In-depth: Winning the peace: The challenge of AIDS in post-war countries

UGANDA: Expanding health care new post-war challenge

Photo: Stuart Price/IRIN
One day they will go home
GULU, 7 February 2007 (IRIN In-Depth) - If currently stalled peace talks to end 20 years of fighting between rebels and the government in northern Uganda succeed, 1.2 million displaced people will be on their way home; good news for those desperate to rebuild their lives, a new challenge for the authorities struggling to provide treatment to those living with HIV.

Camp life might be squalid and cramped, but the camps and nearby towns in this desperately poor region offer greater access to health facilities, which is crucial to the success of intense drug regimes like antiretroviral (ARV) therapy.

Joy Akello, 27, is HIV-positive. She cares for her one-year-old child, also infected, in Gulu district's Lalogi camp. "At the moment I live a five-minute walk from the health centre," she said. "I can get treatment when I fall ill, but my village is a two-hour walk and then a truck ride ... I need to go back, but I need the drugs."

HIV prevalence in north-central Uganda (Apac, Gulu, Kitgum, Lira and Pader districts) averages about 8.2 percent, compared to 6.7 percent nationally. The government has not come up with a post-war plan to devolve health services to the rural north once the camps start emptying, to the concern of health workers.

Robert Ochola, coordinator of HIV/AIDS activities at St Joseph's mission hospital in Kitgum district, which provides ARVs to most residents who need them in Kitgum town and the surrounding camps, said the general consensus among nongovernmental organisations (NGOs) and the government was that services would increasingly be made available at sub-county level, giving rural populations improved access.

"When the [security] situation subsides we hope to ... [extend services to] community-based organisations and sub-county health centres," he told IRIN/PlusNews. "So far, we have failed to reach populations far outside the camps and towns because of the war."

Displaced people in the region are receiving the life-prolonging drugs via large hospitals in major towns and a few clinics in camps. An estimated 1,700 people are enrolled in the ARV programme at St Mary's Hospital in Lacor, Gulu's biggest medical facility.

Kimera Mutebi, manager of the Gulu office of The AIDS Support Organisation, one of the oldest HIV NGOs in Uganda, told IRIN/PlusNews that they were supplying ARVs to 1,500 HIV-positive people and were preparing for the eventuality that their patients would move away from Gulu.

"When the war ends we know they will be scattered all over the north. We have planned for community AIDS support agents, along with expert clients and local nurses, to be trained in distributing ARVs to people in their homes and local clinics," he added. "Our field officers will also go to central places in the region, where they can provide the drugs."

Patrick Onen, one of a group of people living with HIV in Kitgum's Akwang camp, agreed that bringing HIV services closer to patients was key, but said there were wider considerations.

"Sometimes people get so weak ... [that they] can't even make it to the sub-county centre, so provisions should be made for transportation," he suggested. "Maybe they could have a phone helpline in parishes, so people who need the drugs delivered can have them, or bicycles could be provided for them to reach the centres."

Although the camps have made it easier to provide access to healthcare, the scarcity of skilled staff has raised questions over the feasibility of decentralised services.

Need to improve existing services

A 'health centre four' (HC-IV) - a large, county-level facility - is located at Lalogi camp and serves about 100,000 people in 14 camps. "They [the HC-IVs] are not really operational; we really lack manpower. You go and you find only one health worker," said John Luwa, the Gulu district health focal point. "Sometimes beneficiaries will go and they won't even find one."

The problem is one of pay and working conditions. "They [health workers] are overwhelmed and overworked, there isn't accommodation; that is a major factor and our priority."

According to clinical officer Bernard Odong, Lalogi camp's HC-IV has only 17 out of 44 positions filled. "As it is, we share a room between three people. We are away from our families and can barely afford to travel home when we have leave."

At St Joseph's, Ochola said a great deal of training would be necessary before HIV prevention and treatment initiatives could reach areas as remote as the Uganda-Sudan border, where few healthcare workers have so far dared to go.

Speaking to IRIN/PlusNews, Ugandan health minister Dr Stephen Malinga acknowledged that "health workers are not as well paid as [others] - these people are running away ... so I think salary increases will be in the pipeline."

Peace talks between the Lord's Resistance Army and government began in July 2006 but have hit trouble, with both sides accusing each other of violating a truce agreement. Should negotiations resume, the government would be under increased pressure to prepare for the displaced to return home, and the expansion of services in the neglected north.

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