Faculty of Health Science

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Competing Demands and Limited Resources in the Context of War, Poverty and Disease: the Case of Lacor Hospital
(Uganda Martyrs University, Department of Health Sciences, 2003) Accorsi, Sandro; Corrado, Bruno; Massimo, Fabiani; Iriso, Robert; Nattabi, Barbara; Ayella Odong, Emintone; Ogwang, Martin; Onek, Paul Awil; Pido, Bongomin; Declich, Silvia
Difficult choices have to be made among competing demands for health care in the context of severely limited resources and persistent humanitarian crisis prevailing in Northern Uganda. In particular, the challenge of a burden of disease from largely preventable and treatable conditions, the spread of emerging or re-emerging infections, the appearance of new, previously unknown, diseases (such as Ebola), and the heavy burden of poverty and war on health, make it imperative for getting information for identifying priorities and for decision making. However, major information gaps exist, and the little data available has been provided from scattered surveys and from incomplete reporting systems. In this context, readily available information collected using standardized procedures, such as data from hospital discharge records, becomes extremely important, in that these data can provide useful indications on the health situation at a low cost, in a long-term, sustainable way. This study is based on 155,205 medical records of inpatients admitted to the Lacor Hospital during the period 1992-2002, and its objective is to describe the health profile of the population of Northern Uganda, in order to estimate the impact of war, poverty, and social disruption in terms of morbidity and mortality. It analyses also the performance of Lacor Hospital in coping with this emergency situation, exploring pathways and mechanisms that link disease patterns, hospital performance, quality of care, and health outcomes, therefore providing an example of the thinking process leading from information to decision to action.
Economic Impact of Lacor Hospital on the Surrounding Area
(Uganda Martyrs University, Department of Health Sciences, 2003-12) Maniple, Everd; Akello, Evelyn; Asio, Salome; Auma, Vento; Kazibwe, Francis; Lule, Haruna; Corrado, Bruno; Odaga, John
The health care industry is an important contributor to the economy, especially to that of the area surrounding health institutions. This effect is even more marked in the case of rural facilities. At national level, it comes in the form of ensuring a healthy productive population and saving costs that would have otherwise been spent on treatment, thus liberating them for use on other developmental purposes. However, being a labour-intensive industry, it also contributes by providing employment for a significant section of the working-age population. At local level, in addition to the general benefits mentioned above, it comes in the form of attracting significant government and external investment to the area, and providing a market for local goods and services. It also helps to ‘keep health dollars at home’by ensuring that locals are treated within their area and thus retaining their health expenditure within their own economy. Yet, the economic impact of the health care industry is still under-estimated the world over, Uganda inclusive. Until recently, most studies of economic impact concentrated on the contribution of activities other than health care (Scorsone 2001; Scorsone 2002) and as such, there are few articles available to be reviewed about healthcare. Although healthcare contributes to economic growth, some studies have not found it to be among the leading causes of rural economic growth. In a study of rural USA, presence of healthcare services was not perceived by the respondents to be even one of the top 25 causes of rural economic growth (Aldrich and Kusmin 1997). This study in Lacor was therefore done to try to identify and highlight the economic contribution of St. Mary’s Lacor Hospital to the war-torn Gulu region of northern Uganda, which contribution though quietly perceived, has never been quantified and, as such, appears to have been ignored. By the economic impact of an organisation on an area, we refer to the influence of that organization on the local economy in terms of the level of economic activity generated as a result of the presence of that organisation. This could be the amount of money it injects into the area from its budget, the employment it provides, the goods and services it consumes from the area thus providing a market for them, the money it attracts to the area from the government, donors and researchers, and its role in the attraction and retention of businesses and other gainful economic activity in that area. The net economic impact of such an organisation is, therefore, the expansion or contraction of an area’s economy. This should, however, be distinguished from the gross economic effects due to mere influence on the jobs, businesses or incomes (Weisbrod and Weisbrod 1997). The diagram below shows a model of the interaction between an industry like a healthcare institution producing health care and the community, containing other industries and households. The institution absorbs inputs from outside the local economy and uses some from the local economy to produce its products. Its products are consumed by the local community and beyond. The institution may also make expenditures and investments outside the local economy as shown in this second model. Economic impact studies try to measure the direct, indirect and induced effects of an institution on the economy. The institution’s direct expenditure, such as when a hospital pays its local staff, is a direct input into the local economy. Purchase of goods and contracted services from the local area such as office and medical supplies, kitchen, cleaning and laundry supplies, masonry etc. is an indirect input. When the employees of the health care institution and those of its suppliers of goods and services get and spend their money in the local economy, this is an induced impact on that economy due to the presence of that institution. Thus, initial expenditures in the health sector cause a ripple of expenditures in the economy, the so-called ‘ripple effect’. The health sector and hospitals in particular are regarded by many a policy maker as economic ‘black boxes’, merely absorbing resources with, in most cases, no light on how they spend them or as ‘bottomless black holes’ consuming resources on end. Rarely are they seen as “economic boosters” or ‘productive’ entities. In reality, however, the health sector leads to the creation and thriving of support business and payment of taxes around it (Philippakos et al. 2002). That is not to mention the economic impact that is gained by the local economy when the people are treated and gain energy to produce or the gains due to the cost of illness and death saved by receiving health education on health promotion and prevention of illness or actually being treated or rehabilitated in the hospital. Apart from health care provision at various levels, Lacor hospital makes similar economic contributions to the area of Gulu District.
A Review of Human Resource for Health in Uganda
(Uganda Martyrs University, Department of Health Sciences, 2003-12) Matsiko, Charles Wycliffe; Kiwanuka, Julie
The importance of human resources in health systems needs not to be over-emphasised. Expenditure on health workers forms a significant proportion of total health expenditure in many countries. In order to effectively implement cost-effective interventions, health workers must have the appropriate skills, competencies, training and motivation to do so. However, current evidence (MoH 2001, WHO 2002) suggests that health systems in developing countries are understaffed and exhibit mal-distribution of health workers. Health workers are generally de-motivated and less productive due to inappropriate incentive environment. Demographic, epidemiological, technological, economic and political changes have created huge human resource challenges for such constrained health systems. The situation has been worsened by the spread of the deadly HIV/AIDS pandemic that has had an immense impact on health systems capacity particularly in sub-Saharan Africa. The depletion rate of health workers due to HIV/AIDS related deaths is much higher than the replacement rate, leaving most health systems incapacitated in many ways. Internal and external migration of health workers is a large global challenge that seems to be affecting many developing countries.
Listening to Voices That Matter: Placing Women’s Concerns at the Core of Health Programmes
(Uganda Martyrs University, Department of Health Sciences, 2003-12) Nduhukhire, Owa-Mataze
One of the hallmark achievements in the world today is the increasing recognition that the health of women is central in the development process. Many individuals, governments, non-governmental organizations (NGOs), corporations, policy-makers, and even multinational corporations today talk of increasing women’s access to affordable quality health. They pronounce their commitment to ensuring women’s full participation in decisions, including the development of health policies and programmes, and empowering women to protect and care for themselves. Their commitments extent to maternal and infant mortality, HIV/AIDS and other infectious diseases. Thus, at least at the level of rhetoric, there is a growing consensus that women have claims to social arrangements that protect them from the worst deprivations and abuses. The seeming `re-awakening’ towards women’s interests is against the background of various international concerns that have been expressed in various fora and documents. For example, the International Convention on Economic, Social and Cultural Rights (1966), the Convention on the Elimination of All Forms of Discrimination Against Women (1979), and the African Charter on Human and Peoples’Rights (1981) called for recognition of women’s rights. The 1987 Safe Motherhood Conference in Nairobi, in its “Call to Action”, recognized that: ...the causes of poor health among women and their children are deeply rooted in the adverse social, cultural, political, and economic environment of societies characterized by widespread poverty, lack of educational opportunities, and substandard living conditions, among other factors. They are especially rooted in the environment that societies create for women, who are discriminated against in terms of legal status and access to food and proper nutrition, education, employment, financial resources and health care. This discrimination begins at birth and continues through adolescence and adulthood, where women’s contributions and roles are ignored and undervalued (Isaac S. et. al. 1987) More importantly, since the 1994 Cairo Programme of Action, the 1995 Beijing Platform for Action, the WHO’s Women’s Health and Development Programme (1998), the Commonwealth Plan of Action on Gender and Development (1995), and the International Planned Parenthood Federation’s Charter on Sexual and Reproductive Rights (1999) significant gains have been made in women’s rights, gender equality and reproductive health issuers in most parts of the world. The right of women to live longer and in a less stressful environment and their right of women to survive and enjoy their lives is in the context of enhancing women’s capabilities, that is, expanding their choices and opportunities so that they can lead a life of respect and value. No wonder, the agenda for sustainable human development places women's health and access to resources at the centre. However, the rosy picture stops at pronouncements and much remains to be achieved.
Building Social Capital for Health Information
(Uganda Martyrs University, Department of Health Sciences, 2003-12) Okuonzi Agatre, Sam
The concept of “social capital” has been re-engineered to reflect the level and use of knowledge within society. It includes the extent to which society can create, innovate and use knowledge. This new understanding of social capital is a reconstruction of the World Bank. But the original idea of social capitalism was rooted in the trust of individuals in society. Later, it extended to the trust of the Government and its systems. Social capital was taken to be the trust, solidarity, friendship and good neighbourliness among individuals of a community. It included the social protection networks within a family and in the wider community. A society where individuals reasonably trusted each other, showed solidarity with one another and showed a spirit of good neighbourliness was regarded as community with high social capital. Most societal ideals have these elements of social capital.
International Trade and Health: Before and After CANCUN
(Uganda Martyrs University, Department of Health Sciences, 2003-12) Murru, Maurizio
International trade is potentially critical in stimulating increased production, economic growth and poverty reduction. For this potential to be achieved, transparent and equitable international rules are necessary together with national policies clearly oriented towards social objectives and resource redistribution. Economic globalization, so far, seems to have produced more inequalities both between and within nations. The Poverty, as it is currently structured and ruled, is a tool in the hands of powerful nations used to perpetuate their dominance on international trade. It should, rather, be a forum where inequities and inequalities are corrected to the benefit of millions of people struggling with abject poverty around the world. The recently collapsed WTO Conference held in Cancun Mexico, offers an opportunity for some few considerations on the present state of world trade, its uncertain future and the possible implications of this for the livelihoods of the world poor.
Selective Salary Reward for Health Workers: Realistic or a Distortion?
(Uganda Martyrs University, Department of Health Sciences, 2003-12) Kanyesigye, Edward K.
Uganda’s civil service is perhaps one of those with some of the lowest salaries in the world. This has remained the case in spite of improvements in the pay package over the last decade. Staff working in the delivery of health services (here referred to as Medical Workers) are not spared. In fact, because of their peculiar working conditions, the Medical Workers have been among the most discontented civil servants since Uganda entered the era of misrule and mismanagement of the early 1970s. In 1995, the Uganda Medical Workers’ Union (UMWU) called for and eventually instituted a sit-down, non-violent strike as a method of pressing for better working conditions. The initial reaction from the administration of the Ministry of Health was hostile. There was a blanket condemnation of the strikers who were singled out as individual “antipeople, unethical hooligans”. The executive members of UMWU were picked and locked up, and had to report to the police station every week and later monthly for over a period of year. However, after the dissolution of this strike, Government decided to award an extra pay increase to Medical Workers alone. Since this was in the middle of a budget year, which had seen salary increase in the whole service, it was decided that Medical workers alone receive a monthly lunch allowance. This had an effect of giving them a differential pay rise without having to appear so open and this incited workers in other sectors of the service. Initially, lunch allowances of Ug. Shs. 66,000 for all established Medical Workers and Ug. Shs. 44,000 for support staff were introduced with effect from 1st July 1996. The administrative staff and other common cadres in the health sector did complain and eventually the lunch allowance was extended to them as well. This seemed to quench the fire and although the Medical Workers continued to press for increase in salary, there was no real crisis until 7th July 2003 when the Circular Standing Instruction No.2 of 2003 (CSI. 2) was issued.
Health Workers Demand for Better Pay
(Uganda Martyrs University, Department of Health Sciences, 2003-12) Mungherera, Margaret
hough the recent health reforms which include decentralisation of health services and creation of ‘minihospitals’ at every sub-county indicate that Government is committed to improving the state of health services in this country, not much has been done to retain and motivate staff. For the past 30 years, health workers working in the Public Service have suffered from poor remuneration with subsequent massive brain drain to South Africa, U.S.A, Canada, U.K and Saudi Arabia and various other places. The few who have chosen to stay, have either abandoned the Public Sector entirely, and have either joined U.N agencies, faith-based NGOs, or have opted for full time private practice. The majority of those who continue to work for Government are forced to supplement their meagre salaries through ‘moonlighting’(dual employment) in private clinics. The result has been a grossly understaffed health service with overworked and demoralised health workers, often showing negative attitudes to their patients and their work. Following the strikes of the 1990s, Government set up a Commission of Inquiry to look into the grievances of health workers. The Commission comprised of representatives of the Ministries of Health and Public Service, Uganda Medical Association and the Uganda Medical Workers Union. In addition to low salaries, health workers complained about gross delays in appointments, confirmations and promotions. Other concerns were related to lack of accommodation, transport and protective gear. Recommendations of the Commission included establishment of a constitutional body comprising of experienced health professionals whose main task would be address the delayed appointments, confirmations and promotions. The Health Service Commission has done a commendable job in this regard and in developing recruitment guidelines for the districts. Indeed, its continued existence as an autonomous body will be vital in ensuring a quality Health Service. Another recommendation of the Commission was to evaluate and appropriately grade jobs in the Health Service with the aim of improving the remuneration of health workers hence the Job Evaluation Exercise whose report was eventually completed and passed by Cabinet in 2000.
Health Inequalities Within a Nation: a Review of Two New Theories
(Uganda Martyrs University, Department of Health Sciences, 2003-12) Maciocco, Gavino
What policies and values influence inequalities of health of individuals and populations? There are two main interpretations: a “materialist”, and “psycho-social” (Coburn D, 2000). It is suggested that the more a regime is neo-liberal, the bigger are the inequalities in income. The more a society is market oriented, the smaller is the trust and social-cohesion. It has been known for a long time that there is an inverse proportion between the socio-economic conditions and the state of health of a population. In the majority of industrialised countries health inequality has not been reduced despite the improvement of welfare, as reflected by, among others, life expectancy. The latest report on health inequality in England (Department of Health, London, 1998) analyses among other things the mortality rate over the last 30 years, through all causes and a series of specific causes, correlating it with six different population groups selected according to kind of work they do. Figure 1 gives the mortality rate from all causes among the male population of 20-64 years, taken from the years 197072, 1979-83 and 1991-93. The graph shows that: a) the mortality rates of the six social classes register an order that is inversely proportional to the level of social class; b) clear-cut differences are seen between professionals and technician-managers, who register the lowest mortality rates, specialised and semi-specialised, who occupy a middle position; and the non-specialised who have the highest mortality rates; c) in the space of 20 years the mortality rates diminished in all the classes, but the gap between the richer and poorer classes widened considerably; between the early 70s and 90s the mortality rates fell by 40% in classes I and II, by 30% in classes IIIN, IIIM and IV, and only by 10% in class V. These growing differences in state of health among the various social groups are also reflected in the specific causes of death: coronary disease, stroke, lung cancer, and suicide among the men, and respiratory diseases, coronary disease and lung cancer among the women. These differences in the mortality rates are reflected in the differences in life expectancy at birth between rich and poor classes: by five years among the men (75 instead of 70), by three years for the women (80 instead of 77). Similar tendencies are found in the USA where, analysing the state of health (expressed in healthy life expectancy at 30) of various population groups –whites and Afro-Americans with different levels of education –growing inequalities are registered both between the two racial groups, and within themi Crimmings E and Saito Y (2001). (figures 2 and 3).
All That Glitters is Not “Macroeconomics”
(Uganda Martyrs University, Department of Health Sciences, 2003-12) Cattaneo, Adriano
Despite many problems, the Report on Macroeconomics and Health is an important document. It re-launches the role of the WHO, which in itself is a good thing, as the WHO is an organisation potentially more independent and democratic than the World Bank. “Combating disease will be clearest proof of our capacity to construct an authentic global community. There is no justification in the world today for those millions of individuals suffering and dying every year for lack of the $34 dollars per head necessary to have essential health care services. A world that is just and looks to the future will not allow this tragedy to continue. Governments will follow commitments taken in recent years with what actions are necessary to give dignity, hope and life itself to the poorer and more vulnerable nations of the world. We know that this is possible and we are sure that in the years to come the world will dedicate all its energy to the service of this noble and vital task’. This is the concluding paragraph to the Report “Macroeconomics and Health: Investing in Health for Economic Development”, published by the WHO on 20 December 2001. Full marks go to Gro Harlem the attempt at restoring visibility to the WHO, which has been obscured recently by a colourless of the World Bank. She has started by evening Primary Health Care and gone on with an important, even if controversial, Annual Report on the performance of health care systems which is stimulating new and hopefully productive discussion of international public health care.
Unrest Over Health Sector Remuneration: What is the Problem?
(Uganda Martyrs University, Department of Health Sciences, 2003-12) Mugisha, John Francis
Employee unrest over remuneration in the Ugandan health sector is an old problem. Although salaries have been increasing since 1990, the country has witnessed more strikes in this period than before. In fact, one has the impression of a constantly looming strike by the health workers over poor remuneration. The salary is still meagre when compared to the cost of living. But I will also argue that the cause of pay unrest is associated with lack of pay policy and proper job evaluation. I will demonstrate that government has largely managed salaries by crisis –mainly responding to emerging complaints. Although remuneration refers to all forms of employee reward, here it will simply mean salary because of the notion of “consolidated pay package” in the Uganda public service. And although I am aware of its wide definition, I will use the term “health sector” to mean public departments that are financed and, or regulated by the Ministry of Health, for the purpose of this presentation.
How Should Doctors Be Paid? Lessons From Theory and Practice
(Uganda Martyrs University, Department of Health Sciences, 2003-12) Ogwang, Peter O.
For long now, doctors in Uganda have been complaining that their terms of service, particularly remuneration, are not commensurate with the years that they spend training and the amount of work that they do. This issue has persistently been raised at several fora over the years but with no definite resolution. But how should doctors be paid? This paper attempts to answer this question. In the developed world, policy makers attempt to answer the question of cost containment. In Uganda, due to limited financial resources, the overriding question is where will the extra resources to adequately pay doctors be found? Two further questions should be considered: How can consumers of medical care be protected against the financial risk of health expenditure? In other words, how can patients who seek health care be protected from becoming impoverished through 1. seeking health care? 2. Secondly, what is the best way of providing efficient levels and types of health care services without affecting the utilities of both the providers and consumers of health care (i.e. being fair to both consumers and providers)? The main problem here is that payers (private or third party) for health services can only imperfectly observe the true costs borne by health care providers. In an attempt to solve this problem, two alternate strategies for controlling healthcare costs can be suggested.
Costing Health Services in Lacor Hospital
(Uganda Martyrs University, Department of Health Sciences, 2003-12) Murru, Maurizio; Corrado, Bruno; Odaga, John; Ahairwe, Denis; Akulu, Ernesta; Bavcar, Alessandro; Bonane, Emmanuel; Kirunda, David; Mwesezi, Henry; Nagujja, Angela; Ndindayino, Kalire
Health institutions all over the world are troubled by the intractable problems of shrinking resources and increasing demands for good quality services. Private-Not-For-Profit (PNFP) health units face even more serious problems. The financial support coming to them from donations has significantly decreased in the last 20 years. Raising user fees is not a viable option as fees high in relation with families’ income exclude the poor from using the services. Yet, the mission of PNFP health units rotates around the idea of serving the poor and the disadvantaged. This leads to the need to reconcile the apparently irreconcilable: financial accessibility of services and their sustainability (Flessa 1998). Health managers at all levels (regional, district, sub-district, hospital, lower level health units) are ignorant about the actual cost of the services they produce and deliver. The very notion of “cost” is not clear to the great majority of them. In most cases the terms “cost” and “price” are used as if they meant the same. In the best cases, only direct costs are thought of when trying to assign a monetary value to services produced: expenditures are mistakenly taken to equal “actual costs”. So-called “hidden costs” are rarely considered or thought of. Yet, the knowledge of actual costs incurred in producing health services, can be of great use to health managers at all levels to make more informed decisions and to assess efficiency and effectiveness (Shepard et al. 2000, Green et al. 2001). In addition, a more detailed knowledge of actual costs of producing services can be useful for “political” reasons. All too often, lay people as well as technicians, seem to equate “fees” with “profit”. Sound information on actual costs of producing services, obtained with a clear and acceptable methodology, can help in clarifying the above mentioned misunderstanding. The authors of this study used cost finding and cost analysis techniques to calculate the actual cost of producing final units of outputs in Lacor Hospital, Gulu District, Northern Uganda.
Health Inequity In Uganda: The Role Of Financial And Non-Financial Barriers
(2004) Odaga, John
Inequality in health is known to be rampant among different socio-economic groups, with the poor typically suffering more ill-health and facing greater economic cost of ill-health than the rich. Yet a number of other non-economic factors are also known to concurrently operate, in a complex way, to further ration healthcare in favour of the rich. Measuring, monitoring and understanding the influences these factors pose in determining health-seeking behaviour at district and sub district levels are necessary to guide policy. Policies based on intuition alone can be misleading. The household survey was an attempt to understand the level and direction of disparities in health by socio-economic differentials in Uganda; and the roles of both financial and non barriers to healthcare use. A total of 843 households were sampled (by probability proportionate to size technique) from four health sub districts. We found that the poorest quintiles were 2.4 times more likely to suffer ill-health than the richest quintiles, with a greater proportion of them lacking access to publicly-provided health services than the richest counter-parts. There were no rich-poor differences in the types of illnesses/injuries. Although the findings of this survey confirm the conventional wisdom, they also reveal healthcare use patterns that reflect, not only the importance of financial barriers, but also the opportunity costs in travel (and possibly waiting) time, and other important factors including the availability, affordability and the perceived quality of services.
Comparison of tympanic and rectal thermometry: Diagnosis of neonatal hypothermia in Uganda
(Elsevier, 2004-01-01) Bergström, Anna; Byaruhanga, Romano; Okong, Pius
Although newborn body temperature monitoring is not a routine occurrence in labour wards in Uganda, postnatal hypothermia is a significant problem. This study was undertaken to find a convenient and accurate method of measuring body temperature in order to assess the prevalence of neonatal hypothermia in a low-income tropical setting. Tympanic thermometry was compared to rectal thermometry in three hundred newborns up to 90 minutes after birth.
50 Years of Cuamm's Passion: What More Needs to be Done to Tackle Inequity?
(2004-03) Okuonzi, Sam Agatre
Established over fifty years ago, CUAMM, an abbreviation for Collegio Universitario Aspiranti Medici Missionari, or University College for Aspiring Missionary Doctors is a humanitarian non-governmental organization (NGO), which deals with health and health related issues in a unique way. The picture conveyed by the name as a college for doctors aspiring for mission work is lamentably inaccurate. It is much more than a college; it is an NGO, whose members are trained and prepared. Planning for their work is carried out in the field offices and cordnated by the organisation's headquarters in Padua, Italy. Its activities, carried out by visionary and innovative, daring, passion-driven, and selfless individuals span a number of countries in Africa. They work in hospitals and some 30 health projects in the poorest and/or war-torn countries in Africa - Angola, Ethiopia, Rwanda, Mozambique, Tanzania and Uganda. After half a century of missionary work, CUAMM is taking stock of what it has achieved and what needs to be done. That the organization has helped save millions of lives is beyond dispute. Yet, the suffering of most people of sub- Saharan Africa has not reduced. No doubt, the economies of these countries have grown, but disparities and inequities have increased. In other words, unfairness and injustice have increased. CUAMM was created by a group of doctors and priests inspired by the principles of the Christian church, based on equity and justice for all. The organisation is open to all those who share these principles and care for them, irrespective of their religious or political affiliation. But how can CUAMM address such an intractable societal problem of inequity and injustice? To consider this and other related questions, CUAMM organized a conference in Padua, on November 20, 2004 to sensitize the public stakeholders on health equity, and to assess whether indeed CUAMM was meeting equity targets. The theme of this issue of our journal was inspired by this conference and the articles published to discuss it were, also, presented there. CUAMM is determined to tackle health inequity with renewed strength and commitment. This is in keeping with the Holy See's counsel to refrain from a looming culture of indifference to the increasing worldwide inequity. There were no easy solutions to health inequity, the basis of human suffering. But some broad strategies came out of the conference. To tackle inequity CUAMM would have to do more than provide emergency services. It would work to empower communities, through knowledge, skills and resource generation. It would balance between health care and determinants of welfare. This means it would have to work with other partners to influence local and global governments and activities. For example it could lobby Northern Governments to increase aid to the poor and suffering, lobby for a fair trade between South and the North, and lobby for the removal of harsh economic austerity measures imposed by the World Bank through its structural adjustment programmes (or its latest version, the Poverty Reduction Strategy Papers). CUAMM can also work locally with governments to influence policies on more equitable and sustainable financing and provision of health and other social services. Many approaches such as removal, reduction or flattening of user fees discussed at the conference, were found to have had dramatic positive effect on the use and quality of health care. As equity involves redistribution of resources, which in turn are driven by power and politics, CUAMM's involvement in influencing national and international policies will be inevitable. In this issue, we also publish articles debating the export of Ugandan health workers, appropriate staffing levels for district-size hospitals and patient satisfaction with health care. We also publish other articles discussing the subject of corporate responsibility using the Bhopal accident as an example as well as field experience of improving service quality and immunisation coverage in Uganda. Copyright 2004 - Department of Health Sciences of Uganda Martyrs University
Political Economy of Health with Reference to Primary Health Care
(Uganda Martyrs University, Department of Health Sciences, 2004-04) Okuonzi, Sam Agatre
Politics and economics have dealt with resource allocation from time immemorial. However, the basis for resource allocation and sharing depend on the nature and type of politics and economics, which also depend on different value laden ideologies on which they are based. Two key types of political economies have emerged: collectivism which permits the sharing of social benefits; and free market or neoclassical political economy, which provides economic advantages to a section of society at the expense of or regardless of the suffering of the majority of the population. HC was conceived with the experiences of these two political economies in mind. However, the current free market has reached unprecedented dimensions. It is not possible to implement and accommodate the values of PHC in this sort of political economy. Fortunately, it is predicted that this sort of social and economic order cannot last long, and that its end is at hand. There are many signs that show that it is not sustainable. Only in a socio-economic order where human welfare is the central focus and where the market plays a peripheral role will the principles of PHC be successfully implemented.
The Bamako Initiative Was Not About Money
(Uganda Martyrs University, Department of Health Sciences, 2004-04) Paganini, Agostino
The Bamako Initiative (BI) was a pragmatic strategy to implement primary health care (PHC) in the era of economic structural adjustment. Championed by UNICEF’s charismatic leader, James Grant, it sought to fill the gap created by WHO’s open-ended approach to health for all and a hard-nosed economic reform pursued by the World Bank and International Monetary Fund. Economic reforms virtually destroyed social services and safety nets. The idea of BI was to select a few critical elements of PHC for child survival, which would be funded partly through community contributions. These contributions were expected to be in addition to donor and Government expenditure. But this approach was rejected by public health experts. And in the end the initiative did not make a significant impact on the deteriorating conditions of child welfare. Therefore it was abandoned. But it sowed the seeds for communities to seek for accountability for social services.
The Millennium Development Goals: The Ultimate Test of Will and Determination
(Uganda Martyrs University, Department of Health Sciences, 2004-04) Paganini, Agostino
On the eve of the 3rd millennium, stock was taken of PHC and health sector reforms. The results of a shocking failure of previously advocated goals were evident. Therefore, a new set of goals and mechanisms were adopted under Millennium Development Goals (MDGs). The MDGs are 8: on hunger, education, gender disparity, child mortality, maternal mortality, HIV/AIDS, safe drinking water and partnership. They have implications for multi-laterals as well as for national Governments. Multi-laterals are expected to implement unified and harmonized programmes. Governments are also expected to improve governance, respect the law and mobilise resources for social investment. Recent reviews do not show that much progress has been made. But perhaps it is still too early. What seems to be missing though is a powerful lobby for the implementation of MDGs.
ARV Treatment in Poor Settings: the State of the Art
(Uganda Martyrs University, Department of Health Sciences, 2004-04) Cicciò, Luigi
Universal access to antiretroviral drugs (ARVs) has created enormous debate and controversy in developing countries. But it seems to be a more feasible prospect by the day. Prices of ARVs have dramatically come down, and there is an unprecedented commitment by the international community to make universal access to ARVs happen, under WHO’s initiative of 3 by 5. However there are a number of issues to address. First, the criteria for selection of those to be on treatment have not been agreed upon, especially using clinical methods. Second, the compliance to ARVs has been found to be problematic in Africa. It would require a Directly Observed Treatment Strategy (DOTS) approach to improve on compliance. Third, universal access to ARVs will require integration into national health systems, and strengthening these systems. Fourth, monitoring ARV treatment for safety, effectiveness and acceptability will be critical. This will require investment in laboratory services as well as in information management systems. Fifth, sustainable financing of ARVs will require Governments to commit, for a long time to come, substantial funding for ARVs, and to the health systems into which ARVs are to be integrated. Lastly, there are risks that need to be expected and prepared for up front. These include increasing the infectitious periods of people on ARVs by prolonging their lives; leakage and misuse of ARVs and the consequent drug resistance that may occur; and a possible disabling or even collapse of health systems because resources are shunted to universal ARV provision. Nevertheless, the treatment of AIDS that was denied to poor countries on grounds of cost, lack of infrastructure, and other excuses is now more than ever possible to the people of these countries.

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