Uganda introduces kits to cut malaria treatment costs

By Esther Nakkazi

Uganda will reintroduce malaria test kits in health facilities nationwide to facilitate malaria diagnosis that could improve the management of the disease.

From next month, National Medical Stores (NMS), the Uganda government’s supplier of pharmaceuticals products, will distribute Rapid Diagnostic Tests (RDTs) that could save thousands of doses of anti-malarials.

The RDTs will enable health workers to detect the presence of malaria within a few seconds cutting down on over diagnosis, time and over prescription of malaria, health experts say.

Research has established that for every 20,000 doses supplied per month to a district, up to 16,000 doses of anti-malarials are saved when health workers use RDTs.

Some of the $90 million from the Global Fund and government resources will be used to buy RDTs that will not only stop presumptive diagnosis, a common practice among most health workers but also avert a tendency of stocking medicines in houses that has cropped up.

Presumptive treatment identifies the likely condition a patient has; it is widely practiced where microscopy or RDTS are not readily available.

Most health workers use presumptive diagnosis, giving all patients anti-malarials after they present with headaches, fever and loss of appetite. In most cases the health workers are ‘playing safe’ especially with children who progress rapidly to severe malaria and death.

But also recently after the switch from the user driven for drug selection and quantification-pull system to the ‘modified’ push system where government estimates pharmaceutical supplies required, the public has adopted a tendency to pick drugs even when they are not sick.

“People line up pretending to have all sorts of illnesses especially malaria and keep the medicines for a rainy day while others sell them off,” said Moses Kamabare the General Manager, National Medical Stores.

Typically when NMS delivers medicines to health facilities, which is once every two months, in just about 2 weeks the Coartem would be finished. “RDTs would ensure that they pick medicines especially Coartem, which is very expensive only when required.”

There is no doubt that using RDTs is a cost effective venture in the treatment of malaria as has been tested in Zanzibar and Ghana. In Uganda, Government supplies free ACTs to all government health facilities but on the open market a dose costs Ushs 15,000 ($7).

Indeed, when an RDT test is administered that turns out negative, Ushs 10,000 ($4) would be saved for every patient. This would save lots of money as few people who claim to have malaria actually have it, but would also ensure reduction of over exposure of the population to drug toxicity.

A study by Malaria Consortium Uganda, found that use of RDTs resulted in a 2-fold reduction in anti-malarial drug prescription at Low Level Health Care Facilities (LLHCFs). The study entitled the ‘Use of RDTs to improve malaria diagnosis and fever case management at primary health care facilities in Uganda’ was published in July 2010. 

Dr. Daniel Kyabayinze the principal investigator of the study said they found that when RDTs are administered only 20-40 percent of patients who claim to have malaria would have it, so it is very cost effective.

The study says that nationwide deployment of RDTs in a systematic manner should be prioritized to improve fever case management but cautions that there is need to further educate health workers about use of RDTs in order to maximize acceptance.

“The study found that 1/3 times a person will have a negative test but the health worker will give them anti-malarials anyway,” says Dr. Kyabayinze from Malaria Consortium Uganda.

In the study, health workers said they treat RDT-negative patients because they are afraid of challenges of severe malaria given the long distances to the referral hospitals in case need arises.

Also, among negative patients with RDT results, children under five years were nearly 3 times with more likely to receive anti-malarials relative to older patients, a practice that is in line with the national malaria treatment policy.

The policy encourages presumptive treatment of malaria to reduce malaria-associated morbidity among the under-five age group who contribute a third of the anti-malarial prescriptions for RDT negative results.

“It is likely that health workers found it socially acceptable to offer anti-malarials to RDT negative patients but also that they appreciate the medical care provided,” says the study. But there are also questions of the accuracy of RDTs in diagnosis. 

 
Research shows that 90 percent of the times when the RDT test is positive, the patients have malaria, but the test also picks past infection in the last 2 weeks.

“It is important that those who come in and the test is negative are not given anti-malarials because the test would be 98 percent negative,” said Dr. Kyabayinze.

With the study results government is working on a policy that will ensure that all people who are treated with anti-malarials first get a malaria test.

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Uganda: What causes Jiggers?

By Esther Nakkazi

In the eastern part of Uganda, live the Basoga, a Bantu group who speak Lusoga. Lately, the media have been awash with the Basoga being infected with jiggers. Recently, a three months baby died of jiggers according to the local press.

The mystery of the cause of jiggers has been politicised and even exaggerated. While the medics attribute jiggers to poor hygiene especially for people sharing accommodation with animals, economists say it is due to chronic poverty - after all research shows that the highest poverty density in Uganda is in Busoga.

The politicians have blamed jiggers on political discrimination in the area by the ruling government. The religious people have said God is angry with the Basoga so the jiggers are a punishment while traditionists are convinced that wizards are active in that area. Some myths have suggested that the jiggers attack mentally retarded people.

Now the environmentalists headed by (Dr. Afunaduula) say we need an environmental approach to eradicate them. However, in the old times, even today the herbalists recommend that after extraction, they put red chilies (pepper) in the wound.

In an effort to eradicate them many volunteers have been to the jigger infested areas and their approach is to help extract them from feet, hands, and bodies of course with cameras recording their good works. But nothing has worked.

Although floods of people showed up to be treated, some schools refused their pupils to go saying it would bring shame to the school!

At the campaign led by the deputy speaker of Parliament, Rebecca Kadaga, a Musoga who comes from eastern Uganda, villagers were treated and taught good hygiene practices like smearing cow dung on the walls and floor of their mud houses.

Cleary something needs to be done about these jiggers killing people in this century! But it is a question of good hygiene and that does not need much debate and unfounded myths. 

Everyone has a role to achieve Millennium Development Goals

By Esther Nakkazi

Africa could be on track to achieve most of the Millennium Development Goals (MDGs) but some of its gains have been eroded by climate change, armed conflicts and unmet commitments for resources by the international community.

But this year, which marks five years to 2015, the target year for MDGs, shows that the goals are attainable though the pace of progress needs to be increased.
Recently, UN Secretary-General Ban Ki-moon announced the development of a Joint Action Plan to be launched this month at the MDG review Summit to intensify the global effort to meet the goals.

So this September, world leaders will meet to agree on strategies and actions to meet the Goals, which represents human needs and basic rights that every individual around should enjoy.
“The world posses the resources and knowledge to ensure that even the poorest countries, and others held back by disease, geographic isolation or civil strife, can be empowered to achieve the MDGs,” said Ban Ki-Moon.

Ban Ki-Moon says meeting the goals is everyone’s business as falling short would multiply the dangers of the world.

In Africa, there are improvements made to attain the MDGs but they are slow while the hard won gains are eroded by food and economic crises as well as climate change.
Experts say Africa could have a chance to reach the target for access to clean water and it is still on track to achieve the MDG target of cutting the rate of extreme poverty in half by 2015, says the UN 2010 report.

Robust growth in the first half of the decade reduced the number of people in Africa living on less than $1.25 a day from 1.8 billion in 1990 to 1.4 billion, while the poverty rate dropped from 46 to 27 percent.

“Many countries are moving forward, including some of the poorest, demonstrating that setting bold, collective goals in the fight against poverty yields results,” says the report.
At the global level, the poverty rate is expected to fall to 15 percent by 2015, just about 920 million people living under the international poverty line, half the number in 1990.

Africa has also made strides in getting children into primary schools with enrollment reaching 89 percent. The 2010 UN report shows that the total number of children out of school decreased from 106 to 69 million in 1999-2008, almost half of the number of these in sub-Saharan Africa.

According to experts from UNESCO, this is encouraging because education is the single one intervention that is likely to have a multiplier effect on progress across all the MDGs.

One year of schooling can increase a person’s earnings by 10 percent and lift their average annual GDP by 0.37 percent, according to a UNESCO report. The girl child- has benefited from this more, as overall more girls are now in school today in Africa with at least three million more children enrolled in school in Ethiopia and more than double in Benin compared with the number in 2000.

Increase in school enrollment has been aided by the abolition of school fees for instance in Burundi, a threefold increase to 99 percent in primary school enrollment was realized in 2008. Tanzania doubled its enrollment ratio over the same period.

Strong interventions have also been made in addressing HIV/AIDS, malaria and child health for instance increasing the number of people receiving anti-retroviral drugs.
According to the 2010 MDGs report, comprehensive and correct knowledge of HIV increased by 10 percentage points or more among women aged 15-24 years.

Between 2000-2008 Rwanda reported 50 percent and more in knowledge about HIV prevention among women and similar progress was made by Namibia.

But there are two MDGs that seem to be unattainable although commitment with resources to address them has been made.

MDGs 4 and 5 which call for reductions in the number of deaths among children under 5 by two thirds, and reducing maternal deaths by three-quarters by 2015. Africa will need $32 million for interventions to attain them.

Although under five-year-old mortality rates in sub-Saharan Africa declined by 22 percent since 1990, this rate is still insufficient to meet the target.
Studies show that all the countries with under five mortality rates exceeding100 per 1,000 live births in 2008 are in sub-Saharan Africa except Afghanistan.

Less than half the women giving birth in Africa get skilled health care when giving birth, but disparities also exists in rich and poor households, says Sha Zukang, the UN under secretary General for economic and social affairs.

According to the UN 2010 report women in rich households are 1.7 times more likely to visit a skilled health worker at least once before birth than the poorest women. Also contraceptive use among educated women is four times higher than those with no education as access is a big problem.

In Africa for every woman who dies, at least 20 other suffer injuries, infections and disabilities, like obstetric fistula but Countdown to 2015 report emphasizes that almost all maternal deaths are preventable.

This is because complications during pregnancy and childbirth are the leading cause of death for women of childbearing age, which can all be dealt with. Countdown to 2015, a global scientific and advocacy movement in its 2010 report, found that 49 out of the 68 high burden countries are not on track to meet MDG 4 on child health. While Botswana, Egypt, Eritrea, Malawi and Morocco are on track to achieving improved maternal health.

The Millennium Declaration represents the most important promise ever made to the world’s most vulnerable people, says Zukang. Accelerated action needs to be done. But it is for each one of us to play a role to attain the MDGs.

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Tweeter pays money in Africa

Last week was a break through, as user of social media in East Africa, Uganda to be able to earn from a new tool Twitter. I keep a twitter account @Nakkazi, but had not thought much about mastering the skill of tweeting until last week.

The East African Internet Governance Forum (EAIGF) 11th to 13th held a meeting in Kampala, Uganda and Maureen Agena a citizen journalist and I, were invited to tweet and blog.
On the tweeter account @#EA_IGF and the blog name http://eaigf-uganda.blogspot.com (check out the stories and tweets) we tweeted away for three days.

The pay was not bad at all, but what is interesting to note in my opinion is, was it because it was an Internet gurus gathering? Almost all the 100 or so participants knew about twitter and were following on the screen in the conference room or on their laptops.

It would also be interesting to have a business model to offer the client a full package with twitter, blog stories with pictures, pod casts and video clips. Let us see if the market can respond to the offer and what prices they would be able to afford so we get in business.

British Barristers urge African states to stand together to defeat ICC

By Esther Nakkazi

During the Kampala African Union summit, i saw many colleagues hurrying to some place. Naturally, i decided to follow the train and there, a press conference on Sudan President Al-Bashir addressed by two London based Barristers and a Sudanese Human Rights official. Here are the excerpts of the press conference

Plans to lodge a complaint to the International Criminal Court (ICC) on the indictment of President Omar Hassan Al-Bashir by British lawyers are under way. The barristers with Temple Gardens Chambers said they are representing over 8 million people from the Sudanese Workers Union in this case.

They want to challenge the international court over Al-Bashir’s immunity as a serving head of state and if it is lawful for the UN Security Council to refer to the ICC a non-member state like Sudan.

“ We think that these issues which now seem to concern only Sudan may have wider consequences for Africa,” said Geoffrey Nice a barrister with Temple Gardens Chambers, London at the sidelines of the AU summit

The lawyers advised that if other African states behaved like Chad they could stand together and say ‘NO’ to the ICC on the arrest of a serving head of state.

The lawyers were attending the AU Summit in Kampala drumming up support for the AU leaders to say ‘No’ to the ICC even if they emphasized they were not against the ICC and justice. 'Justice should not be selective.'

“If there are countries that think like Chad, they could gather together and say we regard Bashir to be having immunity until his presidential term ends,” said Rodney Nixon, another barrister with Temple Gardens Chambers, London.

They advised that a grouping by African States could carry more weight and the case could be lodged with the International Centre for Justice (ICJ).

The ICC should have a provision so that States should observe other head’s of States immunity and take a clear position whether they are signed up or not.

They warned that unless this is made clear, it would affect relations between states in Africa.

The lawyers said they are collecting sufficient evidence, which they have already worked through to challenge the prosecutor, Luis Moreno-Ocampo.

They also have details of the victims of the genocide and have presented them with legal options and they are challenging the ICC on allegations of Al-Bashir committing genocide.

“We are coming up with steps to challenge the sufficiency of the genocide evidence. We have recognized the crimes, it is not the ICC to deal with it,” said Nice.

But they want the case to be tried under the Ocampo regime so that they test the system and also because they anticipate that the next prosecutor will come from Africa, which will be an even bigger challenge.

The African prosecutor will be under pressure to try all these leaders that Ocampo fails to prosecute, said Nice.

Mohamed Ansari, the president of the African Crisis Relief Centre, a Sudanese non-governmental organization argued that there could be no definitive ruling on the case before there is sufficient evidence.

“There should be a desire to get to the bottom of this – these things are not be looked at critically? If nothing were done, then it would get greater strength,” said Ansari.

African Union Summit

It has been a long week of tight security, many interviews and press conferences at the African Union summit in Munyonyo. As a science writer, it has been an interesting time to see that at least some attention is being devoted to health- maternal health and children development.

For this week, I have been going to Munyonyo, it could have been at least 10 security checks per day. That makes it 70 in a week! If there are any health effects these machines cause I could become a victim.

Well brother leader jetted in on Saturday, causing a traffic jam of about 2 hours in the small city of Kampala. I saw some boda boda riders wearing t-shirts with Gaddaffi’s picture. The extra long convoy, big bill boards welcoming him and the fight between his detailed security with Ugandan security is not new but typical of his visits to African countries.

Agenda setting: many international organizations, civil society and African musicians are in Kampala to persuade African leaders to devote at least 15% of national budgets to health. It is expected that this will not be businesses as usual of pegging their signatures onto documents and forgetting them.

This time, with the impressive turn up of African leaders for the Kampala summit and the many voices involved we only hope that the matter is taken seriously.

But of course, everyone is aware that African leaders are the least interested in health. If the agenda were to be set by them, the summit would just be discussing Somalia, Al-Shabaab and Sudan’s Bashir.

Precisely, that is where the hot discussion are except that big brother donor is watching and there is prompting. It is interesting to see how tempers rise when the issue is discussed!

Electricity could control Uganda's high birth rates?

I once sat in a workshop and one official from the Ministry of Finance, Planning and Economic Development told us that finally they are ready to tackle Uganda’s high fertility/birth rates (6.7 per woman) not by using family planning security but by providing electricity to rural areas.

It has been a debate,  no one has ever proven it scientifically but it is said that boredom is one of the reasons that the rural folk engage in birth giving activities. With all the myths about using family planning it is envisaged that if they were kept busy say with the youth provided with Internet then they would be engaged and birth rates would go down.

Now, it is official that by the end of FY 2008/09, rural electrification coverage increased to 6%, up from 1% in 2001. The overall access to electricity in Uganda also increased from 5% in 2001 to 15% in 2008.

It would be interesting if there were any such research done to see the impact of electricity on rural births. Unfortunately, we don’t have the data for places that now have electricity. The study would control for other factors including family planning security and then see the impact of electricity on births. I would love to read such research.