5 November 2008
interview
Dr Anthony Mbonye is among the 105 individual scientists worldwide who have won grants from the Bill and Melinda Gates Foundation to explore bold and largely unproven ways to improve global health.
The assistant commissioner in charge of reproductive health in the Ministry of Health and an associate professor of public health at Uganda Christian University, Dr Mbonye will be researching on involving the Private Sector in the Prevention of Mother-to-Child Transmission of HIV in Uganda. He talked to Kakaire A. Kirunda on his upcoming three-year-study and PMTCT in general.
Tell us about your upcoming research.
In simple terms, most HIV testing and antiretroviral treatment is done in the public sector. But now we want to involve the private sector. Our theory is that since most reproductive health indicators are stagnating, can we use the private sector to improve our health status? And these include maternal mortality, post natal care, HIV prevalence, STD management and treatment, contraceptive prevalence, deliveries at health units and antenatal care. There is a government policy on public-private partnership but how do we operationalise this policy to improve the health status of our population?
Can private midwives, if trained in HIV counselling and testing, family planning and antiretroviral treatment (ART) improve the health of especially pregnant women? Can we use these midwives to reduce mother-to-child transmission of HIV (PMTCT) by training them to give the necessary drug to HIV-positive pregnant women?
The driving force of the private sector is to make money. How do you ensure they will not exploit the poor?
We know the private sector charges money. And in the last demographic and health survey, women were asked what constraints limit them to use health services. Their number one response was cost, number two was distance to health units, and number three was availability of drugs and supplies.
So if number one was cost, how do we address this?
In this study, we want to introduce the voucher system. We want to discuss with the private mid wives and agree that if a woman went to them for antenatal care for four visits and she returned to deliver, how much will you charge? Say they charge Shs5,000, we shall agree and give the women in the surrounding community vouchers to get antenatal and delivery services. We shall then relay the results to the government.
But we shall also do a cost effective analysis. We shall know what it costs to save a mother and her child. Using our example, if a mid wife helps 20 women to deliver in a month, she will earn Shs100,000 which is just $50. The most important thing is that this midwife will have protected the life of a mother and a child.
Why is the uptake of PMTCT still very low yet many people know that it is available and free?
The answer to that is the very reason why only 42 per cent of women deliver at health facilities, is the same reason that only 23 per cent of women use contraceptives, is the same reason that only 46 per cent of our children are immunised against the killer diseases.
The reason is the barriers I told you earlier. The real barrier is cost of accessing services. Services in government health units are free but there is the cost of moving from your home to the health unit. On average, a boda boda ride from a rural area (for 10 kilometres) to reach the health facility costs between Shs7,000 and Shs10,000 to and fro.
And you are talking of spending a whole day at the centre because there is waiting time. We are talking of going there and being told there are no drugs and one has to buy them, and also lunch. There is also what we call opportunity cost of time. If I am a pregnant woman, then leave home and spend a whole day away, who will look after my children?
How much farm work am I forfeiting? People wonder who will look after their animals and shambas, and then they promise themselves to go next time. So the priority is not their health. But they are not alone. Does the government prioritise health in expenditure, infrastructure, motivating health workers, paying them a good salary? Yet there is real poverty in Uganda that even if an individual prioritised health, they would not afford.
HIV testing is vital to PMTCT but research in some parts of this country has indicated that women who test positive never accept their results. Isn't this affecting PMTCT?
That goes to the quality of counselling. If a client voluntarily goes to a health facility, what kind of counselling has this person received especially on acceptability of results and the impact of the results? But also, there is a problem of stigma. It's still high.
Very many people are not willing to accept that they are sick. But there is also lack of knowledge on the existing interventions to address HIV/Aids.
They do not know that there are drugs and people can live positively. There is also the problem of gender relations. We have data that for some, testing for HIV causes domestic violence. Women are beaten for allegedly bringing HIV in the home.
We have regularly heard of stock outs of ARVs, isn't this also impacting PMTCT?
That does not only impact PMTCT but also the general provision of services. Stock outs are a very real issue; even of simple drugs. Stock outs are caused by three issues. Health workers are supposed to estimate what they need and then requisition. Many are failing to do this well. But there is also a problem at the National Medical Stores which sometimes fails to process requisitions that come in early.
Districts have no funds to send the drugs to the health centres. We are now making sure we train health workers to make requisitions in time. The Ministry of Health is working towards building the capacity of NMS. But all this requires funding manpower and supervision.
Should HIV-positive pregnant women have children amidst poor PMTCT services?
The ministry is addressing that but the study I am going to do will also be looking at how women with the HIV infection can access family planning. We know that women with HIV get pregnant. But HIV makes pregnancy worse and vice versa. So one of the options is for them to use family planning and the best method for HIV-positive women is using condoms. And for those who really want to have children, we help them go through counselling and many other ways. But the issue is improving quality of care.
There has been a problem of turning research into policy in this country. Do you think if you came out with good results, the government will easily take them on board?
I am a policy maker, programme manager and a researcher and we are very concerned, sometimes research ends up somewhere hanging. But we [Ministry of Health] are trying to change that together with the Makerere University School of Public Health, the University of Copenhagen, the Uganda Malaria Research Centre and other stakeholders. We have convened symposia on getting research into policy.
This is a concern for everybody. Developed countries are where they are because they use their research findings. On this we are working towards incorporating everyone who matters including the media.
The other problem here is that our research is not valued by some people.
Also, our policy makers have not done research before. Some of them have been clinicians in hospitals and do not know the usefulness of research. When you do a PhD, you are treated as a threat. When you want to do good work for the ministry, they say no. They label you as an academician who should go to Makerere and teach. But we are the people who are supposed to do these studies and prove that we can improve the health of Ugandans using innovative approaches.
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