Monday, July 18, 2011

Uganda to verify informed consent among communities in research

By Esther Nakkazi

Uganda is one of the few countries over outsourced for research involving human participants or clinical trials. With the hundreds of trials held it is important for communities who participate to fully understand informed consent.

The Ugandan National Council for Science and Technology (UNSCT) on 11th -13th July, held the 3rd annual national research ethics conference and one of the issues they discussed was ethical issues in research with communities.

With most of the research carried out among poor and illiterate communities it was noted that it was important for communities to fully understand informed consent.

One of the questions from the conference was ‘how do you know that the participants have understood informed consent?’

Scientists then suggested that Uganda should have a standard metric to measure or verify that communities have understood informed consent. This would evaluate the prospective communities to verify that they have understood the message passed to them for it.

Researchers reported that most times after explaining about the consent process, participants hardly ask any questions, either a fact that they have fully understood or that they have NOT understood anything.

With the low literacy levels it is most likely that they have not understood but go ahead to sign the forms anyway because the clinical trials come with free health care, which most families cannot afford. People always ask what is in it for me?

One of the ways noted by the researchers was that participants agree to participate but when they tell them to come back after one week for follow up they do not show up. Does that mean they did not understand?

Secondly, the percentage of participants that drops out of the research is so small at less than 10% in comparison to an average of 30-40 percent in the developed world.

The lack of independence for the participants to drop out of clinical trials was attributed to fear, intimidation but researchers were advised to assure them that they would get the same quality of services as dropouts.

Researches were reminded by Prof. Florence Mirembe to use innovative approaches to informed consent using the simplest language, flip charts, videos, explaining the procedure, the potential risks and discomforts as a result of the research.

For instance, drawing of blood may result into fainting, this does not have an equivalent word in the local languages but it should be explained thoroughly.

The poor bear the burden of clinical trials and they should be protected from exploitation to gain from the products of the research.

With the number of clinical trials increasing in Uganda, so are ‘safari’ research and the increasing lack of understanding of informed consent among communities.

I have only written about one site where participants were given pre-service tests that they had to pass before undergoing male circumcision. If more protection and understanding is not done for participating communities in clinical trials the scale will be topping more towards exploitation.    


Tuesday, July 5, 2011

Traditional birth attendants outlawed in Uganda but practice persists

By Esther Nakkazi
June 13th 2011

Throughout the African continent,  many public officials believe their most powerful tool for improving health outcomes for mothers and infants is to ban or severely limit the influence of so-called Traditional Birth Attendants, and steer women to public health facilities.

However, many observers note that this strategy is complicated at best, and too often fraught with danger. For example, in Uganda, the government banned Traditional Birth Attendants (TBAs) in 2009 because they had deviated from their major role of identifying and referring women pregnant mothers to health centres.

But they are still the providers of choice of many women in Uganda’s rural areas. This is because the country’s health system problems include health workers who are rude and insensitive to the needs of poor, uneducated clientele, substandard care given to pregnant women, or lack transport to government sanctioned health centres.

So with the demand for their services still high, some organisations are training TBAs to work more closely with the official health care system by doing more referrals. This is a complicated proposition, because while many TBA’s are dedicated and professional, they may not possess the nuanced ability to know when it’s time to stop depending on their own skill and call on mainstream health professionals. In many cases, they may wait too long to admit they cannot handle a complicated delivery, resulting in death or serious injuries to baby and mother.

“They can give them herbs to stop vomiting and for bathing to bring down temperatures. But we encourage them to refer all mothers to health facilities for antenatal, delivery and postnatal services,” said Primrose Kyeyune, a technical advisor to Traditional and Modern Health practitioners Together against Aids and other Diseases (THETA) in Uganda.

Across the globe, experts readily acknowledge that many traditional birth attendants are often skilled enough in normal labor and birth. The problem arises when TBA’s lack the back up resources to transfer women enduring obstructed labor, or who need caesarian sections to nearby health facilities.

On average, sixteen women die of pregnancy-related problems everyday in Uganda, most of them due to emergency complications like excessive bleeding at delivery or during 42 hours after giving birth. Two thirds of maternal deaths occur during that window of time.

At least 22 percent of women die due to infections developed during pregnancy, labour, and even after birth.

Dr Sentumbwe-Mugisa, a reproductive health expert, says women develop severe infections and die because the birth canal, the abdomen, or sometimes the blood becomes infected, a condition called septicemia. Other women get infections after abortions.

But Uganda also has many survivors of obstetric fistula; women who survived obstructed labour, often lasting for days, but rarely with a live child at the end of it. Officials believe most of these cases may involve a TBA who did not seek outside help.

Why Demand remains high

Ms. Bernadette Nabatanzi, a former TBA, says most women choose TBAs because they are confidants and counselors.

Nabatanzi a 70-year old reproductive health and counseling expert says she learned the skill from her grandmother, who was also a traditional birth attendant.

“I remember very well when women used to give birth to premature babies, and we placed them in underground holes we had dug in the house.

“My grandmothers’ house had eight holes in different locations, which were padded with dry sorghum leaves and old cloths for the baby’s mattress.

“When a premature was born, we would wrap them in a clean cloth and place them in those holes, only to be removed to breastfeed. After about two weeks, the child would be grown enough to go with the mother.”

Indeed, stories like these help explain the complicated clash between tradition and modernity when it comes to providing appropriate health care for pregnant women and babies. For example, many rural Ugandan women about to deliver go to a nearby banana plantation, hold on to a plantain and push the baby. Banana leaves are spread below to act as a bed for the delivery and the TBA stands by, to administer herbs.

In communities where these practices are common, it takes more than just a government decree to convince women they need to choose public health facilities over the kind, trusted older women they’ve known all their lives.

“I give my clients a lot of time to express themselves and talk about anything. They do not pay consultation fees, there are no long lines,” says Nabatanzi, who has delivered hundreds of babies but now only refers pregnant women to health facilities.

Nabantanzi says she now only gives herbs for bathing and to stop vomiting. But she adds that she is a mainstay in her village- ‘Always available, reliable and people trust me.’


Monday, July 4, 2011

Uganda Health Budget rises with impact on service delivery


By Esther Nakkazi

The Uganda government increased budget financing to the health sector for 2011/12 financial years further reducing on donor dependence, which is expected to improve sustainability and improve quality of health care delivery.

Financing the health sector increased to Ush 985.8 billion (412 million) this year from Ush. 660 billion (270 million) the previous year while financial assistance from development partners is expected to reduce in line with the overall budget. Uganda will fund 71 percent of its budget.

Mrs. Maria Kiwanuka the minister of Finance said the funds for health would mostly be spent on infrastructure development, drugs and basic medical equipment procurement as well as recruitment of key medical personnel.

The largest gaps have been in infrastructure, human resources, drugs, vaccines and consumable sundries.

Health care will be delivered more efficiently and we shall have a greater impact with increased financing of the budget, said Dr. Asuman Lukwago, the Permanent Secretary, ministry of Health.

The continued increase of financing its health sector budget and reduced aid flows to the sector will enable strengthened planning, better accountability and financial management said a health sector official.

Francis Runumi, the commissioner health services planning at the ministry of Health has always encouraged the government to increase its financing to the sector to match with the growing population.

“The budget is only a slight improvement which is good but it does not address the human resource issue. If Ushs. 400 billion ($165 million) of that money is used for infrastructure how will it impact directly on service delivery?” asked Runumi.

According to Mrs. Kiwanuka the health sector registered a growth rate of 12.6 percent in 2010/11, which was a better performance, compared to the 11.9 percent increase in 2009/10.

The trend in disbursements have been growing but still fall short of the demands for the large population creating a funding gap. The ministry of Finance National Budget framework paper shows that in the financial years 2006/07, 2007/08 and 2008/09 allocations where Ush139.23 bn ($57 million), 150.9 bn ($62 million) and 253.08 bn ($104million) respectively.

In 2010/11 and 2011/12 the financing from government amounted to 660 billion (270 million) and 985.8 billion (412 million) respectively. Over the years also the ratio of government to donor financing the health sector has continued to go down from 60:40 in 2008/09 to 75:25.

But most of the health sector funding from development partners is off budget, which has created a big disconnect between donor funding and implementation on the ground, health officials say.

For instance in 2010/11 financial year project aid for the health sector was Ush. 90.44 billion (37 million) and is expected to increase to 397.1 billion ($162.4) this financial year.

Of this the World Bank has already approved US$130 million to strengthen Uganda’s public health systems through improved human resources; provision of physical infrastructure; and greater accountability for service delivery.

Some of the funds will be used to support the Government to renovate hospitals, improve management of health workers, strengthen leadership in the sector and provide reproductive healthcare, including family planning services, according to Kundhavi Kadiresan, World Bank Country Manager for Uganda.

Effect of cutting travel and workshop budgets

Mrs. Kiwanuka in the 2011/12 budget proposed a 50 percent cut on advertising budgets for all Ministries and Agencies as well as 30 percent cut on the budget for allowances, workshops and seminars, travel inland and abroad.

The cuts will also be effective for allowances of fuel, vehicle maintenance, printing and stationary, welfare, entertainment, books, periodicals and newspapers, special meals and the purchase of furniture.

Purchase of new Government vehicles has been frozen and there will be an immediate forensic audit of Government salaries, wages and pensions.

“When these expenditures are cut off we shall improve efficiency and create a big impact in delivery of health services in the sector,” said Dr. Lukwago.

Health is one of the ministries that have been spending big sums of their budget on sectoral policy functions. For instance fuel costs and management took up almost 10 percent of the ministry budget in 2009/10 because of large fleet management.

Workshops and seminars accounted for 7.3 percent of the ministry recurrent budget in the same year twice the total sum allocated to 15 referral hospitals for non- wage expenditure.

Kenneth Mugambe the director budget, in the ministry of Finance said there is a higher priority attached to sectoral policy functions and a comparatively lower priority accorded to the actual health service delivery functions of hospital services. But this will now change with the new budget announcement.