Monday, August 29, 2016

Sex education in Uganda schools was a bad move?

By Esther Nakkazi

It was at the celebrations of the 2016 World population day held in Isingiro district that I first heard President Yoweri Museveni talk about the unessential need for Uganda to have sex education in schools.

The theme was ‘invest in teen girls’ and in his speech, Museveni juxtaposed high teenage pregnancy with teaching sex education in schools.

“I want to discuss with all stakeholders about sex education in schools. There is a time for everything,” he said meaning he actually wanted to fix what he started.

Sex education started being taught in primary and secondary schools in 2001 when Uganda was preaching abstinence-only. It was an official program of President Museveni under the Presidential Initiative on AIDS Strategy for Communication to Youth (PIASCY).

PIASCY was launched by President Museveni in 2002 to promote abstinence and life skills education among school children. It was funded by the US lead government agency USAID and the Centres for Disease Control and Prevention (CDC). It was later bounced to the U.S. President's Emergency Plan for AIDS Relief (PEPFAR). 

The main aim of PIASCY was to empower young people to delay their sexual relations until marriage through abstinence. Thus, materials of instruction were made and distributed in primary and secondary schools and at youth rallies.

For kids aged 5-12 years the message was mainly abstinence and its benefits and as they grew older the subsequent message was correct condom application and uses. For kids 13-18 years it was upgraded to also include age sensitive subjects like masturbation, abortion, homosexuality but there was also some misleading and inaccurate information on condoms and HIV prevention.

Fifteen years down the line, after pumping kids with comprehensive sex education in schools, this is the scenario.

Uganda teen pregnancy incidence rates are sky high compared to its neighbors, HIV rates among adolescents are growing, teens spend happy moments exchanging porn and according to Parliamentarians the God-fearing Nation- read Uganda- is getting ‘more gay’.

Of course, there are positive contributions that sex education has made to Uganda's teens but the policymakers are adamant about them. All that is cited are these bad stats.

Latest stats from United Nations Population Fund (UNFPA) say 140 per 1,000 teenage girls get pregnant annually in Uganda compared to 41, 101 and 128 in Rwanda, Kenya, and Tanzania respectively.

The Ministry of Health reports that 25 percent of Uganda teenagers become pregnant by 19 years and face four times the risk of maternal death compared to women older than 20 years plus their rates of neonatal death are about 50% higher.

According to the 2011 Uganda Demographic Health Survey (UDHS), many of the pregnancies in female adolescents aged 15-19 years are neither desired nor planned and those who had a child five years prior to the survey did not want to have it at that time.

Abortion is illegal in Uganda except under exceptional circumstances that include saving the life of the woman or preserving her physical and mental health. Studies show unplanned pregnancies in adolescents coupled with high teen pregnancy rates contribute to the high incidence of abortion and its related deaths.

A study done at the national referral hospital, Mulago, showed that almost 50% of the women who died from abortion complications were adolescents. But these also tend to seek an abortion later than others and are more likely to use unskilled providers.

In mid-August, a month after President Museveni who signed onto this program complained, the Uganda parliament debated the motion to withdraw sex education in schools.

Lucy Akello, a Member of Parliament, Amuru district moved a motion, which appreciated that ‘comprehensive sexuality education lacks defined approaches to guide children at their tender age and to uphold Uganda with its morals, virtues of an Africa setting and a God fearing Nation.

It was agreed that the ministry of education halts dissemination of comprehensive sexuality education training materials and conduct of such programs in any schools in Uganda until a policy has been laid out in Parliament. 

Also, the National Curriculum Development Center in conjunction with relevant stakeholders would develop a comprehensive sexuality education curriculum in line with Uganda’s cultural values and practices.

During the debate, every member who spoke supported the motion. They blamed sex education in schools for the widespread 'immorality' inclusive but not limited to early sex, abortions, homosexuality and teen disobedience.

Of course, there should be other things to blame like the increasing exposure to porn and ‘raw and uncensored material’ on the Internet but in the meantime according to our legislators adopting this motion will fix everything.

Here is another scenario from a highly educated Ugandan.

So last year, I was attending the Makerere University Walter Reed Project (MUWRP) stakeholders meeting in Kampala thematized ‘Mitigating disease threats of Public Health Importance: 13 years of MUWRP in Uganda’.

Prof Vinand Nantulya, the Chairman of the Uganda Aids Commission (UAC) was the key speaker. He juxtaposed Uganda’s HIV new infections increase to the vulnerability of young women who are increasingly getting lured into sexual activities. He said it is worse.

UNAIDS estimates that 380 new HIV infections occur in Uganda making it the third leading contributor to new HIV infections in Africa after Nigeria and South Africa.

Prof Nantulya said one of the ways this would be fixed was to have more education about HIV in schools, which is also part of the comprehensive sexuality education package. He said more funds needed to be provided for PIASCY.

“PIASCY, which was good and helpful to educate the youth is not as good as it used to be. I want PIASCY back,” he said.

So its either that Uganda children and adolescents do not need sex education at all or that the PIASCY project got it wrong. Whatever it is we are not going back to the era when Uganda’s children got sex education from their grandparents, parents or relatives as Museveni suggested. No one has that time anymore. It is easier done in schools with the right messages and at an appropriate age. So since it cannot just be blown away, fix it.

Tuesday, August 23, 2016

Is a malaria free Africa by 2030 possible?

By Esther Nakkazi
Is a malaria free Africa by 2030 possible? The glass is half full.

Forty-seven World Health Organisation member states in the African Region unanimously adopted a new malaria framework with specific actions to reach ‘an African Region free of malaria’ by 2030.

In a meeting held in Addis Ababa on 21st August, they came up with a framework to guide member countries towards attaining targets of the Global Technical Strategy (GTS) for malaria (2016-2030) within a given time frame.

The GTS was founded in May 2015 at the 68th World Health Assembly on the vision of a world free of malaria and consists of four goals and related targets to be achieved by 2020, 2025 and ultimately by 2030.

It for instance aims to reduce malaria mortality rates and case incidence by at least 90% by 2030 as well to eliminate malaria from at least 20 malaria endemic countries. It also aims to prevent re-establishment of malaria in all Member States that are malaria-free.

A press release from WHO AFRO says this framework's priority interventions and actions have been organized according to programme epidemiological strata in order to engender evidence-based targeted interventions.

The GTS has guiding principles like country ownership and leadership with involvement and participation of communities within a multisectoral context. It also encourages mobilizing and working with other sectors in malaria control and elimination.

To an extent some of these goals are achievable.  Some projects have demonstrated it. Six countries; Algeria, Botswana, Cape Verde, Comoros, South Africa, Swaziland have the potential according to the WHO to eliminate local transmission of malaria by 2020.

Meanwhile, two countries, the Democratic Republic of the Congo (DRC) and Nigeria alone account for more than 35% of the global estimated malaria deaths so if efforts are concentrated here that would give a lot of mileage I suppose.

But how possible is it that the Africa region can be malaria free by 2030?

Well, there is some impressive progress so far in controlling it. Since 2000, malaria death rates have plunged by 66%, translating into 6.2 million lives saved, most of them children. Between 2000 and 2015, the number of malaria cases and deaths within the African Region declined by 42% and 66%, respectively says the WHO.

In addition, more people with suspected malaria get tested before treatment and many more are sleeping under insecticide-treated mosquito nets. In 2014, 65% of the suspected malaria cases got tested before treatment compared to only 41% in 2010. In 2015, two in three households in Africa had their own insecticide-treated mosquito net, compared to only 2% back in 2000.

And like Dr Matshidiso Moeti, the WHO Regional Director for Africa said, “Malaria is no longer the leading cause of death among children in sub-Saharan Africa. More and more children get to sleep under a net.”

Malaria is also still on top of the global and regional agenda and so it remains a priority, identified in target 3.3 of the Sustainable Development Goals (SDGs) which commits to end it by 2030. The WHO also reaffirms to end it by then.

However, despite the significant progress made, malaria continues to be a major health and development problem in the Africa Region as it still bears the biggest malaria burden with about 190 million cases (89% of the global total) and 400 000 deaths (91% of the global total) in 2015 alone.

We cannot talk about a malaria free Africa without talking funding which the World Malaria report 2005 says increased substantially by 410% between 2005 and 2013 for programme financing. Overall, international financing for malaria control increased from US$ 100 million to US$ 1,640 million in 2013.

But the report also shows that even with these increases the annual investment per person at risk remained low at US$ 2 in the year 2013 and this funding situation is further threatened by low domestic financing.

So in the period 2005-2013, the proportion of total malaria funding contributed by national governments in Africa stagnated at less than 10% and these rely on external funding.

Meanwhile, based on GTS cost estimates and at a fixed 2013 population at risk of malaria in Africa of about 830 million, the total cost of malaria elimination in Africa by 2030 is US$ 66 billion.

There is thus a funding gap which is not new because most health projects are suffering from low aid.

Furthermore, implementation of the GTS will necessitate addressing some key challenges like weak health systems (which were tested during the Ebola outbreak).

As well there is the threat of resistance to the medicines combined to a lack of a vaccine and the adverse effects of climate variability and change.

One of the reasons for reversing the malaria deaths as mentioned earlier was as said by Dr Moeti; ‘more children slept under a net but there is need to continue to invest in changing people’s behaviours.’ She also said more people with suspected malaria got tested before treatment.

It is only if people in the region change their behaviour and sleep under treated nets and also seek treatment within 24 hours after testing. These are some of the sustainable ways to keep the gains achieved and also move forward.

Otherwise, the glass really remains half full as the balance for the gains and the challenges for implementing the GTS remains glaringly odd.

Wednesday, August 17, 2016

Anne Merriman Hospice Africa Foundation launched

By Esther Nakkazi

The 2014 Nobel Peace Prize nominee Professor Dr. Anne Merriman's efforts to improve palliative care for Africans are starting to pay off. She is also an advocate of a good death, which is a basic human right.

While in 1993 only three African countries had palliative care now 35 have support care and 20 have affordable oral morphine based on Merriman’s formula which she developed in 1980. Hospice Africa Uganda (HAU) the model she founded for Africa is also producing enough oral liquid morphine for all in need in Uganda, with the support of the Ugandan government.

Since its founding, Hospice Africa Uganda has cared for more than 27,000 patients. It currently provides family centred care for up to 2,000 patients across its three centres in Kampala, Mbarara and Hoima. 

 “An Africa where Palliative Care reaches whoever needs it is a very big vision. This vision can only be achieved if impeccable clinical services, like the ones offered at Hospice Africa Uganda, are spread all over the continent and are integrated into the health service delivery system of every country, said Dr. Eddie Mwebesa, the Chief Executive Director of HAU.

Also recognising the shortage of morphine prescribing doctors,  Merriman’s work has changed the law in Uganda to allow specially trained nurses to also prescribe morphine. 

So Uganda is the only country in the world where nurses can prescribe morphine, hence it was in 2015 ranked by the Economist, Quality of death Index as the second country in Africa (35th worldwide) for the highest quality of death.

It is estimated that 50 percent of people in Africa will not access a health worker in their lifetime, and less than 5 percent reach chemotherapy or radiotherapy.

On Wednesday, 17 August the Anne Merriman Hospice Africa Foundation was launched in Kampala by Dr. Jane Aceng,  the Uganda minister of health during the 5th International African Palliative Care Association Conference. 

“Every human being on the planet no matter their colour, creed or social background should expect a pain free, peaceful, end of life. Unfortunately in Africa this is not the case for most," said Merriman.

"I have worked with dedicated teams for the last 23 years to change this and now that I am 81-years-of age, our loyal supporters and I, want to ensure that this work continues, until the vision is a reality. Together we have achieved a lot - but so much more needs to be done.”

She appealed to world leaders and policy makers to take note and to do all in their power to ensure that people in Africa experience a good death. “We need strong and powerful advocates to support this cause.”

“We are here because we want to move the ethos of care: compassionate, team oriented, and patient centred, forward together. It's for this purpose that the Anne Merriman Hospice Africa Foundation will thrive in its vision," said Mrs Shelley Enarson, a founding advisor to the Foundation, at the launch.

"The AMHA Foundation will promote the spirit of keeping the patient at the center of our care, and ensuring that the ethos of organisational partnerships are encouraged” said Dr. Mwebesa.