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.

Accounting for variations on ART program sustainability outcomes in health facilities in Uganda: A comparative case-study analysis

Abstract Background: Uganda implemented a national ART scale-up program at public and private health facilities between 2004 and 2009. Little is known about how and why some health facilities have sustained ART programs and why others have not sustained these interventions. The objective of the study was to identify facilitators and barriers to the long-term sustainability of ART programs at six health facilities in Uganda which received donor support to commence ART between 2004 and 2009. Methods: A case-study approach was adopted. Six health facilities were purposively selected for in-depth study from a national sample of 195 health facilities across Uganda which participated in an earlier study phase. The six health facilities were placed in three categories of sustainability; High Sustainers (2), Low Sustainers (2) and Non- Sustainers (2). Semi-structured interviews with ART Clinic managers (N = 18) were conducted. Questionnaire data were analyzed (N = 12). Document review augmented respondent data. Based on the data generated, across-case comparative analyses were performed. Data were collected between February and June 2015. Results: Several distinguishing features were found between High Sustainers, and Low and Non-Sustainers’ ART program characteristics. High Sustainers had larger ART programs with higher staffing and patient volumes, a broader ‘menu’ of ART services and more stable program leadership compared to the other cases. High Sustainers associated sustained ART programs with multiple funding streams, robust ART program evaluation systems and having internal and external program champions. Low and Non Sustainers reported similar barriers of shortage and attrition of ART-proficient staff, low capacity for ART program reporting, irregular and insufficient supply of ARV drugs and a lack of alignment between ART scale-up and their for-profit orientation in three of the cases. Conclusions: We found that ART program sustainability was embedded in a complex system involving dynamic interactions between internal (program champion, staffing strength, M &E systems, goal clarity) and external drivers (donors, ARVs supply chain, patient demand). ART program sustainability contexts were distinguished by the size of health facility and ownership-type. The study’s implications for health systems strengthening in resource-limited countries are discussed. Keywords: Sustainability, HIV treatment, Health systems, ART scale-up, Implementation, Case-study Authors: Henry Zakumumpa, Sara Bennett and Freddie Ssengooba FULL TEXT: http://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-016-1833-4

Idle reflections on Robert Bolt's A Man for all seasons

Last night I stayed up late watching 'A man for all seasons' on Turner Classic Movies. The movie is an adaptation of Robert Bolt's play of the same name which was a set text for my A'level literature class a decade ago. The play is about Thomas More, Lord Chancellor to King Henry, the eighth. He was put to death for being true to his conscience(even under the most trying and unjust persecution) and denying that Henry's second marriage was legitimate. His opposition to King Henry marrying a second wife was out of religious (catholic)conviction. As chief counselor to King Henry, it was expected that he would go along with all the 'kings's men' and rubber stamp the decision to allow Henry a second wife even when it contravened the legal, religious and moral norms of the time. It is utterly amazing how much more meaning and thematic relevance I can now derive from a text I read as a boy to pass my A'levels. Having seen a bit of the world and known how incredibly trying it is to remain true to one's conscience, I appreciate Thomas More's example even more. The price of a life of convenience is a dearly expensive. As a secondary school student one often asks why they are 'forced' to read certain set texts. But yesterday, the answer came through. Some literature texts are an education in character. Being steadfast in upholding your virtues amidst trials and tribulations. Being loyal to truth and justice even at the cost of one's own life. How many times to we fail this test?, in our daily lives, at work, at home, in politics? Thomas More was truly 'A man for all seasons'. He was true to his convictions and beliefs in all the seasons of his life,when he was a great man and when he was banished from office. He never,even once, flinched when he was unjustly imprisoned, tried under sham charges,isolated from his friends and family and even when he was sent to the gallows. He believed in his heart that Henry's second marriage was a nullity and no amount of persecution would bring him to see matters differently. He spoke truth to power.

How Tobacco use deprived Ugandans of the' Father' of Arsenal's brand of football

Many Ugandans are ardent fans of Arsenal FC's style of football and Barcelona's attack-minded blend of Soccer.Many analysts agree this has a lot to do with one man. Johan Cruyff. Arsene Wenger, Frank Rijkaard and Pep Guardiola have variously acknowledged being influenced by Johan Cruyff's football philosophy. The Dutchman had an illustrious stint with the Dutch national football team famously captaining it to the 1974 World Cup final which they lost to West Germany. He later coached Barcelona to unprecedented success. The Dutchman even has a striker's dribbling manouever named after him. The Cruyff turn is a scenario where a striker makes a swift 180 degrees turn away from a defender. Dennis Bergkamp, Arsenal fans recall,executed this move in the twilight of his career there. Johan Cruyff would still be with us today to inspire more Arsenals and Barcelonas if it wasn't for one tragic habit-cigarette smoking. He passed away about two months ago from lung cancer. Tobacco use is responsible for 90% of all lung cancer deaths in men. Johan Cruyff repeatedly admitted that cigarette smoking had a lot to with the cancer that finally claimed his life and a heart bypass operation he underwent when he was still a football coach. '' Football gave me everything but tobacco almost took it all away'' said Johan Cruyff when it seemed that he would beat the lung cancer. Later in life, he emerged as unlikely poster boy for tobacco control causes. As we commemorate World No Tobacco Day today, it is an opportune moment to go beyond regurgitating the statistics of the victims of tobacco to reflect on the human face of the tobacco epidemic and the one billion lives tobacco use is set to claim this century unless action is taken. WHO has selected plain tobacco plain packaging as this year's World No Tobacco Day theme. Australia led the world in implementing a plain tobacco packaging rule. This simply means that if you buy a packet of cigarettes in Australia you will not find the manufacturer's colours and brand displayed on a cigarette packet as is the case in Uganda today. The United Kingdom implemented the plain tobacco packaging rule this month with France and Ireland set to follow suit this year. Clearly, tobacco packaging is a form of advertising and research has determined that glossy cigarette brand packaging makes smoking seem attractive and induces demand especially among impressionable young people. Last year, the Parliament of Uganda passed a Tobacco Control law which was assented to by President Museveni.The Tobacco Control Act(2015) provides for increasing the size of health warnings on tobacco packaging to provide for messages such as ''Smoking harms your health and those around you'' complete with graphic images illustrating tobacco-associated illnesses such as throat cancer. The Uganda Tobacco control law came into force on 19th May 2016 following a 6-months period since it was gazetted.At this year's World No Tobacco Day in Kampala, a ceremony has been organized to mark the coming into force of the new Tobacco control law. The Ministry of Health and CSO partners are in the process of passing regulations to give full effect to the Tobacco Control law to save the next generation of Ugandans. In Kenya, passage of the tobacco control law was greeted with law suits from the tobacco industry and in Uganda the industry is expected to follow a similar template. Johan Cruyff would not approve of such moves. His story is testimony to kind of lives the law seeks to protect in the first place.

Vergiss mein nicht: 'Forget me not' A German film review

An adult son takes a few days from work to visit his parents' home to relieve his caretaker father from the grueling task of looking after his 71 year old mother who has end-stage Alzheimer disease. From this simple plot flows an intimate family portrait of the effects of Alzheimer on a German family.On a more sophisticated level, Vergiss mein nicht, which is German for 'Forget me not' is a introspective tale of mortality and human transition and how we negotiate this journey in the intersection of a family setting. We see first hand how a elderly woman loses her memory to the point of being unable to tell the difference between her own husband of 30 years her adult son. The pain of being forgotten in an instant by a loved out of mental disability brought on from an advanced disease couldn't be more stark. The almost complete memory loss by the filmaker's mother, except for a few flickers of memory such as being able to recognise her father, tell an intimate story of the struggle of a family to come to terms with a mother who can longer identify the closest people in her life or even recall the use of the most basic domestic tools. A painful moment in the film shows the filmaker's mother being told how to use a fork to pick on a tomato in a food bowl. The films provides some rich background of the filmaker's mother when she was a very pretty, young, politically-active wife of a young German mathematics lecturer in Zurich, Switzerland flashbacks from the 1960s and 1970s and cuts to the image of an elderly woman suffering from dementia who is much more at ease in sleep than awake with the inevitable outcome all but clear. The story touches on the interesting subject of monogamy in married unions. We learn from the filmaker's narration that her mother and father agreed on an 'open' relationship where they allowed each other to see other people when they were a young idealistic couple. From the woman's long-kept diary we learn she wasnt as tolerant of this open union as she let on. The unfairness of fates comes into play when we learn that 71-year old woman's mother in law (who is several years older) appears in better command of her physical and (certainly)mental faculties her being in a retirement home notwithstanding. The family debates whether to institutionalize their mother or to look after her at home with some very painful moral choices. Vergiss mein nicht will make you cry and laugh at the same time.

Intriguing perspective from Alex de Waal-' A social science in Africa Fit for Purpose'

Alex de Waal A Social Science in Africa Fit for Purpose Introduction In this presentation I will argue that African scholarship on Africa is operating at only a fraction of its true potential, and that it is hampered by the preferences, policies and politics of the western academy. I will make three major points. First, the state of knowledge about African economics and politics is poor because in the higher reaches of the western academies, the focus is not on generating accurate information, but on inferring causal associations at a high level of abstraction, from datasets. And that those datasets are in fact far too weak for any such conclusions to be drawn. Second, the structure of academic rewards and careers systematically disadvantages those who either do not have the skills or capacities for this kind of high-end quantitative endeavor (although it is profoundly flawed), or have serious misgivings about it. One result of this is a severe dissonance between actual lived experience, and academic work validated by the academy. Third is what I call ‘Occidentalism’ in theory and policy. Occidentalism is the variant of Orientalism, it is the tendency to ascribe a cogency to the intellectual and cultural products of the west, that it does not in fact possess. Despite sustained critique by historians and anthropologists, the western experience of state formation remains the standard against which the rest of the world is indexed. African Data There’s a long-standing joke that 87.7% of Sudanese statistics are made up on the spot. This is not a laughing matter. Too much social scientific ‘fact’ about Africa is actually fiction because it is not based on real data. We are all familiar with the way in which a foreign researcher relates to his or her research assistant. It can be mutually respectful, or it can be exploitative. Fundamentally it is unequal. It corresponds to the designation of knowledge as either ‘expert’ or ‘local knowledge’. Let me give three examples of how this is reflected at a macro level to the detriment of both scholarship and policy. First, macroeconomics. I highly recommend a recent book by Morten Jerven: Africa: Why Economists Get it Wrong. His starting point is that the economic data used for the study of African econometrics are highly unreliable. Econometricians have tried to compensate for this deficiency by using sophisticated statistical techniques. This cannot legitimately be done. Much of African econometrics is simply a vast exercise in garbage in, garbage out. For example, economists have spent much time and effort trying to explain the supposed African chronic growth deficit. They take governance data from the late 1990s or early 2000s and use it to try to explain why Africa grew more slowly than the global average over the last fifty years. But, as Morten points out, cause should come first and, effect later. Because of lack of data—and lack of awareness of the deficits of the data—econometricians have made a simple error. They are trying to explain something that didn’t actually happen. Africa’s chronic growth deficit didn’t happen. What happened—as everyone who lived in the continent knows—was that African economies grew in the 1960s and early 70s, stalled in the 1980s and early 1990s, then grew again, albeit in a different fashion. Africa’s story isn’t one of chronic slow growth, but of boom, bust and boom again. There was a time-specific economic crisis—deeper and more protracted in Africa than elsewhere in the world—and that is what needs to be explained. The dominant feature of African economies is their extremely high sensitivity to global economic conditions. That conclusion would lead to radically different economic policy prescriptions at the World Bank and other international financial institutions and donors. My second example concerns wars. Everyone knows that there are no inter-state conflicts in Africa, only internal wars. Look at the databases of the Correlates of War and UCDP/PRIO databases: they have zeroes for the number of inter-state wars in Africa for most years. So there is an academic industry explaining civil wars, and why state formation has not needed to worry about borders. So the policy requirement is internal governance not inter-state relations. But hold on a moment. Anyone who follows politics and conflict knows this is false. Countries regularly invade one another, or have border conflicts, or sponsor proxies to fight against their neighbors. In the Horn of Africa alone I have enumerated 35 of these conflicts over the last 55 years. If we expand the dataset to include conflicts across borders among their immediate neighbors too the number goes up to 92. Once again, political science is trying to explain something that didn’t happen. A third example is from politics, namely governance indicators and failed/fragile states index. Did anyone notice how Mali still performed on the Failed States Index even while it fell apart during 2011-12? We all know the story of that period: Mali faced a near-perfect storm of corruption and institutional collapse at the center that left the state eviscerated and penetrated by international drug trafficking cartels, with parts of its territory surrendered—with state complicity—to criminal gangs and Al Qa’ida in the Islamic Maghreb, which avowed extremist and separatist agendas. A military coup by a junior officer and the near total evaporation of state authority followed, leading to first a rescue plan by neighboring African countries, quickly overtaken by a French military intervention, which despite some battlefield successes, became bogged down in an intractable conflict. There are datasets and indices specially designed to predict such crises. Specialists on Mali certainly predicted the crisis, in some detail. But if we turn to the most prominent of these measures, the Foreign Policy/Fund for Peace index of failed states, and turn to the data published in 2012—the year the crisis struck, based on the values of the indicators as they stood in 2011, we note something quite striking. The index ranks countries in reverse order: head of the list at number one is Somalia, and 191st out of 191 is Finland. In 2012, Mali stood at number 78, more or less the same as India and China. In the 2013 index, Mali came crashing up this list, reaching 39. But still it barely reaches into the quintile of the most at-risk states, assessed as far more stable than, for example, Ethiopia (ranked at 19). We may have concerns about Ethiopia’s human rights record, but few would dispute that it should rank as a far more effective and stable state than Mali. Where is the ‘real politics’ of political management in all this? African scholars first destination is history or political ethnography: documenting what actually happens. This is vital but grossly undervalued. It is done principally by country experts working for think-tanks like the International Crisis Group and the Carnegie Endowment. For sure, these institutions do some superb analysis, and their senior staff can move into academic positions. But it is extraordinarily hard to build a career based on knowing what is really happening a country, especially if it happens to be your own country. What Knowledge is Valued The structure of academic careers is in need of serious attention and reform. We are all familiar with the biases in academic reward and promotion, that undervalues teaching, and that rewards peer reviewed publication, biased towards high-ranking journals that prefer certain methodologies and questions. Those methods are typically quantitative, building beautiful castles in the air, or palaces on foundations of sand. This career structure marginalizes the African scholar. Supervisors in foreign universities rarely have the subject matter expertise and so tend to guide students towards more theoretical approaches. Examiners and peer reviewers likewise reward and reinforce their own disciplinary biases. On the other hand, it is common to see junior western scholars doing rather uninteresting quantitative studies, or superficial case studies, which they nonetheless are able to publish. This means that they thereby becoming the peer group that undertakes peer review. A lot of substandard material comes out, particularly on fashionable subjects. The African scholar of political science may be compelled to adopt a schizoid personality. In order to become an academic in a western university, she or he may be obliged to unlearn important knowledge, and learn frameworks and skills that are actually irrelevant to the situation at hand, but necessary for being considered a professional academic. Occidentalism in Theory and Practice "Occidentalism" is an inverse variant of Orientalism, which was western scholars’ exoticization of eastern (and by extension) African societies. It is the tendency to ascribe a cogency to the intellectual and cultural products of the west, that it does not in fact possess. Occidentalism persists in scholarship and in policy. One prime example of Occidentalism is the concept of ‘the state’. Despite the best attempts of historians and anthropologists to problematize this concept, it nonetheless carries with it a strong teleology: a one-way process of state formation and state-building. It is a process of turning robber barons to barons to constitutional government, moving from a traditional patronage-based political order toward a Weberian state, which means essentially an imitation of a north-west European state, or France, or the U.S.—all countries that established their modern statehood at the zenith of imperialism. The rise of Asia will challenge this for sure. We will see a diversity of destinations for the consolidation of governance, sharing only the common factor of international recognition. This diversity reflects the fact that the vernacular in most countries doesn’t contain a word for ‘state’—but rather for power, authority, government, the regime of the day, etc. It is the same in Africa: political vernaculars have words for many things, but if we are to talk about ‘states’ it must be in English or French, in the domain of scholarship or the practice of international law and international relations. Occidentalism also occurs in policy engagement. We shape our analysis to suit our audience, and end up speaking their language. Rather than evidence-based policy, we have policy-based evidence-making. The paradigm of this is engaging with western governments, the World Bank or the United Nations. Much of the policy-related discourse on good governance, post-conflict reconstruction, development, etc., takes place in a fantasy land that exists only in the minds of international civil servants. It is very welcome that we are here in Addis Ababa. The African Union has in important respects deviated from the standard international practices. But we need to guard against treating the African Union as just a regional institution under Chapter VIII of the UN Charter. The AU’s legitimacy derives from the extent to which it reflects the aspirations of the African people, not its juridical and financial relationship with international bodies outside Africa. The Need for an African Academy Everything I have said does not lessen the need for rigor. To the contrary, it is more difficult to produce first rate scholarship by being true to the realities of this continent, than it is to slot into the established track. Generating accurate data about African economies, African conflicts, and African political systems is hard. It is harder than pretending that the datasets that actually exist are good enough. It requires doing fieldwork, gathering information in a thorough and painstaking way. Writing and publishing good quality, fact-heavy accounts of African realities is also not easy. Detailed accounts of what is actually happening don’t fit neatly into 5,000-8,000 word journal articles, and the market for books is very small, so that there is not much chance of publishing the kinds of local histories or detailed political memoirs that are commonplace in Europe. Constructing frameworks for explaining how societies actually function, is intellectually demanding. It involves challenging the dominant frameworks and replacing them with better ones. I am confident that these things will happen, and as they do, that scholars in this continent will feel less divided between their real selves and their scholarly selves.

Intriguing perspective from Dr Alex De Waal-Full Length article

From Alex De Waal

The Uganda Tobacco Control Bill 2014 on verge of passage

The Uganda Tobacco Control bill (2014) is currently before the parliament of Uganda for deliberation with the press reporting, earlier this week, that a handful of legislators expressed misgivings. Actually, the story began much earlier. In 1950, a British doctor observed an increase in the number of lung cancer cases. He was curious, why the spike in lung cancers? Dr Richard Doll decided to investigate this puzzle in 20 London hospitals. What he discovered was ground-breaking. But his results would be kept from most of the world for more than 40 years. Richard Doll discovered that patients with lung cancer case had in common history of tobacco smoking. To be sure, he conducted the study again in 1954. This time following up on 40,000 British doctors who smoked. The results confirmed his earlier findings. Lung cancer was strongly linked with tobacco smoking. The mainstream world would have to wait much longer to know these results. At the time, global tobacco sales were on a high and the powerful tobacco industry would have no one spoil the party. That Uganda should spend more than four years debating whether we need a tobacco control law, in defiance of science, speaks volumes, partly, on the power of the tobacco industry in Uganda today. The UK’s University of Bath has published research results detailing how the tobacco industry in Uganda has interfered in the tobacco control legislative process since 2011. This has included peddling falsehoods that the bill bans smoking when all it does is ban smoking in public places. For the record, Kenya passed a tobacco control law in 2007 and Rwanda did the same years ago. Although tobacco control has largely been constructed as a public health matter, research we conducted in Uganda last year, with funds provided by the Bill and Melinda Gates Foundation, shows that tobacco use is also solidly a poverty issue. Ugandans in the two lowest income groups have higher tobacco use rates than those in higher income groups even when they can afford it the least. We analyzed two combined Uganda household expenditure data sets of 2009/2010 and 2010/2011 and asked a basic question. How much do poor households in Uganda spend on tobacco per week and what could this money potentially buy the household? We then looked at the prices of commodities in the Uganda Consumer Price Index of June 2010 and the potential purchases of selected alternative items with regard to food, health and education. We found that money Ugandan households spent on tobacco every week could have bought 8 litres of fresh milk or two loaves of bread. Studies done in Bangladesh show that households which spend on tobacco suffer more malnutrition than those which don’t. In the case of Uganda, we found that households’ weekly expenditure on tobacco was equivalent to the price of three and a half kilograms of maize flour during the same period. The results also showed that money spent by a parent on tobacco could buy their children a set of primary school exercise books or 21 ball-point pens. In the context of the rising epidemic of diabetes and high blood pressure in Uganda, we found that the money households spent on tobacco monthly was equivalent to a monthly dose of a standard prescription for high blood pressure or diabetes. The study also looked at the spending habits of households which use tobacco. We found that they spent less on eggs and consumed less litres of milk than the average household. These households would potentially spend 39% more on five selected food items if they didn’t spend on tobacco. There would be a 51% increase in expenditure on medical care in households which spent on tobacco. Almost 50% more wore would be spent on education if households didn’t spend on tobacco. Research has determined that the poorer a smoker is, the less cigarettes they will consume if their price is increased through government taxes. Uganda has one of the lowest tobacco taxes in East Africa. The Uganda Tobacco control bill proposes an inter-ministerial committee whose brief would include pushing for a pro-poor tobacco tax policy.

Social media and the opening up of political space in closed African polities

Fearing that the mainstream media may be stifled or infiltrated by Ugandan government functionaries, former Ugandan Prime Minister and presidential hopeful turned to You Tube to announce he would contest against President Museveni. Meanwhile, the former Prime Minister's staunchest supporters including his sisters' in law turned to Facebook to defend him soon after his candidature was announced. In Nigeria,opposition election agents in rural outposts posted results onto Twitter to beat the present and clear danger of ballot stuffing and deliberate misreporting of the election results. During the height of the failed Burundi military coup, President Nkurunziza turned to twitter to announce he was still President even when the centre couldn't hold in Bujumbura. President Museveni recently scoffed at Whatsapp discourses which he perceived as fanning ethnic hatred. Social media is revolutionizing the contestation of political power and space in Africa. Factors working in favour of this trend include the fact that the majority of African populations are incredibly young, the proliferation of smart phones and the reduction in cost of internet charges. This however is still an elitist trend that is not yet mainstream but growing in importance with each passing day. African governments accustomed to controlling state media monopolies are having a hard time keep tabs on discontent. Will they go the nine yards of the China government which reportedly controls the internet and bans inconvenient web sites?

Reflections on the Kampala Euro-African Film Festival of June 2015

They are serving a sumptuous visual feast in Kampala. Its all happening at Cineplex,Cinema at Oasis Mall. It is bigger and better than the last outing which was last year at Theatre Labonita. The film selection are excellent indeed and this time around we have selections from afar a field as Romania. And they are serving an engaging visual menu as well. A Hijacking: A Danish take on sea pirates intertwined with a hostage drama which contrasts sharply with the Tom Hank's Captain Phillips. The tone is not condescending and there is an intelligent depiction of the Somali pirates without lazily demonizing them,with commendable nuance. It's free from Hollywood hyperbole and almost a phenomenological treatment of Somali pirates. The lead played by a Danish Sea transport company CEO is a remarkable one as he seeks to take matters into his own hands and negotiate the release of his men while going on an emotional roller coaster in the process. Marussia: The French-Russian feature film about a (willing)homeless mother and her young daugther on the streets of Paris. Very heartfelt indeed. An almost romantic treatment of a homeless mid-30's attractive Russian mother who is in a self-imposed homelessness. Despite her destitution she has a pride and dignity about her that is admirable.There is however need for a resolution in the story as it plods on without much break and is a little tedious to viewers despite the heart-warming story. Hotell: A Swedish mental health drama about an upper middle-class woman who lives in denial after delivering a brain-damaged baby and decides on an eccentric therapy. With a bunch of colleagues from their therapy group,they head out to a new hotel each day where they act out their fantasies making for unlikely relief. The bald-head comic relief stands out for me. Of Snails and Men: A Romanian comedy and by way the funniest movie in the ensemble. A state-owned car factory is closing down due to bad economic times and the factory is up for sale to a French business man and his son. That is until the workers devise a hare-brained strategy to save their jobs: sell their sperm to an American sperm bank. Run and Jump: An Irish-American film that makes an intimate portrait of an Irish family where a father has a stroke-induced mental disorder and there is a live-in American psychologist on a case-study research project. The researcher gets more than he bargained for posing critical ethical issues.

There was a Ugandan currency

I wish to borrow today from that recently departed Nigerian enigma, Chinua Achebe. I wish to borrow the title of his last work. 'There was a country'. The Ugandan shilling is suffering an enduring pounding from the US dollar. It has reached an all time low of 3,000 Uganda shillings for one US dollar. We are told its an external matter.The the US economy is rebounding strongly and that all major currencies are affected. ''It is beyond our control'' the new Uganda Finance Minister has gone on to allege. But most economic problems are actually local. And what we are not getting much appreciation of is the connection with Uganda forthcoming presidential polls in 2016. The press is awash with reports of election-associated cash bonanzas. Ugandans have not forgotten the economic melt down that followed the presidential elections in 2011. Many friends I know have converted their few coins into US dollars. And surely this must be a part of the problem. But the truth is the first casualty in war.

Why Uganda must wake up to the cancers and heart disease epidemics

This year is set to be a land mark year. In 2015, the UN will converge on New York to set new millenium development goals(MDGs) for the next 15 years. Reducing extreme poverty and maternal deaths were some of lofty goals set in the past 15 years. In all likelihood, Non-communicable diseases(NCDs) will form part of the next set of MDGs. Uganda has been slow in aligning its development agenda towards the budgeoning cases of cancers, heart diseases and diabetes. The World Bank and World Health Organization (WHO)have separately published major reports which come to the same conclusion. NCDs such as cancers and heart diseases will be the leading cause of death by 2030 in low and middle income countries such as Uganda. And yes they are projected to outstrip HIV,malaria and Tuberculosis. That is just 15 years from now. To be sure, infectious diseases such as HIV are still of emergency importance and in many ways we have a double-trouble situation where infectious and non-infectious epidemics are co-occurances. In some instances they are even interacting. Take the case of HIV-associated cancers such as skin cancers which have been on the rise at the Uganda Cancer Institute. Reading the reported causes of death of the majority of middle class Ugandans in the press in the last five years, one cant escape two facts. The majority of these deaths have been reported to be as a result of NCDs. The majority of the deaths have occured before the 70 year mark.When I was growing up in the 1980s and 1990s, people, on average, died much later in life. Last year I spent two months in South Africa and I believe what is happening there is instructive for Uganda. Universities have re-focussed alot of their research towards NCDs particularly diabetes and heart diseases. I attended several PhD research seminars and was astonished at how much research attention NCDs are getting. Remember South Africa has a much higher HIV burden and we were told in some rural villages, HIV prevalance is as high as 40% but they have not taken their eye off the ball regardless. Prof Shane Norris of Witwatersrand University talked about exciting research they are doing in Soweto which shows that newly born babies who gain weight in the first week after birth have been shown to have a higher risk of diabetes later in life. We were told that a study on sugary soft drinks done at Wits found that an ordinary bottle of soda contained 8 spoons of sugar. But there some challenges at the global level.The global health lobby is still largely focused on infectious diseases. The US has officially declared that combating HIV is in their national interest. Academia, researchers and 'big pharma' are all heavily invested in HIV and other infectious diseases even when the terrain is changing. Of course South Africa is a middle income country and Uganda is not but there is lots we can do. One of the problems we have is that there is not much national-level data on NCDs in Uganda and most NCDs dont give off symptoms until one has a really advanced condition. Most Ugandans with NCDs dont even know it. We need to strengthen the NCDs office in the Ministry of Health led by the dedicated Dr Gerald Mutungi. Health workers need to probe for NCDs when patients visit health facilities. NCDs prevention is a much more cost-effective approach when compared to treatment which in most cases is life-long and prohibitively expensive as many Ugandans who flock to India already know. Dr Joseph Babigumira of Washington university told us that Nigeria spends a billion dollars on treating its citizens abroad every year. Measures aimed at life style changes such as reducing salt and sugar-intake, raising tobacco taxes and increased physical activity are critical. On a policy and planning level, small incremental steps such as integrating NCDs in current infectious diseases programs such as HIV would be advisable.

Blaise Compoare and the African spring

After 27 years, the people of Burkina Faso have had enough. And so handsome Blaise was bundled out in an unceremonious exit he hardly hoped for. Generations of Burkinabes had only known one leader. Parliament was set to rubber stamp his quest for a constitutional change to pave way for another term in office and certain victory in the joke that is African presidential polls especially when they involve incumbents. We have been told that Africans (south of the sahara) are incapable of what we saw in Egypt, Tunisia,Libya, Syria-the so called' Arab Spring'.But the people of Burkina Faso have now spoken. We have had enough. Thank you very much. The message is now all too clear to all African presidents who have been in power for over two decades 'winning' sham elections, one after the other. It is amazing how electoral democracy in Africa has been subverted and gone against the very spirit in which it was intended by western civilization.

Of Uganda's 'arrested' development and vested interests

I was recently invited to Nairobi by Partnership for Governance Research (PASGAR) to attend a political economy analysis symposium which attracted thirty participants from across Africa, courtesy of the British government. Why do development programs and interventions in poor countries like Uganda not succeed? There has been tonnes and tonnes of studies on this very subject with explanations ranging from geography to work ethic.It turns out we were blind to the potency of political economy analysis tools. This has began to change among western donors who have wisened up over the past few decades. They now acknowledge that the best-laid development plans and programs in poor countries will not necessarily get a red-carpet welcome. In a word, 'politics matters'!. That a sophisticated understanding of the context and mechanisms that maintain poverty or some other status quo is instructive. To over simplify, some quarters of society benefit from the way things are and may not be too keen on new 'interventions' which may turn them into 'losers'. The symposium was ably facilitated by Dr Tim Kelsall, an ex-Oxford don and our own Dr Fred Golooba-Mutebi. It is early 2013. You work as Chief Technical Advisor for an aid agency, lets call it JICA. Your brief is to support Uganda construct the Mukono-Katosi Road.You base all your plans for succeeding on sound planning and technical expertise. We now all know how that ended and which determinants impacted on implementation. And the scenarios are numerous. Britain's DfID actually commissioned a political economy analysis of road works procurement in Uganda that makes compelling reading. Imagine here what interests are ranged against an efficient passenger railway network across Uganda. What economic interests would you displace? Or picture this. You want to distribute free bed-nets in a malaria-endemic district of Uganda but the District chairman owns the largest shop in that district selling bed-nets. A few years ago,I was part of a team evaluating a foreign-funded effort to support a local government in Uganda provide HIV treatment at its lower health centres. I was told that before the project could even get off the ground, some 'good will' fees were demanded before the local government could allow to be supported to provide HIV treatment! The British,Dutch and Swiss international development arms ,and even The World Bank, now conduct political economy analyses that seek to anticipate impediments to their sponsored development interventions. When I was an impressionable fresh graduate, I imagined that the best development intentions would deliver Africa from what Paul Collier calls 'the bottom billion'. But as one makes their way through the world, one begins to see how complex the world is and how 'arrested' development can be. I have witnessed first hand how vested interests fail or stall development. From Uganda passing a sub-optimal law impacting on access to generic HIV drugs to Uganda taking more than 5 years to legislate a tobacco control law when Kenya took less than half that time. Indeed,it is worthwhile to analyze the key actors, interests and 'institutions' that facilitate or impede development programs. We were also told that when engaging with public offices, we may need to to look beyond people in formal positions and that key actors may be 'outsiders' who are actually in the 'inner circle'.It reminded me of Charles Rwomushana when he commented on a recent squabble in a most pinnacle office in the land. He opined that people in that office were not taken seriously depending on their official titles but on their perceived closeness to the 'principal'. Political economy analysis is not an imperative for western donors alone but for government programs as well. Why, for instance, hasn't NAADS succeeded despite its clearly noble goals? It was an opportune moment to brush up on my mid-1990s undergraduate political economy 101 and revel in the new importance attached to a discipline which had long been stigmatized because of its 'incorrect' roots.