Thursday, February 23, 2017

Community Health Extension Workers to Aid Uganda achieve health SDGs

By Esther Nakkazi

Uganda had an outbreak of Ebola Hemorrhagic Fever in 2000 and although there were deaths, the country largely managed to contain it. At the time the Director General at the Ministry of Health was Prof Francis Omaswa.

Using this example at the first international symposium on community health workers ongoing in Kampala, Omaswa said what helped to not turn this into a catastrophic event like what happened in west Africa was among others village health workers.

The symposium is convened by Makerere University College of Health Sciences, School of Public Health, Uganda in partnership with Nottingham Trent University, UK and Ministry of Health, Uganda. Dr. David Musoke is the symposium chair and its theme is community health workers and  their contribution towards Sustainable Development Goals (SDGs).

The communities listen to the village health workers teams who helped to disseminate information but the most important ingredient here was trust.

For 16 years now, Uganda has engaged Village Health Teams (VHTs) but it will soon switch to Community Health Extension Workers or the CHEW strategy.

Switch from VHT to CHEW strategy;

There is no doubt as to the positive contribution towards promotion of health, mobilisation and containing outbreaks made by VHTs in Uganda. But 16 years after their existence, 75% of the disease burden in Uganda is preventable and the top 10 killers are still the same.

So could it be that the village health team strategy is wrong, it was a cut and paste or it needs an overhaul? Well, the government is now moving to CHEW strategy. This does not mean that VHTs will disappear, no they won’t.

VHTs will remain with their role of mobilisation and some will be absorbed into the CHEW system said Dr. Christopher Oleke at the health workers symposium.

Currently, Uganda has 180,000 VHTs working as volunteers and of these only 60,000 have been trained. With lack of monitoring, supervision and accountability these have been engaged in an unharmonised and uncoordinated structure.

One of the challenges with VHTs has been the supporting partners who have been messy as each trains their own VHT. Imagine this scenario; in one parish a partner trains a VHT to distribute bednets and check for malaria, another one is trained to preach nutritious feeding, one looks out for pregnancy problems, another encourages is trained to encourage delivery in health centres etc.

So the interventions are not bad and by the way they have produced some visible results as in the case of Kanungu district in south Western Uganda where they have improved maternal and new born health outcomes but the governance and lack of leadership among supporting partners has created chaos rather than progress.

You cannot blame partners entirely, the voluntary role can carry only so much responsibilities. But some VHTs are working 7 days a week for long hours and are untrained.

So Uganda wants to fix it. The CHEW strategy will engage only 15,000 health workers. They have to be between 18-35 years and with a minimum education to qualify. They will be paid a salary by the government and get regular training. Their roles will be defined among them conducting baseline and other important surveys.

As Prof Francis Omaswa put it, ‘they should not be the big doctors in the villages’, as has been the case so they should be monitored, supervised and supported through a proper governance structure. “They should not be left in isolation,” he cautioned.

But most importantly, the CHEWs will reorient the minds of Ugandans. How? According to Dr. Oleke many Ugandans think that having medicines in health facilities and doctors equals to improvement in health.

The CHEWs will focus on the household as a totality promoting good hygiene, standard health practices and most of all promote the use of less alcohol which is causing Ugandans numerous health issues said Dr. Oleke.

They will also play an important role of registering all pregnant women and new borns electronically who will be followed through the system that way Uganda hopes to improve the mother and new- born well being.

The CHEW strategy will have a strong monitoring, supervisory, accountability and will be under a harmonised structure said Dr. Oleke.

Innovative financing for health workers;

But there are cautionary voices and suggestions before the roll out begins this financial year. Dr. Elizabeth Ekirapa from the School of Public Health warned this should not create a parallel administrative structure instead they should integrated within the national health care team.

Ekirapa also said the CHEW strategy should be sustainable and be home grown or customised to Uganda. It copies a lot from Ghana and Ethiopia CHEWs.

Dr. Patrick Kadama from ACHEST was concerned about the financing structure which if not well thought out might distort equity. It comes amidst Uganda trying to create a social health care insurance scheme and other tax based systems.

Dr. Kadama also thinks the CHEW strategy implementers should ensure good returns on the investment thus a specific investment case should be done before roll out. They should also ensure that the CHEWs boost primary health care.

Concurring with everyone else he said the CHEWs should work in tandem and in sync within a defined national health care system - read - ‘not in isolation’ and the roll out should be gradual. Talk about the best of the best. 


Tuesday, February 21, 2017

Who should try accused health workers?

By Esther Nakkazi

Ugandan health workers are fighting back. As cases of what the public view as health workers negligence build up, most of them end up detained in police cells and tried by public courts.

Today the Executive Director for African Centre for Global Health and Social Transformation (ACHEST) Prof. Francis Omaswa said enough of the police officers interference and trials in public courts for Uganda health workers.

“It is wrong to arrest health workers and detain them at police stations,” Omaswa said to which we got a loud applause at the first International symposium on community health workers held in Kampala, Uganda.

The theme is contribution of community health workers in attainment of the Sustainable Development Goals (SDGs) convened by Makerere University College of Health Sciences, School of Public Health, Uganda in partnership with Nottingham Trent University, UK and Ministry of Health, Uganda.

He said doctors and nurses who commit offences should be tried by their respective professional governing bodies.

In this case the Uganda Medical and Dental Practitioners Council (UMDPC) responsible for licensing, monitoring and regulating the practice of medicine and dentistry for doctors and the Uganda Nurses and Midwives Council (UNMC).

Omaswa has a point after all armed forces accused of offences are court-martialled. Justice is dispensed by their own.

The reasoning could be that people who have no knowledge of the challenges and proceedings in an operation theatre have no business questioning and detaining an accused doctor whose patient has died on the table.

These cases now have a trend in Uganda. Usually, a patient whose case will be viewed as ‘non fatal’ by the concerned parties, such as a pregnancy will report to a health facility. The health workers will demand a fee, a pricey drug not available at the facility or even tell the patients to wait for a senior doctor.

Time is of the essence here. While demands are being made, the patient needs attention and by the time whatever is demanded is availed and the patient is taken to theatre or given treatment, it is the apex of an emergency. A life or two are lost.

With the health system clearly lacking some health workers find themselves in a tight corner inspite of every effort they put in to save lives. So the larger thinking would be to blame the system.

“The best way to manage a system is not to blame an individual,” said Omaswa. Quoting the law, Omaswa who is celebrated as the most efficient Director General at Uganda's Ministry of Health and is remembered for the phrase 'health is made at home and repaired in hospitals' said the Ministry should be led by a technical person and it should not have both a director general and a permanent secretary because it duplicates roles and wastes resources.

While Prof. Omaswa clearly makes a valid point, the larger public has no knowledge of whoever is in charge of accused health workers nor the governing bodies, UMDPC and UNMC, so their immediate action is to go to police.

It also does not help if in some cases the health workers put money ahead of saving lives to which they swear the hippocratic oath. To show that justice is attainable, the health workers governing bodies need to create awareness and show that they can indeed punish those found guilty.

There is a proverb in Uganda which says a person does not just die. The translation is that there is always someone to be blamed for a death.

The public will never understand the system nor medicine but if they for sure suspect that a life could have been saved their only option will be to turn to police for justice!

Tuesday, February 14, 2017

Abortions decline in Uganda; it could cut maternal deaths

By Esther Nakkazi

Uganda is gaining positive results in saving the mother with a decline in the rate of abortions a new  study by U.S based Guttmacher Institute and Makerere University indicates.

Over a decade, the number of women aged 15–49 years who carried out abortions in Uganda declined to 39 abortions per 1,000 women in 2013 from 51 in 2003. This in tandem reduced the annual hospitalisation rate for complications in the same age group to 12 per 1,000 women from 15 over the same period.

Naturally, less abortions would translate to less maternal deaths in Uganda, which are caused by four major preventable factors; unsafe abortions, haemorrhage, hypertension and sepsis.

According to a press release from the Institute, the study also found that 93,300 women were treated across the country for complications from unsafe procedures. Abortion is illegal in Uganda but the law allows it to save a woman’s life.

The 2012 National Policy Guidelines and Service Standards for Sexual and Reproductive Health and Rights permit abortion under additional circumstances—including in cases of fetal anomaly, rape and incest, or if the woman is HIV positive—in practice, legal abortion is both difficult to obtain and to provide.

The country’s abortion laws and policies are inconsistently interpreted by law enforcement officials and the judicial system, and many providers and women remain unaware of the circumstances under which abortion is legal. As a result, most abortions in Uganda are clandestine procedures, which are often unsafe.

“Close to one third of Ugandan women who have abortions each year are treated in health facilities for complications resulting from unsafe procedures, and many other women who experience complications do not get the care they need,” says Elena Prada, consultant with the Guttmacher Institute and the study’s lead author.

“Notwithstanding the Ugandan government’s efforts to improve postabortion care services, stigma and fear of mistreatment are significant barriers for many women in need of these services.”

Over 50% Ugandan women still have unintended pregnancies:

The study also produced new pregnancy estimates, finding that 52% of all pregnancies in Uganda in 2013 were unintended and about a quarter of these unintended pregnancies nationally ended in abortion.

Given that most abortions result from unintended pregnancies, improving family planning services is critical to reducing the incidence of unsafe abortion.

The high proportion of unintended pregnancies reflects the finding that among women of reproductive age, 38% of married women and 45% of unmarried sexually active women had an unmet need for modern contraception in 2011.

“Despite some gains in modern contraceptive use over the past decade, unmet need for contraception in Uganda remains high and must be addressed by improved family planning services,” says Professor Christopher Garimoi Orach, head of the department of community health at Makerere University’s School of Public Health and a study coauthor.

“For example, integrating comprehensive contraceptive counseling into all postabortion care visits can be a powerful intervention to help women avoid future unintended pregnancies.”

The study’s authors recommend efforts to expand existing postabortion care services to ensure that all women with abortion complications are able to get the care they need, particularly in rural areas.

In particular, contraceptive counseling should be strengthened to address high rates of method discontinuation and women’s concerns about side effects. The authors emphasize that counseling must acknowledge the challenges women experience and provide accurate information on the side effects of different methods.

Further, they recommend that family planning services provide a full range of modern contraceptive methods, including long-acting reversible methods such as IUDs and implants, so women can choose whichever method works best for them.

Finally, the researchers suggest clarifying and raising awareness of existing laws and policies on abortion in Uganda among the medical community, the judicial system and women.

Every woman who meets the criteria for a legal abortion should be able to obtain a safe procedure at an affordable cost from a trained health care provider.

Wednesday, January 11, 2017

Zika re-enters Africa as encroachers take over its forest habitat in Uganda

By Esther Nakkazi

The Zika virus has re-surfaced in Africa through Angola. As we all know, Zika was first discovered in Uganda in 1947.

Unfortunately, as it resurfaces in Africa, the Zika forest where it was first identified in Africa is just a few decimals, most of it destroyed by encroachers who feel high rise buildings are much more important than a habitat for mosquitoes species and wildlife.

According to Angolan health officials the country's first two cases of the Zika virus, a French tourist and a resident in the capital Luanda, says AFP.

Since 2015, when the outbreak started more than 1.5 million people have been infected with Zika, mainly in Brazil, and more than 1,600 babies have been born with microcephaly, according to the World Health Organisation.

But in Uganda, the Zika virus, which takes its name from ‘Ziika' - the name has always been misspelt - a forest on the shores of one of Africa’s biggest fresh water lakes, Lake Victoria, where researchers caught the mosquito, isolated the disease and have since kept surveillance, the forest is almost gone.

We can say the researchers at the Uganda Virus Research Institute (UVRI) did a good job and continue to do so. They continue to do research, experiments and monitor the mosquito species in the Zika forest and the whole country.

Continuous monitoring and surveillance means Uganda, which is a biodiversity hotspot with some of the world's most virulent pathogenesis on top of its game of controlling diseases.  

Only to be let down by environmentalists who are oblivious of its importance and thus do not advocate for its conservation and the Wakiso land board who continue to sell part of the zika forest land to big shots with no care at all.

UVRI as a research entity was given a piece of the forest (30 acres) for research but from it 10 acres has been allocated to ‘developers’ by the Wakiso Land board, which of course is under the larger Uganda Ministry of Lands, Housing and Urban development.

The researchers efforts to keep the land for its rightful use has fallen on deaf ears.

Recently, Madame Stephanie Rivoal, the French Ambassador to Uganda visited the Ziika forest and almost cried. She thought Ugandans have not heard of the term ‘conservation’ as she saw hundreds of cut trees, numerous construction sites and encroachers.

By the end of her walk thorough the forest reserve accompanied by Erik Orsenna, -also the ambassador of the Pasteur Research Institute in France-a politician, novelist and Nobel Peace Prize contender their energy and enthusiasm was deflated by the depletion.

The Zika forest still houses wildlife especially monkeys and a number of mosquito species like the Aedes Aegypti and Africanus in the forest.

Dr. Julius Lutwama, who heads emerging and re-emerging infections at UVRI warned that if this wildlife habitat is destroyed the mosquitoes could also have capacity to mutate and adapt. What would we expect anyway if there usual prey is eliminated?

Friday, December 30, 2016

Injectable anti-HIV drugs could be available in 2017

By Esther Nakkazi

Science is moving HIV treatment and prevention forward from oral to injections. Instead of taking a daily pill for anti retroviral therapy it will switch to an injection lasting three months at most.

Scientists believe, especially women, who are also the most affected by HIV will easily adapt to the use of these long lasting injectables because of their familiarity with injections through contraception.

Almost one in four new HIV infections in sub-Saharan Africa are in young people aged 15-24 years, and two thirds of these are among girls who are also users of contraceptives and injectables are favourites.

“When you think about young women in particular being very adapted to getting injections for contraception this could be a very nice natural next step,” said Jeanne Marrazzo, the director of University of Alabama at Birmingham school of Medicine Division of Infectious Diseases.

Scientists also believe the injectables will reduce stigma and daily adherence, which are still a challenge to people taking anti-HIV drugs daily and they will also give users a choice.

“Young people sometimes forget to take the pill so if we give them formulations where they do not have to worry it will probably work better,” Thomas Hope, a Professor of Cell and Molecular Biology at the NorthWestern University, Evanston at the biennial HIV Research For Prevention conference (HIVR4P 2016) held 17-21 October in Chicago, USA.

The injectables under development will be used for therapy and for Post Exposure Prophylaxis (PrEP). Two different drugs, Rilpivirine by Janssen Pharmaceutical Companies of Johnson & Johnson and Cabotegravir by ViiV Healthcare, a global specialist HIV company with GSK, Pfizer Inc. and Shionogi Limited as shareholders are collaborating.

For treatment two injections of Cabotegravir and Rilpivirine will be given in the butt at the same time. While for PrEP, only one injection of Cabotegravir - a new drug to users - will be administered.

“The treatment work is well advanced but prevention is still early,” said Joe Romano, President of NWJ Group, LLC.

Although treatment may be an easy sell to users it will be a challenge for PrEP which communities are less aware about.

“PrEP is more like a contraceptive. It is a product you give to healthy people. Overall, individuals are aware of pregnancy risk all the time and less about HIV risk, which comes on and off,” said Nelly R. Mugo, a gynaecologist and a principal research scientist at the Kenya Medical Research Institute (KEMRI).

But although injections for ARVs may be acceptable there are many technical issues yet to be addressed. Men are still naive in this field and most importantly how long can someone go between the injections, explained Romano.

Scientists are looking at injectables with drugs 3-4 millilitres and for it to last for 1-3 months.

“Men have no experience. Healthy men typically do not get an injection normally every three months,” said Romano.

Then variations in the human body around metabolism, drug absorption are also key as well as being cautious that when an injection goes in it cannot come out!

However, the most pressing issue for injectables for ARVs is the so called ‘tail’, which basically means if the drug is injected in an individual at what point does its concentration go down so that they are not at risk before the next dose. If the drug levels are down what happens if infections with a bit of drug in the background?

“I think 3 months is good but if it starts to get less than that and you have to go every month to the clinic that is still a hustle,” said Lynn Morris the head of the HIV Virology laboratories at the National Institute for Communicable Diseases (NICD) in South Africa.


Scientists caution public expectations on 2016 HIV cure breakthrough research

By Esther Nakkazi

In the year 2016, there was so much excitement about cure research opportunities from the ‘functional cure’ for HIV. However, scientists cautioned the public about high expectations.

Scientists at the National Institutes of Health (NIH) and Emory University in an experiment induced sustained remission of SIV in animals, which if translated to humans could mean that there is a possibility of having people on anti-HIV drugs sustain suppression of the virus and get off of the drugs. 

This is called sustained HIV remission or a ‘functional cure’ which is not a cure but an outcome of a treatment that induces prolonged, undetectable levels of HIV viremia without the daily anti retroviral treatment (ART).

I attended the biennial HIV Research For Prevention conference (HIVR4P 2016) held 17-21 October in Chicago, USA and Anthony Fauci, an immunologist who heads the U.S. National Institute of Allergy and Infectious Diseases (NIAID) and had carried out a landmark research about it explained that some people call it a cure others sustained remission.

Fauci with his team carried out an experiment, which involved infecting monkeys with SIV, the simian form of HIV. The research was published in the Oct. 14 issue of the journal Science.

According to a press release from the National Institutes of Health (NIH), the investigational treatment regimen consisted of 90 days of ART combined with 23 weeks of treatment with a laboratory-derived monkey antibody against a cellular receptor called alpha-4-beta-7 (a4b7) integrin. 

This antibody is similar to the human drug vedolizumab, which is approved by the U.S. Food and Drug Administration (FDA) for treating ulcerative colitis and Crohn’s disease.

The animals’ immune systems suppressed the virus to undetectable levels for as long as 23 months and the regimen led to the near-complete replenishment of key immune cells that SIV had destroyed, something unachievable with antiretroviral therapy (ART) alone.

Way Forward: 
While speaking to the press at the HIVR4P 2016, Fauci said there was so much that they (scientists) do not know, especially the mechanism, but what was loud and clear was the effect. So they decided to start a study in humans. 

The NIAID team will start an FDA approved study with 15-25 people with this profile; HIV infected, 18-65 years old, stable with controlled viremia, CD4 count of 450+, not pregnant and generally with a relatively healthy immune system.

They will get treatment interruptions of combined short-term vedolizumab treatment and ART for 30 weeks. Thereafter, both will be stopped and they will be followed for at least seven months.

The study investigators hope that what happened in the monkeys suppressing SIV replication will be repeated in humans - basically control the virus levels in the absence of ART and the antibody - so the immune system controls the virus in the absence of ART. Preliminary results are expected by the end of 2017 or beginning 2018.

“If we discontinue therapy in the 15 and 4 of them do not rebound that is the best anybody has ever seen,” said Fauci. Most patients immediately rebound after discontinuing therapy.

He also cautioned on public expectations. “Even if it is dramatic in animals we do not want to take a human who is infected and do more harm than good that is why we are starting off with a small phase I study whose primary goal is safety.”

African scientists comments about the 'functional cure' research; 

I interviewed some leading African scientists who attended the HIVR4P 2016 about the 'functional cure' research. Here is what some of said about it.   

'Cautious hopeful'. “It is exciting that we are beginning to get signals. However, these are monkey studies but bring hope. Over the years, we have learnt that people and animals are different so I would say -cautious hopeful, said Nelly R. Mugo, a gynaecologist and a principal research scientist at the Kenya Medical Research Institute (KEMRI).

'Surprising result.' “It is a very surprising result and I think everybody recognises that. I can say we do not really know how it is working, obviously we have some idea but we do not really know the mechanism,” said Lynn Morris the head of the HIV Virology laboratories at the National Institute for Communicable Diseases (NICD) in South Africa.

'It is too early.' “It is exciting because it offers another opportunity. If it is confirmed by other studies it will be quite exciting because people might be able to come off ART. But I think It is very early,” said Thumbi Ndung’u an immunologist and Scientific Director of the HIV Pathogenesis Programme at the University of KwaZulu Natal in South Africa.

Studies in Africa

Many HIV studies are done in Africa and Morris hopes that if a study is done in the US as Fauci promised there will be interest in doing it in South Africa.

In her opinion, from a cure perspective it is going to be a simple study do to. "The point is it is a licensed product so let us not waste time figuring out the mechanism let us just try it. If it works we can figure out if it really prevents rebounding then we can try and figure out how we can do this,” said Morris.

“It is exciting because integrins unlike the virus are the same. The big issue is going to be cost,” said Morris referring to monoclonal antibody therapies which are extremely expensive.

“But cost should never ever be used as a barrier to doing things because if there is a need the cost is a flexible controlled by demand. People should not come with negative things like cost I think the studies have got to be done and if they work people will find a way around the obstacle,” she said.

If the drugs work they will be re-licensed for HIV and it is envisaged that there will be a different pricing structure and there will be mass production. 

Over 37 million people according to UNAIDS need ART. Currently, they are only produced for the niche market for people suffering from inflammatory bowel disease. 

“It is yet another piece of evidence that we are moving closer to a situation where HIV is like cancer where it can be treated and does not come back in a long time,” Thumbi Ndung’u said.


Thursday, December 8, 2016

Ban on sex education in Uganda schools to be lifted

By Esther Nakkazi

By early next year, the ban on sexuality education in Uganda schools will be lifted after a policy to guide the curriculum on what will be taught has been developed.

We all had concerns that the sex education ban was unjustified but recently we talked about it at a Science Café and shockingly authorities in the know said it was a blessing in disguise.

The Science Café was the 14th held by the Health Journalists Network in Uganda at their home in Ntinda and the second one sponsored by United Nations Population Fund (UNFPA) Uganda Its theme was ‘teenage pregnancy’ held on November 30th with oversight from Reach A Hand.

Penninah Kyoyagala Tomusange the national programme officer, Adolescent and youth sexual and Reproductive Health and Rights at UNFPA-Uganda said although we all thought that the ban on sexuality education was a bad thing it was actually a good move by the government. Why?

Apparently, the previous content and packaging was terrible. So right now all stakeholders are meeting to create a package that will have relevant and accurate information for sex education in Ugandan schools.

“Sexuality education is about accurate information,” emphasised Kyoyagala. “No teenager wants to be a dad or Mum.”

Sexuality education is also a life long thing since environments keep changing, sometimes its verbal other times non verbal.

One misinformation that was in the old package was on condom use. So the new curriculum talks about proper condom use but condoms will not be distributed in schools. The students will be informed on where to find them in health facilities.

This is a good move but will it work given the disconnect between health facilities and education centres. The two government entities do not seem to speak to each other at all! Look at the way youth are always begging for youth friendly services in health facilities.

It is only a song well sang but only practiced by a few facilities like the Naguru Teenage Information Health Centre.

We also had Denis Lewis Bukenya the deputy director, Naguru Teenage Information and Health Centre (NTIHC) talk to us at the science Café. He too emphasised the need for accurate information and to regularly sensitize and empower teenagers to make better-informed decisions.

“Provide accurate information so that the decisions teenagers make are accurate,” said Bukenya.

He said the youth need to have ready access to youth friendly sexuality education services so they can get their needs and questions attended to. Bukenya also stressed a need to educate boys who are not only active participants in creating teen pregnancies but are also custodians of the decision making process.

Godfrey Walakira the training and development manager, Straight talk foundation Uganda, was also a speaker at the science cafés and gave astounding statistics. He said research shows 43% of all Uganda teenagers are forced into the first sexual encounter. The early sex debut is also at the young age of 12/13 years in Uganda.

Pregnancy usually leaves stigma around the girl yet many times it is not their fault entirely. Many are defiled and according to the Police crime report 2011, defilement was the most prevalent crime.

Meanwhile, teenage pregnancy is still a big problem in Uganda. Walakira noted that the national average prevalence of teenage pregnancy currently stands at 24% according to the Uganda Demographic Health Survey (UDHS 2011).

Regionally, the rate of teenage pregnancy is highest at 30.6% for Central Uganda, 30.3% for Eastern, 29.7% for Karamoja, 26.4% for West Nile and 25.6% for the North Uganda, Western Uganda is at 22.6 while south western is at 15%.

Walakira stressed the need to handle a number of issues that lead to teenage pregnancies including child marriages whose prevalence stands at 59% for Northern Uganda, 58% for Western region, 52% for Eastern region, 50% West Nile, 41.9% for central region, 37% for southWestern and 21% for Kampala according to the 2011 UDHS.

One way that Uganda can reverse these stats is increase in teenagers’ access to age appropriate sexual reproductive health information, which, can effectively be done through provision of appropriate information to the schools or directly through the communities.

The conclusion therefore at the Science Café was that Uganda should popularise sexuality education in schools. It will delay their sexual debut, probably reduce teen pregnancy but most importantly when the teenagers get accurate sex information they are empowered.