‘The drugs are now expiring in our stores across the country because we seem to be pushing to have them but don’t have the expertise to clinically dispense them to the multitude who need them’ a medical doctor in the busy national referral hospital of Mulago in the Ugandan capital, Kampala tells this reporter as he struggles to clear a seemingly endless queue in front of his office in the biting Kampala sun.
Due to increasing international partner funding, anti retroviral drugs are increasingly becoming available in the developing world. International funding such as that from the Global Fund on HIV/AIDS,TB and malaria , the billion-dollar United States President Emergency Fund of AIDS relief programme and access initiatives such as those supported by the Clinton Foundation have made anti retroviral drugs widely available albeit at mostly urban health centres in the developing world.
In Uganda, despite reaching 42% of the population in need of Anti Retroviral Therapy in 2005, the number of those in need of Anti Retroviral Therapy continues to grow each year. It is estimated that there were 270,000 HIV-infected people eligible for anti retroviral therapy in 2007; this number is projected to reach 332,000 in 2012 . The most current figures as of September 2008, from the Ugandan Health Ministry are: 1.1 million infected; 357,000 in need; 43% on active treatment.
But in countries such as Uganda, questions remain regarding the capacity of the health care systems to scale up access to anti retroviral drugs. A few years ago it was reported in East African newspaper that $ 700,000 worth of drugs had expired in Uganda’s National Medical Stores and similar reports, more recently have run in the government-owned daily ’The New Vision’ with reports that some government drug stores across the country were reporting expiry of stocked anti retroviral drugs when thousands of clinically –eligible patients in Uganda are still waiting their turn to access these life-prolonging drugs.
Several recent studies in academic journals suggest that fiscal funding for AIDS treatment is no longer the most important barrier to access to antiretroviral drugs and that health systems in developing countries are the gravest impediment to accessing anti-AIDS drugs to the millions who need them. The notion that financial resources alone will not bring about accelerated access to AIDS treatment in resource-limited settings was emphasized further in a survey conducted in July of 2008 in six countries including Uganda by the International Treatment Preparedness Coalition (ITPC).
Some observers contend that even if these drugs were suddenly sufficiently available, there wouldn’t be sufficient capacity to absorb them and dispense them to those who need them as concluded in a study led by Dr Konde- Lule a renowned Ugandan AIDS researcher based at Makerere University
Analysts suggests that there are two conflicting schools of thought with one suggesting that scaling up access to ARVs is possible like has happened in Brazil while the other school argues that health care systems in developing countries don’t have the capacity to mount ambitious national AIDS treatment programmes due to institutional resource constraints. It is shown for example that there is a severe deficit in the health workers available to manage Anti Retroviral Therapy in developing countries which has compounded an already existing shortage of medical workers owing to many factors which include brain drain and uncompetitive reward systems.
It has been estimated that while Africa has 25% of the world’s disease burden, it has only 1.3% of the world’s health work force.
The absence of national laboratory networks to manage disease diagnosis-the first step of AIDS treatment, as well as unavailable CD 4 count machines all pose questions as to the feasibility of implementing ambitious AIDS treatment regimes in the developing world .An ART adherence study conducted in Botswana and Tanzania led by University of Amsterdam’s Dr Anita Hardon found a lack of laboratory facilities to conduct CD4 counts at the study sites visited . There was a lack of prescribing capacity in several health centres since they didn’t have diagnostic equipment .The study found that patients had to wait two weeks before they could be put on therapy owing to delays in diagnostic tests.
Interviews with regular clinicians at the fore front of treating AIDS in Uganda suggest the need to question the institutional assumptions underlying contemporary international AIDS treatment funding priorities. Should ARV drugs themselves be the current focus of drugs access initiatives or should the institutional resource base for administering them be the prerogative? A question whose answer would be critical to international bodies such as WHO,UNAIDS,UNICEF,PEPFAR,The Global Fund, The World Bank etc. As well as national governments in AIDS- ravaged countries,NGOs,HIV/AIDS advocacy networks and of course the millions living with HIV/AIDS .In the race to treat global AIDS, are we putting the cart before the horse? Drugs or health systems which should come first?