Understanding the dynamic interactions driving the sustainability of ART scale-up implementation in Uganda

Henry Zakumumpa, Nkosiyazi Dube, Respicius Shumbusho Damian and Elizeus Rutebemberwa Global Health Research and Policy20183:23 https://doi.org/10.1186/s41256-018-0079-6 Received: 6 February 2018Accepted: 16 July 2018Published: 6 August 2018 Understanding the dynamic interactions driving the sustainability of ART scale-up implementation in Uganda ABSTRACT Background Despite increasing recognition that health-systems constraints are the fundamental barrier to attaining anti-retroviral therapy (ART) scale-up targets in Sub-Saharan Africa, current discourses are dominated by a focus on financial sustainability. Utilizing the health system dynamics framework, this study aimed to explore the interactions in health system components and their influence on the sustainability of ART scale-up implementation in Uganda. Methods This study entailed qualitative organizational case-studies within a two-phased mixed-methods sequential explanatory research design. In Phase One, a survey of 195 health facilities across Uganda which commenced ART services between 2004 and 2009 was conducted. In Phase Two, six health facilities were purposively selected for in-depth examination involving i) In-depth interviews (n = 44) ii) and semi-structured interviews (n = 35). Qualitative data was analyzed by coding and thematic analysis. Descriptive statistics were managed in STATA (v 13). Results Five dynamic interactions in ART program sustainability drivers were identified; i) Failure to update basic ART program records contributed to chronic ART medicines stock-outs ii) Health workforce shortages and escalating patient volumes prompted adaptations in ART service delivery models iii) Broader governance issues manifested in poor road networks undermined ART medicines supply chains iv) Sustained financing for ART programs was influenced by external donors v) The values associated with the ownership-type of a health facility affected ART service delivery and coverage. Conclusion The sustainability of ART programs at the facility-level in Uganda is a function of a complex interaction in elements of the health system and must be understood beyond sustaining international funding for ART scale-up. https://ghrp.biomedcentral.com/articles/10.1186/s41256-018-0079-6

Is Uganda truly ready for HIV 'test and treat'?

In November 2015, The World Health Organization released new guidelines recommending that all diagnosed as HIV positive be enrolled on antiretroviral therapy (ART) regardless of disease stage. The universal ‘test and treat’ (UTT) policy soon followed. There is persuasive research which forecasts that, globally, if as many people as possible are tested, and immediately enrolled on treatment (if diagnosed as HIV positive), their ability to transmit the virus will be limited rendering the end of the HIV epidemic as a feasible target by as early as 2030. Indeed, many countries have rolled out ‘test and treat’. In Africa, Botswana is among the countries which have registered tremendous success in this regard. In Uganda, many health facilities began implementing ‘test and treat’ this year following its inclusion by PEPFAR, a predominant donor in Uganda, in its annual program targets. Without a doubt, ‘the test and treat’ policy is a potent strategy in the national HIV response in Uganda and globally. However, field research we have been conducting across Uganda with colleagues from Makerere University, School of Public Health and a partner U.S. university , over the last 6 months, suggests that a myriad of bottlenecks stand in the way of Uganda’s implementation of ‘test and treat’. Perhaps the most prominent of these is the widespread and prolonged stock-out of antiretroviral drugs (ARVs), especially second-line regimens in the regions of Busoga, Bugisu and Acholi which we visited twice this year in two rounds of data collection (mid this year and about a month ago). Patients who used to get a 3-month supply of ARVs have had that reduced to as few as 2 weeks. An un-interrupted supply of ARVs is a cornerstone of the ‘test and treat’ strategy. As the print media has consistently reported in the last couple of months, Uganda is in the throes of a nation-wide stock-outs of ARVs with the clear and present danger of a systemic drug resistance. It was welcome news a few days ago, when the Deborah Malac, the US ambassador announced over 18 million dollars US government grant to address ARV stock-outs. We can’t wait for operationalization of Uganda’s AIDS Trust Fund (ATF) to reduce our heavy dependence on international assistance in our national HIV response. Clearly, ‘test and treat’ demands new kinds of performance of the Ugandan health system and requires unprecedented resources. In one of the health facilities we visited, active patients on ART almost doubled from 2,000 to 3,800 in a space of less than 6 months. Health workers partly attributed ARV stock outs to increased demand due to ‘test and treat’ but we now know that factors were also at play at national level. Health workforce shortages, a perennial constraint, featured prominently. Despite a dramatic increase in patient volumes, the number of health workers remained the same or declined. In some health facilities, health workers shunned ART clinics due to punishing workloads. Because of implementation of ‘test and treat’ and escalating patient burdens, the waiting time for patients was reported to have become longer. As a country, we need to evaluate our readiness for implementing ‘test and treat’ or double our investments at the level of government and donors to realize its successful implementation. Surely, pilots must have been conducted before full-scale roll out as I have seen reported elsewhere. This piece is by no means aimed at discrediting ‘test and treat’ but is intended as a reflection on our national readiness for implementing of a clearly worthwhile and potent strategy. As things stand today, the more clinically needy patients may have been denied life-saving treatment as ‘test and treat’ may have spread ‘us’ thin. We found little evidence in the field of implementation of ‘differentiated care models’ which have been touted as another strategy for managing the escalating demand for HIV treatment where visits to clinics are reduced for ‘stable’ patients and more are permitted for patients not achieving viral suppression. This strategy too could potentially aid in Uganda’s implementation of ‘test and treat’.

The Emmy goes to Reese Witherspoon

I know. The Emmy actually went to Nicole Kidman. I think Reese Witherspoon deserved it more. Make no mistake here, Nicole Kidman put it an award-worthy performance in her role in Big Little Lies. However, for me the award would go to Reese Witherspoon. I get that Nicole Kidman played a more understated, albeit more nuanced performance compared to Reese Witherspoon which I imagine was based on their characters but still for me, Reese Witherspoon played the more consistent and authentic role in Big Little Lies. Her lines, on comparison were more endearing. It is possible that Nicole was favoured over Reese because of the physical investment in her role, the violent sex scenes and the physical assault taken from her co-star. Reese truly inhabited her role and was utterly believable. At times it seemed an effortless performance. Like this was trully Reese Witherspoon in real life. And that is the mark of fine acting. Kevin Spacey said an actor should never be caught 'acting' they should seamlessly inhabit the character and be one with it. Reese Witherspoon fit the bill. They said Big Little Lies was 'desperate housewives' fare but I found it a more sophisticated take. The series actually reminded me of American Beauty-the 2002 hit starring Kevin Spacey. American Beauty-look closer.

A Ugandan review of the John Akii-Bua autobiograpical film ''An African Tragegy''

That it took me this long to finally settle down to watch this tragic film of John Akii-Bua the first Ugandan to win an Olympic gold medal is a little Ugandan tragedy of its own. And this viewing was courtesy of the French cultural centre in Kampala. Now, you know why 'the tragedy' bit is not entirely misplaced. But I am getting ahead of myself. The film is an autobiographical account of Ugandan 1972 Olympic gold medalist, John Akii-Bua in Amin's 1970s Uganda. The story is told based on Akii-Bua's own unpublished written notes of his life although the production betrays a British-centric lens even when the majority of characters are actually Ugandan. John Akii-Bua's British coach who led him to the 1972 Munich gold medal is a dominant voice in the film. This is really helpful as well. Before watching this film I was unaware of how prominent a role the coach played in Akii-Bua's rise. Perhaps it shouldnt be suprising that Akii-Bua's decline starts with the return of his British coach to the United Kingdom an exit forced by a Uganda in the throes of Amin's reign of terror. The film makes intelligent use of interviews with sports greats who ideally were Akii-Bua contemporaries.These include British and American 400 metre hurdle specialists-Akii-Bua's track and field speciality. Perhaps because of its British connections, the film takes an unhealthy dose of commentary on the Idi Amin personality. And this is not to say that Amin has nothing to do with Akii-Bua's rise and fall. Quiet the contrary. But I am familiar with the British obsession with the personality of Idi Amin. The Last King of Scotland is only one among a slew of indulgences in pax Aminiccana. The film itself is a commendable piece of work and I thoroughly recommend. And mostly to Ugandans who I am sure have watched it less than the International audience. I must say the film is a pretty sad tale really. It left it me a little depressed as I really felt sorry for John Akii Bua and what could have been. His rise from utter obscurity in rural Uganda after the premature death of his father when he was only a small boy and is own premature death at 47 are gut wrenching facts and then that heart-breaking boycott of the 1976 Olympics by African countries on account of Apartheid South Africa. Akii-Bua was meant to defend his 1972 gold medal during the 1976 olympics which was not to be. He ends up as an utter destitute in a Kenyan refugee camp after barely escaping certain death during Amin's ouster by the Tanzanians in 1979. Again that bit about the African tragedy..how an Olympic gold medalist could end up in a nondescript existence in a Kenyan refugee camp is truly astonishing. That goes to show how Africans value their heroes. Akii-Bua died a poor man even when he was a senior police officer. Although Amin is rightfully demonized, from the film I got the sense that Akii-Bua only enjoyed the spoils of his stardom only in Amin's Uganda. A house gift and stratospheric promotion in the Ugandan police. It was downhill from there on after Amin's fall. Sad but true, Akii-Bua's reluctance to ply his trade outside Uganda meant his true potential was never realized. His decline is a microcosm of the African tragedy of misrule, ethnicity, corruption, public decay, political instability, poor work ethic..and you can go on and on. Akii-Bua did eventually find his way to Germany after being sported by a PUMA sports wear executive on television in a Kenyan refugee camp. He has an uneasy relationship with Germany and returns to Uganda to find a country which has moved on. I know why Americans like Hollywood endings. This is not one of them

I liked Woody Harrelson's 'Wilson'

I bought a copy of 'Wilson' from one of Kampala's movie DVD outlets. Then I checked movie reviews of the film. Normally, I check with 'Rottentomatoes' first if I am in doubt. Well the verdicts were clear. 'Wilson' was not supposed to be worth my time. Well, I liked 'Wilson'. Not its entirety (I loathed the part where the Woody Harrelson character desperately begged the father of his biological daughter the chance to be a part of her life)I actually reached for remote to pass up this pathetic scene. Clearly, 'Wilson' doesnt follow the traditional holly wood template of happy endings and political correctness. This time around, this was refreshing. 'Wilson' seemed to me like a European film in that sense. I found the writing smart. Lots of wit and really terrific lines. Not altogether in good taste but I found the film's frankness refreshing. And Woody Harrelson is one reason I was drawn to this film in the first place. Laura Dern was another.'Wilson' is biting social commentary on the superficiality of American human relations. I found its take on the emergent multiple themes; happiness, adulthood, relationships,aging, loss, parenthood...thoughtful. I agree that there were some implausible bits of the plot or the story in general. Yes, I too wondered what the Woody Harrelson character did for a living as they seemed untroubled with paying bills and some how muddled through without worry of paying rent and gas. Dont believe the negative reviews. Go see this film if you want a refreshingly 'un' hollywood film. One for grown ups. A film that doesn't take itself seriously and takes a light hearted dig on life.

Failure to launch: a hasty movie review of 'Life'

I usually trust the judgement of James Berardinelli of Reelviews.net. And so, when I saw he had given 3 stars to 'Life', I dragged myself to the cineplex in Kisementi in Kampala. Well, James I am going to let you off on this one. But only because you have consistently reliable in the past. Not on this one I am afraid. They say 'Passengers' was a critical bum but I found it a lot more appealing and watchable than 'life'. In terms of the plot, character development and the imagination of the setting. I was taken in by the all-star cast. But even that couldnt bring this movie to fly. The only bright spot was the character played by the British scientist who was a refreshing find for me. What I found annoying was the hapless actions of the film characters. Shooting themselves in the foot at every turn. It was exhausting. I could even afford a couple of shut-eye moments during the movie. There was no real solid lead in the movie. The plot and elimination of characters was hasty and not altogether intelligently done. This is a movie that promises so much but delivers so little.

An alternative christian worship

I am visiting a small town in Michigan. I looked for a church to attend this sunday. The christian science church came calling. And I figured, its all about christ. Right? So, I took the courage to attend a totally new church in this snowy town in Michigan. It was different here. Refreshingly so. No loud pastor. No imposing choir. No sermon even. But it was worship alright. We recited more bible verses than I ever remember reciting in a single service in the catholic, protestant and Pentecostal churches I have attended. No church branding and events advertising. Very refreshing. And then beside scripture there were words of wisdom which they called 'christian science' and I thought these could only be inspired by the holy spirit. And I was spiritually fed. It is amazing how much we so trapped in our churches and forget that christ is everywhere and not only in that church you attend. He is everywhere from wherever you search for him. And this is the church he has chosen for me today and yes, He never makes mistakes.