New Vision (Kampala)

6 December 2012

Uganda: Abuja, Maputo Declarations Haunt Uganda As HIV Prevalence Rises

In one by-partisan debate, the opposition and NRM legislators ganged-up against the executive, demanding increased budget allocation to the health sector.

It was one of the rare sights in the Ugandan parliament. The unity was far from the usual NRM loveaffair when the ruling party's numbers prevailed in the House, as, often, consensus was futile and decisions reached through voting.

And when the dust finally settled, a sh11.4 trillion budget was, on October 3, adopted for the 2012/13 financial year, with an additional sh6.5b sawed from other sectors to enhance pay and recruitment of more health workers as well as sh49.5b through a supplementary budget.

As it stands, the health sector claimed a sh847b budget, accounting for 8% of the national budget. "We want the health sector budget increased to at least 15% (from the current 8%) of the national budget, as agreed in the Abuja Declaration," Dr. Sam Lyomoki, the parliamentary health committee chief says.

The Abuja Declaration

Recognising the high mortality arising from limping health services provided in their countries, heads of state of African Union states, in April 2001, pledged to increase their health sector budget allocation to 15% of their annual budgets.

They also urged donor countries to fulfill the yet to be met target of 0.7% of their GNP as official Development Assistance (ODA) to developing countries, drawing attention to the shortage of resources necessary to improve health in low income countries.

The heads of state reaffirmed their commitment in 2003. And, like in the Abuja Declaration, they vowed to increase their countries' health budgets to 15% of the Gross Domestic Product (GDP) in the Maputo Declaration.

Progress on the declarations

Since 2001, few African countries have scaled-up health sector funding to match the 15% Abuja target. Only Rwanda and South Africa, according to a World Health Organisation (WHO) report, Abuja Declaration; 10 years on, have reached the 15% mark.

The African Union Commission (AUC), meanwhile, reports that six AU member states have met the 15% benchmark that is Rwanda (18.8%), Botswana (17.8%), Niger (17.8%), Malawi (17.1%), Zambia (16.4%), and Burkina Faso (15.8%).

Only eight countries in Africa are also on track to meet the Millennium Development Goals (MDGs)-Algeria, Cape Verde, Egypt, Eritrea, Madagascar, Rwanda, Seychelles and Tunisia and most African countries are achieving less than 50% of the gains required to reach the goals by 2015.

Most countries are achieving less than 50% of the gains that would be required to reach the goals by 2015, with progress on MDG 5 (maternal health) being particularly slow.

The Commission on Macroeconomics and Health (CMH) has calculated that a country needs to spend at least $34 per capita per head in order to provide an essential package of health services to their population.

According to the African Union, governments in Sub-Saharan Africa make averages of $25- 27 per capita per head, yet 32 of the 53 AU member states invest less than $20 per capita per head (this includes four of the six countries who have met the 15% benchmark).

WHO notes that the median level of real per capita government spending in Africa has increased from $10 to $14 per capita per head from 2001 to 2011, although the lowest observed level is still very low at $ 0.47 per capita per head.

Of the 14 countries that spend more than $ 33 per capita per head, 71% are middle income. Nonetheless, 27 have increased the proportion of total government expenditures allocated to health since 2001, including Uganda, but there is no up or downward trend in 12 countries.

A report, health spending in Uganda, April 2010 authored by Action for Global Health and German Foundation for World Population, notes that since 2000, Uganda's Health Sector Strategic Plan (HSSP) has benefited from direct donor support accounting, on average, for 40% of Uganda's health sector resources.

In the 2008/09 FY, the total Government funding to the health sector was sh628.46b (about 8% of the national budget) and sh636.9b for the 2009/10 FY. In 2012 the government approved sh847b funding for the health sector.

But, like in the previous FY budgets, the health sector's envelope comprised only 8% of Uganda's GDP or national budget, a situation health experts warn is counterproductive in fighting HIV/ AIDS, among other ailments.

Prof. George Kirya, a former health service commission chairman, notes that the under-funding makes it hard for Uganda to achieve the Millennium Development Goal 6 (MDG 6) on combating HIV/AIDS, malaria and other diseases, especially Target 6.A of halting by 2015 and reversing the spread of HIV/AIDS.

"We are doing well at all (on Abuja Declaration and MDG 6)," he says. "we are not funding the health sector adequately and we have also abandoned ABC method of fighting HIV. People are misbehaving and we are getting new cases of HIV infections." The Abstinence, Be Faithful and Condom use (ABC) formula has been Uganda's strongest weapon in the fight against HIV.

As a back-up to the ABC strategy, the government undertook mass male circumcision, considering that a circumcised person has up to 40% chance of surving HIV infection compared to uncircumcised one.

A 2010 UN HIV report on the global AIDS epidemic noted that 5,340 men were circumcised between October 2008 and March 2010 when the exercise was launched, pointing to inadequate political will and insufficient resources as challenges to increasing access to highquality HIV/AIDS care and support services.

HIV in schools

Considering that 56% of Uganda's 34 million population is below 18 years, according to the Population Secretariat, the education sector is under threat of HIV because this is the age most people are in school, exacerbated by a high teenage pregnancy of 24%. In Uganda, about 1.2 million children are living with HIV.

Of these, about 150, 600 children are living with HIV, with 50% of the 27,000 children born with HIV expected to die by their second birthdays. While 76,000 children urgently need ARVs, only 28% of them access the life-prolonging drugs.

Antiretroviral coverage for children at is18%, compared to 43% of Ugandan adults have access to antiretroviral treatment. Dr. Yusuf Nsubuga, the director of basic and secondary education, notes that HIV is increasing in the education sector.

"It is a bigger problem among teachers," Nsubuga says. "We need more action in stopping new infections."A 2008 study on the impact of HIV/AIDS on Uganda's education sector, done by International Development Consultants, found that 10,000 primary and 5,000 secondary school teachers, respectively, were living with HIV.

A woman taking an HIV test. People are constantly reminded to test and know their HIV status

About 1,100 non-teaching staff was HIV positive. Due to inadequate funding, the education and sports ministry mainstreamed HIV/AIDS into its various programmes, including the Presidential Initiative on AIDS Strategy for Communication to Youth (PIASCY) present in 15000 schools.

The government, Nsubuga says, has also introduced a general HIV/ AIDS policy on education to curb the virus' spread. "We also have a school health policy and workplace policy that promote behavioural change and positive living for HIV positive people, as well as sanitation, nutrition and exercise in schools" Nsubuga explains.

According to Christine Ondoa, the health minister, about sh220b of the 2012/ 13 FY budget was earmarked for salary and wages and sh200b for medicines and ARVs.

"HIV is a behavioural issue," she says. "She argues that it would take an individual to change behaviour to fight it. Even if we had adequate funding for the health sector, but people are promiscuous, we shall still have high HIV prevalence."

So with more sensitisation amongst the 12-26-year age groups, HIV infections will fall, alongside the national HIV prevalence rate that rose from 6.4% in 2005 to 7.3% currently.

"But we need a collective effort," she says. The ministry or government alone cannot win this war on HIV.", Ondoa says.

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