1.3 trillion

In the coming year, approximately 1.3 trillion shillings, close to US $780 million, will be spent on the health sector in Uganda. The official budget weighs in at about Ush 630 billion (including both domestic and external funding), and off-budget support is approximately Ush 700 billion. Yet, awash in cash, the health sector is drowning.

Infant mortality stands at 76 per 1000, and under-five mortality is even worse – 137 out of every 1000 children will die before their fifth birthday, according to the 2006 Uganda Demographic and Health Survey (UDHS). Life expectancy at birth is 49 years for men and 51 years for women. The Ministry of Health (MoH) reports that there is only 1 health worker for every 1236 people. Even this figure distorts reality as an estimated 70% of doctors and 40% of nurses serve only 12% of the population, according to the MoH’s Master Plan for Accelerating Performance in the Health Sector. And it gets even worse – absenteeism in health facilities has been estimated to be as high as 47% on average, according to recent studies.

Though it is difficult to capture off-budget expenditures, it is likely that the health sector will receive more money than any other sector this year – surpassing even the budget for works, which will receive approximately 1.1 trillion shillings in 2008/09. Where is all this money coming from? More importantly, where is it going?

According to the June 2008 budget speech and the Medium Term Expenditure Framework (MTEF), the Ministry of Finance has allocated approximately Ush 375 billion from the domestic budget this year to health, split fairly evenly between the Ministry of Health and District Primary Health Care, with a smattering of funding toward Mulago Hospital Complex and District Referral Hospitals. On-budget, donors will contribute Ush 253 billion, 250 billion of which will go directly to the Ministry of health. Off-budget, the U.S. President’s Emergency Fund for AIDS Relief (PEPFAR) alone will this year contribute US$283 million for HIV/AIDS screening, prevention and treatment. Additionally, another Ush 300 billion will be spent on the health sector off-budget by donors such as USAID, DFID, and the governments of Italy, Ireland, Norway, and Sweden, among others. Altogether – domestic and external, on and off-budget – the health sector is thus set to receive over 1 trillion shillings.

Despite this flood of money, even the president has begun to feel the pain of the ailing health sector – and not just because he is forced to fly his daughter abroad on a private jet to deliver her baby. In April 2008 he wrote a letter in frustration to Minister of Health, Stephen Malinga, titled, “Alleged Gross Mismanagement of the Health Sector.” He lamented, “Whenever I travel up-country, I am accosted with complaints of lack of drugs and absenteeism of health workers in health units.” If it is gross mismanagement and not lack of funding that is resulting in a decrepit health sector, where is all the money going?

There are two major issues at play – allocation of resources and management of those resources. It is not an exaggeration to describe the global community’s interest in HIV/AIDS as an obsession, and this obsession has serious implications for the allocation of money in countries like Uganda, where HIV/AIDS has at times reached epidemic levels. Looking at a breakdown of the budget, US$ 283 million (around Ush 467 billion) from PEPFAR will go toward HIV/AIDS, US$139 million (around Ush 230 billion) from the Global Fund will go toward HIV/AIDS, TB and malaria and Ush 60 billion will go toward the purchase of Anti-retroviral drugs (ARVs) and malaria treatment from the Uganda based pharmaceutical plant Quality Chemicals. Additionally, in their most recent grant proposal from the Global Fund, the MoH estimated that “other AIDS development partners” (not including Global Fund) would contribute between US$22 million and $27 million this year, or approximately between Ush 36 billion and Ush 45 billion. While the aforementioned funds include money earmarked for malaria and TB, the majority will go to HIV/AIDS. Altogether, the sum of funding dedicated to HIV/AIDS, malaria and TB is at least Ush 790 billion, according to sources from the MoH, Ministry of Finance, the Global Fund, and the U.S. government.

The MoH, in its Round 7 proposal to the Global Fund stated that the “overall disease specific needs costing including essential disease specific health systems needs” for HIV/AIDS in 2008 would be Ush 309 billion and in 2009 Ush 329 billion. Even if only half of the Ush 790 calculated above went toward HIV/AIDS programs (an extremely conservative estimate given donor priorities), this should still be enough money to cover the MoH’s self-reported needs for HIV/AIDS. Even if this admittedly back-of-the-envelope calculation was incorrect, the same Global Fund grant proposal specifically states: “Based on the national strategic plan [NSP] prioritized goals and objectives, a resource needs model was applied to estimate the resources needed to meet the coverage costs of the plan. The estimate of the overall HIV/AIDS national response needs costing indicated a requirement of US$ 263 million for the first year of the NSP [2007/8] increasing to US$ 362 million in the financial year 2011/12.” According to this assessment, PEPFAR alone will cover the entire HIV/AIDS national response this year.

Nevertheless, of the Ush 98 billion in additional allocation to the health sector from the Ministry of Finance this year, Ush 60 billion will go toward HIV/AIDS and malaria drugs, the vast majority of which will go toward ARVs. Why? MoH officials say that there remains a large funding gap, in spite of donor contribution, and that an estimated 200,000 people are approved for ARVs but are not as yet receiving treatment. Additionally, in 2005, as an “investment incentive” the government of Uganda signed a memorandum of understanding with Quality Chemicals committing to purchase US$40 million worth of HIV/AIDS and malaria drugs per year. Thus, other sector priorities notwithstanding, US$40 million will be pumped into primarily into funding ARVs. While the idea of the plant was to enable Uganda to become self-sufficient and independent, donors such as the Global Fund and PEPFAR are not buying their drugs from Quality Chemicals – the plant has not yet met the required standards.

However well meaning, donor priorities have hijacked the health sector, pumping it full of money earmarked for specific health issues that do not always align with domestic health priorities. This dependence on donor funding is neither sustainable nor beneficial to Uganda. Already the country has run into serious issues with the Global Fund that has resulted in the suspension of grants. Most recently, the Inspector General for the Global Fund, on a visit to Uganda, warned that if progress had not been made on the recovery of money and prosecution of individuals named in the 2006 Ogoola Report, Uganda’s grant would again be suspended.

Donor funding for Uganda’s health sector on the whole has been “volatile and unpredictable” according to the World Bank’s Uganda Public Expenditure Review (PER) 2008, presented to the budget division of the Ministry of Finance on July 7. It was also noted that “funds are not always aligned with domestic priorities,” and donor commitments were almost always higher than the disbursement of funds. Given the challenges associated with relying upon donor funds, Uganda should strive to become independent of external funding and donor-set priorities.

The PER made several recommendations for Uganda’s health sector. Despite the seemingly staggering budget that the sector will receive this year, the PER concluded that Uganda should increase health spending. It specifically noted that “rapid population growth, increasing unit costs and unsustainably high donor funding create risks,” and that “efficiency gains are clearly possible.”

Many of these efficiency gains can be made in the area of human resources, which was a major area of concern that Malinga noted in his May 2008 letter to the President. Addressing human resource deficiencies and inefficiencies has been a sector priority for some time, but budget allocations have not reflected this prioritization, largely because Uganda has not been setting the agenda for the health sector – donors have. There is much information available on Uganda’s health sector and there has been considerable analysis examining health sector reform.

In April 2008, the Ministry of Health released its Master Plan for Accelerating Performance in the Health Sector, which highlights “areas of strategic concern that require immediate attention,” including Human Resources, Infrastructure, Essential Medicines and Health Supplies, and Operational Budget. Given this strategic plan, it would seem unwise to allow the donor community, however well intentioned, to dictate Uganda’s health budget allocations or distort its priorities. Pumping the sector full of money allocated by donor priorities has led it to burst, with wasted resources leaking out on all sides. The health sector is being trampled in the stampede of donor goodwill and while the Ministry lines its pockets, the greater population of Uganda is suffering.

Exporting Education

In 2004/5 over US $30 million came into Uganda from education services, the fourth highest external earner after remittances by Ugandan nationals, coffee, and fish exports, according to New Vision. Although this statistic is a bit outdated, it is clear that there is an enormous investment opportunity here. In 2006 non-Ugandans made up 13% of the student population enrolled in universities, and in total over 30,000 non-Ugandan students were enrolled at all levels of the education sector. See this report by the Uganda Export Promotion Board for an analysis of potential opportunities and challenges in this sector and others.

Although there is money to be made on this front, perhaps more important is the fact that the sector is as yet unprepared for the massive influx of students that are about to come through the ranks from primary school. There are over 7 million primary students in Uganda today -- a full quarter of the population -- and currently not enough teachers or classrooms to teach them when they reach secondary school. Over 450,000 sat for their primary exit examinations in 2006, but only half were able to continue to secondary school due to space and capacity constraints. And of course at some point one has to wonder what jobs will be available for these millions of students when they graduate in a few years time...

Don't mess with... Equatorial Guinea

Simon Mann was today sentenced to 34 years, 4 months in prison for his role in a failed coup attempt in Equatorial Guinea in 2004. Mann says that Sir Mark Thatcher, the son of former British Prime Minister, Margaret Thatcher, was also involved in the plot to overthrow Teodoro Obiang Nguema Mbasogo, the president of Equatorial Guinea. Matthew Green, author of Wizard of the Nile (his account of trying to track down Lord's Resistance Army leader, Joseph Kony), has an article on Mann in the Financial Times today. Equatorial Guinea is a major oil producer in Africa, which has led to massive inflows of money into that country, albeit inequitably.

The Luckiest Girl?

Nicholas Kristof's op-ed, "The Luckiest Girl," was, on the morning of July 4th, the most popular emailed article in the New York Times. For some reason, this particular piece irked me when I read it this morning, and I have spent the day trying to understand exactly why. I think it is because in this piece, Uganda, the place I now consider my second home, morphs into just another "African country" and Beatrice into another "African girl," as if using the word "African" somehow ought to convey some implicit understanding among the readers about what Africa or Africans are. I am, of course, glad that Beatrice received a good education, but dismayed at the notion or insinuation that the appropriate course of action for "Westerners" or those to want to "make a difference" is to launch a bunch of goats at poor farmers. Perhaps I am reading too much into Kristof's piece, but I cannot help my instant recoil at yet another portrayal of a very specific place and context as just another generic piece of an amorphous puzzle called "Africa."

Who Should Dictate Policy on HIV/AIDS?

The HIV/AIDS Implementers' Meeting was held in Kampala, Uganda last month. The following article by Sam L. Ruteikara, co-chair of Uganda's National AIDS-Prevention Committee, questions who should dictate the policies of the multibillion-dollar HIV/AIDS industry. The article ran on June 30, 2008, in the Washington Post.


Let My People Go, AIDS Profiteers
By Sam L. Ruteikara

KAMPALA, Uganda -- The President's Emergency Plan for HIV-AIDS Relief (PEPFAR) has been mired in the Senate for months. Last week finally brought signs that a vote, and passage, could be near. The program would cost $50 billion -- that's $165 from each American to fight AIDS, or $1.3 billion from New York City alone. But will the money allocated for AIDS stop the spread of the virus in sub-Saharan Africa, where 76 percent of the world's HIV-AIDS deaths occurred last year?

Not if the dark dealings I've witnessed in Africa continue unchecked. In the fight against AIDS, profiteering has trumped prevention. AIDS is no longer simply a disease; it has become a multibillion-dollar industry.

In the late 1980s, before international experts arrived to tell us we had it all "wrong," we in Uganda devised a practical campaign to prevent the spread of HIV. We recognized that population-wide AIDS epidemics in Africa were driven by people having sex with more than one regular partner. Therefore, we urged people to be faithful. Our campaign was called ABC (Abstain, or Be Faithful, or use Condoms), but our main message was: Stick to one partner. We promoted condoms only as a last resort.

Because we knew what to do in our country, we succeeded. The proportion of Ugandans infected with HIV plunged from 21 percent in 1991 to 6 percent in 2002. But international AIDS experts who came to Uganda said we were wrong to try to limit people's sexual freedom. Worse, they had the financial power to force their casual-sex agendas upon us.

PEPFAR calls for Western experts to work as equal partners with African leaders on AIDS prevention. But as co-chair of Uganda's National AIDS-Prevention Committee, I have seen this process sabotaged. Repeatedly, our 25-member prevention committee put faithfulness and abstinence into the National Strategic Plan that guides how PEPFAR money for our country will be spent. Repeatedly, foreign advisers erased our recommendations. When the document draft was published, fidelity and abstinence were missing.

And somehow, a suspicious statistic attacking marriage appeared. The plan states that the HIV infection rate among married couples is 42 percent, twice as high as the rate among prostitutes. Our requests for the source of this statistic were repeatedly ignored. In fact, the 2004-05 Ugandan HIV/AIDS Sero-Behavioral Survey found that HIV prevalence among married couples is only 6.3 percent, far lower than infection rates among widowed (31.4 percent) or divorced (13.9 percent) Ugandans.

When Washington insiders were alerted to these scandals, the words "abstain" and "be faithful" were quietly reinserted into the plan -- on paper. But that doesn't guarantee these methods will be implemented or promoted. Meanwhile, the dubious marriage statistic remains.

As fidelity and abstinence have been subverted, Uganda's HIV rates have begun to tick back up.

Western media have been told this renewed surge of HIV infection is because there are "not enough condoms in Uganda," even though we have many more condoms now than we did in the early 1990s, when our HIV rates began to decline. Condom promotions have failed in Africa, mostly because fewer than 5 percent of people use condoms consistently with regular partners. Indeed, the loudest HIV-prevention message in Africa is "universal access" to condoms, testing, anti-retroviral treatment, and assorted other drugs and devices. All these commodities must be transported, stored, distributed, advertised and resupplied endlessly.

Meanwhile, effective HIV prevention methods, such as urging Africans to stick to one partner, don't qualify for lucrative universal-access status.

Do not misunderstand me: Treatment is good. But for every African who gains access to HIV treatment, six become newly infected. To treat one AIDS patient with life-prolonging anti-retroviral drugs costs more than $1,000 a year. Our successful ABC campaign cost just 29 cents per person each year.

International suppliers make broad, oversimplified statements such as "You can't change Africans' sexual behavior." While it's true that you can't change everybody, you don't have to. If the share of men having three or more sexual partners in a year drops from 15 percent to 3 percent, as happened in Uganda between 1989 and 1995, HIV infection rates will plunge. It is that simple.

We, the poor of Africa, remain silenced in the global dialogue. Our wisdom about our own culture is ignored.

Telling men and women to keep sex sacred -- to save sex for marriage and then remain faithful -- is telling them to love one another deeply with their whole hearts. Most HIV infections in Africa are spread by sex outside of marriage: casual sex and infidelity. The solution is faithful love.

So hear my plea, HIV-AIDS profiteers. Let my people go. We understand that casual sex is dear to you, but staying alive is dear to us. Listen to African wisdom, and we will show you how to prevent AIDS.