In-depth: Countdown to Universal Access

UGANDA: It takes money to get universal access to treatment

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Is universal access the responsibility of government rather than donors?
Kampala, 1 December 2009 (PlusNews) - As donors tighten their belts in the global recession, health experts in Uganda worry that the national antiretroviral (ARV) programme, which is almost entirely dependent on foreign aid, will be unable to keep providing the life-prolonging drugs.

Uganda is only able to provide ARVs to 57 percent of the 240,000 people who require them, and the number is growing. "We require up to 70 million US dollars every year to treat our targeted patients," said Zainabu Akol, head of the HIV/AIDS programme in the ministry of health.

"[In 2008] we could only secure 20 million from the Global Fund [to Fight AIDS, Tuberculosis and Malaria] for close to 90,000 patients' treatment, and another 20 million from PEPFAR [the US President's Emergency Plan for AIDS Relief] for another 100,000 patients; the situation remains one of shortages."

Funding shrinking

PEPFAR recently announced that funding for ARV programmes would not be increased. "We now have a flat budget for Uganda, since the first phase of PEPFAR ended in 2008. This fiscal year we are going to commit $285 million for our programmes of sustainability, prevention, care and treatment," said Lynne McDermott, PEPFAR's communication officer in the capital, Kampala.

Some local partners too would not be adding to the number of patients they were treating. "The US has been the main funder of HIV/AIDS in Uganda, so what is going to happen to new infected persons?" asked Chris Baryomunsi, a member of parliament on the house select committee on HIV and related matters.

In 2008 the government allocated more than $30 million to purchase ARVs, but the money was diverted to pay health ministry staff. An ARV manufacturing plant, opened in 2008 to cut the costs of AIDS drugs, has so far not made any significant contribution to ARV provision.

The health ministry made an emergency appeal to the Global Fund for $8.9 million to purchase ARVs for three months as an advance on $70 million awarded in Round Seven of its grants, but the world body could only offer $4.25 million in June, which Akol described as "a drop in the ocean".

The Global Fund was forced to cut funding by 10 percent in 2008. A recent World Bank report advised nations heavily reliant on foreign aid to prepare for any impending cash and drug shortages by implementing early warning systems, and work to avoid treatment interruptions as far as possible.

ARV programme in danger

Health minister Stephen Mallinga said it would be virtually impossible to expand ARV programmes. "We would rather sustain those that have started the treatment ... because the ramifications ... [of not accessing drugs] are grave, including resistance to drugs and therefore a requirement to change the combination ... which will lead to an increase in our treatment bill, which we cannot afford," he told IRIN/PlusNews.

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AIDS activists are concerned that funding woes will make it impossible for Uganda to achieve universal access to treatment, or giving drugs to at least 80 percent of people who need them.

"Ways and means within the recession should be found. The alternative to not providing universal access is much more expensive and dangerous - we will not be able to control the epidemic," said Peter Mugyenyi, AIDS activist and founder of Uganda's Joint Clinical Research Centre.

"When drugs are unavailable and patients start to share them, they begin to get side effects and have to switch [regimens], but second-line drugs are double the price of first-line drugs, and the third line are ultra-modern drugs which are unaffordable," Mugyenyi said. "If we are having problems with the first line, what about the second and third line?"

Ministry officials said the government could not afford treatment for everyone needing it, but many activists feel that universal access is the responsibility of government rather than donors, and if the government fulfilled its role as the primary healthcare provider, ARV rollout would be much more sustainable than with donor aid.

Government must own ARV rollout

"It is wrong to say that government cannot afford to ... [provide ARVs]; the main problem is that we have not had our priorities right, and the commitment is not there," said Samuel Kibanga, coordinator of the National Forum of People Living with HIV/AIDS Networks in Uganda (NAFOPHANU). He and other activists have suggested imposing an HIV/AIDS tax, with the proceeds going into a national trust fund for purchasing ARVs.

"Ninety-five percent of treatment funding is from donors, which is very unsustainable. Health expenditure should at least be 15 percent of the total national budget, but currently it is less than 10 percent, while the component for ARV treatment is too miserable," Kibanga pointed out.

"For the public good, and to save as many lives as possible, we should provide universal access," Mugyenyi said. "Otherwise, you create a much more serious problem."


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