.

The consequences for the majority who go to quacks or unskilled medical workers working undercover are dire.

“We recover forks, pens, knitting needles, bed springs, sticks, herbs from women who run to us with botched abortions. Some of these things kill the woman before they even kill the foetus,” he said.

Treatment for those who survive death is expensive. According to CEHURD, sh17.6bn is spent on treating abortion complications.

Not only can this money be saved and spent on worthwhile health causes but women’s lives can be saved as well.

According to Dr. Kiggundu, the Ministry of Health’s comprehensive abortion care includes sexuality education to promote safe sex practices, family planning use including access to emergency contraception, reducing fertility, providing safe abortion services and quality post-abortion care.

Government is also training nurses and giving them skills to perform manual evacuation procedures to attend to women with incomplete abortions.

“There are still many gaps,” said Dr. Kiggundu. “Uganda still produces health workers for export and retains only a few.”

He revealed that only 30% of the vacancies for skilled health personnel required to provide safe motherhood are filled.

It is no wonder that despite government commitments, advocacy efforts, plans and policies to reduce maternal deaths in the country, there has been no progress in this indicator in the past five years.

New data from the Uganda Demographic Health Survey report of 2011 show that the maternal mortality ratio increased from 435 deaths per 100,000 live births in 2006 to 438 deaths, though other international studies show a decline to 310 deaths per 100,000 live births.

“26% of these deaths are due to unsafe abortion,” said Elisa Slattery the Regional Director, Africa Program Center for Reproductive Rights.

Once addressed, reduction in unsafe abortion contributes to reduction in maternal death.

Slattery said studies on the law on abortion in Uganda have found that “abortion is permitted where a mother has severe illnesses threatening her health like cardiac disease, renal disease, eclampsia.”

The Centre for Reproductive Rights study also found that healthcare providers are not required under the Uganda law to consult one or more providers to get their consent before terminating pregnancy as has been previously believed.

The organization is calling on government to broaden access of information among healthcare professionals and the public as a means of stopping the tragedy.


ARVS smuggled to South Africa


While Malawi hospitals are experiencing drug stock outs, some Malawians are smuggling drugs, including ARVs, to South Africa where they sell at informal markets, Malawi News has established.

The findings reveal that business people, mostly women who sell food stuffs like beans, rice, silver fish and groundnuts, sell the drugs secretly at Park Station and Munorurama depot in South Africa.

The drugs include Indocid, Bactrim which is currently not available in public hospitals in Malawi, with ARVs topping the list.

One of the business women confided in Malawi News that they buy the ARVs from private hospitals at K7,000 per bottle. These private hospitals are alleged to have been sourcing the drugs from government hospitals.

“Here in South Africa we sell a bottle of ARVs at R500 (about K18,000) while other drugs like bactrim are sold at R5 (about K180) per tablet. We do this secretly while doing our normal business of selling food stuffs,” she said.

According to another source who has been in this business for over four years, she hides the drugs at very strategic places where no one can notice even if searched.

“I hide the drugs under food warmers, or I pack them in the bags of rice which I also sell in South Africa. Sometimes I pack them in an envelope as if it’s a parcel for someone, or sometimes I would hide them in my top (wind breaker)” she explained.

Asked why she is still doing the illegal business which might put her in trouble one day, our source said: “Apart from monetary gains which I benefit from the business, I am doing this to save lives of my fellow Malawians who are afraid to have access to medical attention at South African hospitals for fear of being deported once discovered that they do not have permits.”

Pharmacy medicines and poisons board confirmed that some business people smuggle the drugs but said they are usually caught.

Acting registrar Aaron Sosola attributed the tendency to lenient sentences that are meted to the culprits once taken to court.

“Our inspectors have been arresting such people the only challenge is that the penalties are very lenient. We have even trained MRA officers on our borders and sometimes they tell us when they have caught the culplrits.

“Drugs like ARVs and bactrim are prescriptions only and for one to sell them they need to have a licence after we inspect their premises,” Sosola said.

In a separate interview, some Malawi Revenue Authority (MRA) officers who work at Mwanza border said that some business women hide the drugs in their under wears, while some hide them in their hand bags.

“These cases have always been there only that all the cases are reported to the regional offices through a situation report. So if you talk to the officials at the regional office, they will assist you with the information,” said one officer.

The officer further explained that on a weekly basis, at least five cases are recorded among the passengers who pass the border through buses adding that some drugs are smuggled through trucks.

Ministry of health spokesperson Henry Chimbali said he could not rule out the misuse of some drugs and other HIV supplies.

“We haven’t been informed about these practices but we can’t rule out some sporadic misuse of the drugs and other HIV supplies. For the other drugs, we know they are sometimes smuggled to other countries through many means,” he said.

Police spokesperson Davie Chingwalu said they have not made any arrests on the issue but said they will treat the issue as a tip to bring the culprits to book.

“We have had cases before whereby some people were found with other drugs or ARVs but they had with them prescription letters so there was no way we could have arrested them because they had proof that they were on medication,” Chingwalu said.


Natco ‘admission’ on cancer drug could hurt public health

It may be an “important lesson” for Hyderabad-based drug company Natco in terms of legal strategy, but a possible setback for public health, say experts dealing with intellectual property issues.

In an on-going case between Natco and multinational Bristol-Myers Squibb in the Delhi High Court, Natco has admitted that it is selling dasatinib, a generic version of BMS’s cancer drug, though it did not infringe the latter’s patent.

The problem, however, is that Natco had in 2009 told the court that it was challenging the validity of BMS’s patent on this drug, and did not plan to launch the drug in the local market. But in June this year, Natco did in fact launch a generic version of the drug.

Since the case is in court, Natco did not want to comment on the development.

Intellectual property experts say the unfortunate development on Natco’s part could lead to see an interim set-back, both for the company and for public health. Natco sells the generic version of the drug for about Rs 9,000 per month, while the patented drug sells at about Rs 2 lakh.


Natco was issued the country’s first-ever compulsory licence for public health in the country. The compulsory licence allows Natco to make a similar version of Bayer’s Nexavar, an advanced kidney cancer medicine, on payment of a six per cent royalty to Bayer.

In intellectual property circles, Natco is increasingly being seen as the poster boy of the domestic pharmaceutical industry for taking on patent challenges against multinational companies.

No one knows why Natco did what it did, says IP expert Shamnad Basheer, referring to Natco’s earlier stand that it was not interested in selling the drug locally.

The company should have said its seeking regulatory approval to sell the drug had no connection with its challenge on the validity of the patent. Specially so, since Indian law does not link issuance of a patent by the Patent office with marketing approvals, given by the Drug Controller’s office.

More clarity will dawn on the development as the case comes up in court later this month.



Living positively behind bars

By Petride Mudoola: Robert Sebunya, who is serving a 45-year jail term for murder in Luzira Maximum Prison, is HIV-positive. His life in jail has been one hell of a nightmare. “Its double tragedy living positively behind bars,” he says.

Sebunya is in bad shape and is required to use Antiretroviral (ARVS) drugs which he is able to get but finds it difficult to take.

“I cannot swallow them on an empty stomach. I end up throwing them away,” he says.

For a man whose state of health requires constant and proper feeding, Sebunya is in danger of experiencing more serious complications.
He says that even though inmates receive the required medication, there is need for authorities to consider supplementary diet for HIVpositive inmates.

The prisons lack the necessary nutrition to cater for HIV-positive inmates, yet those on ARVs are meant to take a balanced diet. Gabriel Mugaga, another inmate living with HIV, says many of his colleagues fear to take ARVs due to the bad feeding in the prison.

“We throw away the ARVs because we cannot swallow them on empty stomachs.” Mugaga wishes to have healthy meals from his family in Kibaale, but they are far away and cannot bring food for him.

Poor feeding is one of the major challenges that HIVpositive prisoners in Uganda face. This has made the already appalling conditions of HIVpositive prisoners even worse.

Frank Baine, the prison’s publicist, observes that while the prison is supposed to cater for HIV-positive inmates, its budget is too small to do.

“We have no specific budget for feeding inmates on ARVs,” he said. He adds that those on treatment are sometimes provided with vegetables and eggs from prison farms.”

Baine says as a prerequisite, prisoners are subjected to an HIV test upon being imprisoned.

Those found to be positive are referred to the inmate’s health facility for treatment and restricted from engaging in hard labour. But there is little support in curbing the spread of the virus among the inmates, he adds.

The HIV prevalence among inmates has also been heightened by the increased sharing of sharp objects among prisoners.

HIV challenges in Ugandan Prisons

According to the prisons department, Uganda’s prisons has over 2,000 HIV-positive prisoners. Three hundred and fifty inmates living with HIV are in Luzira Maximum Security Prison. Only 178 of them have access to ARVs on a regular basis.

During celebrations to mark World AIDS Day at Luzira Prison, Dr. Joseph Andama, the medical superintendent Murchison Bay Hospital, said HIV prevalence among inmates was higher than the national average. He urged the Government to invest in the management of HIV/AIDS and Tuberculosis (TB) in prisons to reduce more infections.

“This investment should consider timely diagnosis, early treatment, observing the dosage strategy, ensuring that HIV inmates are screened for TB and those with latent TB receive isoniazid treatment so that they don’t develop fullblown TB,”Andama explained.

Andama said prisoners’ misuse of sharp objects has worsened the situation. And due to shortage of counsellors, many inmates find it hard to cope with their condition.

Johnson Wavamuno, an inmate in charge of prisoners living with HIV in Luzira Upper Prison, says the limited number of counsellors due to understaffing leaves inmates unable to deal with the consequences of HIV.

He says more trained counsellors should be attached to the detention facility.

HIV at a glance

According to AVERT-An international HIV/AIDS charity, the number of people living with HIV globally rose from around eight million in 1990 to 34 million by 2010.

The World Health Organisation (WHO) statistics for 2010 corroborate this figure. WHO adds that 17% of people living with HIV by 2010 were women.

The overall spread of the epidemic, according to AVERT, has stabilised in recent years. The number of AIDS-related deaths has also declined “due to the significant increase in people receiving antiretroviral therapy.”

Since the beginning of the epidemic, nearly 30 million people have died from AIDS-related causes.

In 2010 there were an estimated 23 million people living with HIV in Sub- Saharan Africa.

This has increased since 2009, when an estimated 23 million people were living with HIV, including 2.3 million children.

In Uganda, incidence rates have stalled at 6.4%. According to the Uganda AIDS Commission (UAC), close to 128,980 people acquired HIV/AIDS last year up from 124,261 in 2009.
UAC estimates that 64,016 people die in Uganda from HIV/AIDS per year.


Do We Really have Drug Shortage?

Analysis by Paul Abusharizi

Nalongo’s son had just under­gone an operation and it was long past the time he was supposed to get his final pain killer for the day. She looked on helplessly as he whimpered in pain as his father went in search of the doctor on duty.

The nurse on duty, when she came around three hours after the 6:00pm prescribed time for the young man’s doze, claimed the drugs were not in stock and that they should go outside the hospital to buy the drugs, which prescription she hastily scribbled on a piece of paper.

As it turns out the drug was very much in stock. For those in the know this was a subtle attempt by the nurse to extract some money from the parents of the in-pain boy.

All this happened at the national referral hospital — Mulago. While the end user is un­der the impression that our health centres are suffering a perennial drug shortage, National Medical Stores is sitting on tons of drugs which are reportedly in short supply.

“My warehouses are full of drugs to the point that I am asking my suppliers to hold with future deliveries as I try to work these ones out of the system,” NMS boss Moses Kamabare told Sunday Vision.

Clearly, between NMS warehouses and the end users, there is a bottle neck that is pre­venting the end users from accessing lifesaving drugs.

Three years ago in an attempt to alleviate the perennial drug shortages in public facili­ties, government centralised the procurement process under NMS.

Previously, the procurement of drugs was decentralised to the national referral hospitals ‑Mulago and Butabika, the regional referral hospitals and the districts, which supplied the health center II to IV.

By centralizing drug procurement govern­ment hoped to take advantage of the discounts possible with the ensuing economies of scale, create uniformity of supply and curb drug thefts.

Under the current system the referral hos­pitals and the districts provide NMS with a procurement plan, which guides NMS as to the drugs and their quantities to buy for the year as well as how regularly they should be dis­bursed. NMS only procures according to these plans.NMS has a delivery schedule which is monthly for Mulago and Butabika and once every two months for everybody else.

Since the capacity to quantify needs was lacking at the lower health centres the health ministry came up with a basic kit, which has most of the essential drugs and supplies like gloves, which are supplied to the health cen­tres two and three.

So NMS clients are supposed to requisition their drugs according to their pre-determined procurement plans and only then will they be supplied with the drugs.

“That is where the problem starts. We quick­ly found out that either they do not requisition, so we don’t dispatch or they requisition less than they already planned for leaving us with unused stock,” Kamabare said.

That is where the discrepancy between shortages at the health centres against the contradiction of NMS’ full warehouses begins.

By not requisitioning or under requisition­ing you have health centres without drugs for months or running out of supplies ahead if schedule respectively.

Why this happens is a mixed bag of motives that range from incomprehensible incompe­tence to sabotage of an innovation that would expose the old practitioners to individual abuse of the system to meet personal needs.

“For example some prescribers can prescribe medicines that are not on our national essen­tial medicines list. The idea being the patient would have to go out of the hospital to order the drugs living the impression that the hos­pital is short on drugs while the truth is that a perfectly adequate drug is readily available in the health facility’s dispensary,” Kamabare said.

Clearly a holistic solution to the prob­lem including increasing health workers pay and welfare and training many more health workers is required.

But as a start beyond the streamlining procurement Kamabare counsels the use of medicines only listed in the national Essential Medicines List and prescribe as stipulated in the Uganda Clinical Guide­lines – which has detailed descriptions of common ailments in the country and how they should be prescribed for.

“Artificial scarcities are being created and sustained contrary to the truth, “ the NMS boss says. “Among the drugs we are over laden with are those for cancer, TB, ARVs, family planning supplies, rabies vac­cines, insulin and mama kits.

My concern is not that my warehouses are full but what is happening to the rightful patients of these drugs …. Aren’t they dy­ing because of a failure of our systems?”…-drug-shortage