13 February 2018

Uganda: Why We Need More TB Funding in Uganda

Pulmonary Tuberculosis (PTB) that is otherwise sometimes referred to as TB of the lungs is a disease that has been eradicated in most parts of the world, but continues to persist in Uganda.

PTB, moreover, is a highly infectious, debilitating and deadly airborne disease, but which is preventable and curable. As is the case with all airborne infectious diseases, early diagnosis of PTB and the isolation and treatment of those infected with active mycobacterium TB is the most efficient way to slow down PTB infection rates and/or to prevent its geographical spread.

Emerging findings from a comprehensive qualitative investigation into PTB in Uganda that was conducted by CPAR Uganda agree with the Uganda national TB survey estimates that thousands of people infected with PTB in Uganda have not been tested.

There is, indeed, good reason to believe that thousands of Ugandans infected with active PTB are unaware what disease afflicts them, or if they are aware, they don't know the dire consequences of not seeking diagnostic and treatment services.

Persons infected with active PTB, some unaware, live freely within their families and communities unknowingly spreading it. The national TB survey estimates that Uganda has 87,000 TB cases annually; an annual prevalence rate of 253/100,000; and a rate that is higher than had previously been thought.

It is feasible that on the basis of a false assumption previously held that Uganda had a lower TB prevalence rate, the World Health Organisation (WHO) declared Uganda as being no longer among countries with a high TB burden.

High level government of Uganda officials, such as the Minister of Health, Dr Jane Ruth Aceng, acknowledge that Uganda's TB burden has continued to cause an enormous health challenge and is a big public health challenge.

Additionally, TB presents an economic challenge and impacts negatively on the livelihood of our people. It is, therefore, baffling that Uganda national budgets for TB management are consistently underfunded.

According to the WHO annual TB report for the financial year 2016/2017, the budget for Uganda's national TB programme is $54 million (nearly Shs 196 billion), of which only 29% is funded, leaving 71% (about Shs 139.2 billion) not funded.

Worse still, of the 29% (about Shs 56.9 billion) only 3% (about 5.9 billion shillings) is covered from domestic sources; while 26% (about 51 billion shillings) is covered by external grant funding.

Emerging findings from the CPAR investigation confirm how underfunding is forcing medical personnel in Uganda to do their work in risky conditions, while they are handling infectious patients.

Some refuse to do their work. Insufficient funding for PTB healthcare services is the reason PTB diagnostic services are not easily accessible to ordinary Ugandans.

Emerging findings from the CPAR investigation indicate that suspected PTB cases often have to travel long distances and at a huge cost on their time and their family financial resources, in order to access appropriate diagnostic services.

Most of the lower level health facilities are equipped with obsolete light microscopes to diagnose PTB by the smear microscopy technique.

The national TB survey, moreover, found that smear microscopy, the main TB diagnostic test in the country, misses about 60% of the cases finding which led the ministry of Health to conclude that there is a need to update the country's TB screening and diagnostic algorithms.

In Uganda, a country with a high PTB burden, emerging findings from the CPAR investigation indicate an average national ratio of physical presence of GeneXpert machines to the population of 1:353,000.

In some regions it is even much higher - the highest ratios being in the range of 1:553,000 in Lango and 1:574,000 in Bunyoro. Under prioritising funding budgets and allocations for PTB healthcare services results in untold suffering for thousands of Ugandans.

Many endure long and painful periods of illness, during which they are mostly treated inhumanely. PTB is a slow silent killer and its sufferers watch their bodies waste away and their spirits are broken, until they succumb to death.

It is imprudent to allow this status quo to continue. The health committee of parliament, which will ultimately determine the health sector budget next financial year, can address this situation by:

1. Paying closer attention to and closely scrutinising the annual budget of the ministry of Health and ensure that, sufficient budget provisions are included in those budgets for PTB healthcare services.

They should also ensure that the ministry of health, in particular, and the government of Uganda, in general, emulates the government of the republic of Rwanda, and ensure that the budgets for the national TB programme are covered 100%, irrespective of sources of funding. This should start immediately with the remaining six months of the 2016/2017 financial year.

2. Monitoring closely the ministry of health's quarterly budget performance and ensuring that funds budgeted for PTB healthcare services are not diverted at both central government level and at the local government level; not even to other emergency health services, for PTB in itself is a disease that warrants 'emergency treatment, timely and sufficient releases of funds (in-cash or in-kind).

Review procurement policies that govern acquisition of services and materials for diagnostic machines and medical supplies with the view of reducing costs.

3. Liaising with other policymakers - other committees of parliament, parliament as a whole, or even the executive, with the intention to advocate for management of PTB to be considered as a crosscutting issue of concern to all.

Policies for building awareness on handling and management of PTB should be enacted and implemented for all public institutions - parliament, detention centres, the armed forces, schools, public transport, houses of worship, the 'modern' closed markets, hospitals, the work place and all places that groups of people gather.

All public institutions should plan and budget for the management of PTB within institutions and for the users of these institutions, so as to stem its spread and infection rates.

4. Causing a review of Uganda's open-door policy of unrestricted free entry and settlement of refugees, particularly those originating from countries in which their healthcare services are likely non-functional due to civil strife, for example.

At the very minimum, Uganda should request assistance from the United Nations for necessary diagnostic machines, equipment, supplies and human resource for mass screening of all refugees at points of entry, in order to identify those who are infected with PTB, isolate and treat them.

This will reduce the strain on local government budgets of refugee host districts.

The author is the managing director of CPAR Uganda Ltd and was the social scientist for the Tuberculosis Working to Empower the Nations' Diagnostic Efforts (TWENDE) study conducted in Uganda last year.


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