Time for Parliament to Act—the FY 2015/16 budget must correct the health worker crisis in Uganda

By: Asia Russell

May 3, 2015

Uganda is in the throes of a health workers crisis—there is an absolute shortage of professional health workers, medics are inequitably deployed across the country, and they are paid abysmally low wages, leading to high rates of attrition and poor motivation.

Astonishingly, government is exploring a plan that would only pour fuel on the fire—by exporting 283 qualified Ugandan health workers to Trinidad and Tobago.

But Parliament has the chance to help stop this ill-advised proposal and to ensure the Financial Year 2015/16 budget corrects the factors that are pushing health workers to leave Uganda in the first place. The 2015 budget will be the final budget before the 2016 elections—no better time for Parliament to show it is responsive to citizens’ priorities. A large national public opinion poll recently conducted by Columbia University in 2014 showed Ugandan voters reported healthcare as the most important issue for the 9th Parliament to address. 25% of Ugandans report it is the most important issue for Parliament—an increase from 17% of voters polled in 2011.

But for too long, the health worker emergency has triggered virtually no intervention by government. This changed in 2012 when civil society attempted to make the health worker crisis a political priority. A prolonged advocacy campaign, led by civil society alongside Parliamentarians, ensured that the national budget was not passed until the health worker crisis was prioritized. Eventually the Financial Year 2012/13 budget committed 49.5 billion shillings to recruit 6,321 additional health workers and deploy them to Local Government clinics, while more than doubling the wages of doctors working at HCIVs.

Parliament also committed itself to prioritize health worker motivation in the Financial Year 2013/14 budget—through wage enhancement, in particular for midwives, who are the backbone of the health system. But this promise was not kept—and up to today health workers continue to toil without adequate pay, with non functioning equipment, and with poor training and support. Parliament is passing budget after budget without addressing this grave injustice.

Meanwhile, Uganda could lose another 283 of its scarce health workers thanks to a government plan to export them to Trinidad and Tobago to work in an elite medical facility. This move would deplete Uganda of midwives, nurses, doctors, psychiatrists, and other highly sought-after cadres of health workers. This move is being challenged in High Court; many Parliamentarians have also spoken out, recently joining civil society to petition the Speaker of Parliament to halt the deal. The Rt. Hon. Speaker herself told civil society that exporting health workers ‘did not make sense’ when women are dying in childbirth in clinics in Uganda.

Rather than correcting the factors that push Ugandan health workers to migrate in search of better pay and better working conditions, government wants to help health workers leave the country—further undermining a health system that is already failing to deliver essential services. Trinidad and Tobago, unlike Uganda, has no health worker crisis. The tiny, oil rich nation has a maternal mortality ratio of 84 per 100,000 live births (compared with 438 for Uganda) and a skilled birth attendance rate of 97.8% (compared with Uganda’s rate of 41.9%). Ugandan women are four times more likely to die during childbirth than women in Trinidad, and three times as many Ugandan children die before the age of five. Exporting 100 midwives effectively denies maternal health services from 900,000 pregnant women and mothers. The transfer of highly qualified doctors deprives care to 1.2 million patients.

Compared to Uganda, Trinidad and Tobago has 10 times as many doctors, 3 times as many nurses, 22 times the per capita health spending, and 32 times the per capita gross domestic product.

If implemented, this plan will mean more suffering and preventable death in Ugandan communities, particularly among pregnant women, newborns, people with HIV, tuberculosis and malaria, and other leading causes of preventable death in Uganda.

Moreover, Uganda stands to suffer an estimated 80.2 billion shillings in lost return on investment from the proposed export deal.

The Budget Framework Paper for the Health Sector 2015/16 describes poor wages of health workers and insufficient numbers as causing a ‘persistent service delivery gap.’ The Ministry of Health estimates that 129 billion shillings is required for salary enhancement for all staff in the sector annually. This is just a fraction of the estimated 377 billion shillings being spent on health care abroad for Ugandan VIPs.

The evidence is clear—Uganda’s acute shortage of health workers can only be fixed through investing in better pay, better working conditions, and better management. All people should be free to travel to seek employment as they please, but government should be prioritizing efforts to increase health worker motivation and retention—instead of developing schemes that would make suffering worse.

Importantly, public outcry has so far helped stall the export of health workers—the medics were meant to have departed more than 3 months ago. Foreign aid to the health sector is also at risk—the Belgian government recently announced 6 million euros in health sector aid would be suspended as a result of the government plan. And while the Minister of Health, Hon. Dr. Elioda Tumwesigye, recently told media that government was ‘rethinking’ the export of health workers, there is no solid evidence that the plan has been stopped.

Meanwhile, the clock is ticking: everyday 16 pregnant women die while giving birth and everyday countless disgruntled medics loose hope that government will enhance their wages and give them the tools they need to save lives. Alongside a halt to this scandalous export plan, civil society calls on Parliament not to pass the 2015/16 budget until it delivers what voters deserve: a) recruitment of an additional 3000 health with a focus on deployment in underserved Districts; b) an increase in wage by at least 50% for midwives and other priority cadres of health workers at HCIVs and IIIs; and 3) an increase in primary health care (PHC) funding for facilities at Local Government level so clinics have the medical equipment health workers require to deliver life saving services to their patients.

Urgent Action NOW: defend AIDS drugs from Fast Track Attack

A deal on Fast Track was reached last Thursday, and it’s a doozy. The agreement was reached between Senators Orrin Hatch (R-UT) and Ron Wyden (D-OR), and Congressman Paul Ryan (R-WA), the Chairs and Ranking Members of Senate Finance and House Ways and Means Committee. The bills will go up for committee votes soon, as early as this week.

Although the bill does contain some nice language we've won together with the late Senator Ted Kennedy on respecting the Doha Declaration on TRIPS and Public Health, it also includes dreadful “TRIPS-plus” policies, including a requirement that US trade negotiators actively work for "accelerated and full implementation” of the TRIPS agreement, as well as even nastier language that makes it a legal negotiating objective of the United States to push other countries to adopt "a standard of [intellectual property] protection similar to that found in United States law” — what a nightmare!

These objectives—even before the TPP is finalized—threaten millions of people with HIV. Some Senators are already talking about trying to amend the bill, and we need to pull out all the stops to halt this bill and make any progress as slow and painful as possible. This flawed Fast Track legislation would allow the TPP and other agreements to skirt ordinary Congressional review, amendment and debate procedures — a rubber-stamping of “NAFTA on Steroids” pacts that denies affordable generic medicines, destroys jobs and drives down wages, and causes dangerous environmental, public health and economic setbacks for people here and abroad.

We’ve stopped Fast Track legislation before and we can do so again. We need you to call Congress now!

1. Call your member of Congress TODAY 
2. Stay tuned for electronic actions in the coming days.

We need you to call Congress now. Its critical that we all make emergency phone calls to your members of congress TODAY. This link will Call congress and give you a calling script to borrow from while you're speaking with your elected officials.

It’s crucial that we continue sending a strong message over the next few days through emails to show that Fast Track is Dead on Arrival. After you've made calls today and tomorrow, this link will send an automatic email to your Senators.

PS for more info: Committee on Ways & Means Ranking Member Sander M. Levin released a very solid blow-by-blow run down on why fast track is horrible and must be stopped.

With your help we can defend access to AIDS drugs from this horrible Fast Track deal.

Ending the AIDS epidemic: ICASO and Health GAP to expand community activism to increase the impact of major global health initiatives

April 1, 2015

 ICASO and the Health Global Access Project (Health GAP) are excited to announce a new partnership. The two organizations are collaborating on a new project to support civi l society-led monitoring efforts and advocacy to ensure that the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund) and the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) continue to play a strong role in the global AIDS response.

 “Our strength lies in the partnerships we build with civil society organizations, working together to accelerate and intensify the fight against HIV. We are excited about this opportunity to strengthen our partnership with Health GAP—a long-standing ally in the global AIDS response,” said Mary Ann Torres, Executive Director of ICASO. 

 The planned three-year project will involve regional efforts in the Middle East and North Africa, Eastern Europe and Central Asia, Asia and the Pacific, Latin America and the Caribbean and Sub-Saharan Africa. In-depth engagement with civil society partners in Uganda and Malawi will contribute to the regional efforts to ensure that major global health initiatives achieve higher impact, and are more effective and responsive to the needs of the communities most affected by the AIDS epidemic. Through coordinated advocacy at the country-level, as well as in the halls of power in Geneva and Washington, D.C., Health GAP and ICASO will collaborate to secure funding for the Global Fund and PEPFAR.

 Health GAP brings a wealth of knowledge of PEPFAR and the Global Fund’s processes, policies and strategies, as well as extensive experience building the capacity of civil society partners and communities in Uganda, Kenya, and other heavily impacted countries, to support efforts to influence the priorities and practices of the Global Fund and PEPFAR at the country-level—where it matters most.

 “The strides we have made in responding to the global AIDS pandemic over the last decade would not have been possible without strong collaboration among civil society activists. We are at a critical moment where the science suggests that we can actually end the AIDS crisis.  Achieving this target will not be possible without increased funding, policies that are responsive to communities’ needs, and the leadership of mobilized, vigilant, informed activists working across North-South divides. Health GAP is excited to join with ICASO in helping to advance this effort,” said Asia Russell, Executive Director of Health GAP.

 Visit ICASO and Health GAP for updates and information about the project, funded by the Bill & Melinda Gates Foundation.


Join us as we take action to honor Dr. Martin Luther King’s legacy

On Thursday March 19, 2015 Rep. Keith Ellison of Minnesota introduced legislation to establish a small tax on certain Wall Street transactions that will reduce dangerous financial market speculation and raise hundreds of billions of dollars every year that can be channeled to address pressing social needs—from HIV/AIDS, climate change mitigation, and eradicating hunger around the world, to ensuring health care for all and strengthening the public school system here in America.

The Inclusive Prosperity Act H.R.-1464 reflects the principles and goals the U.S. Robin Hood Tax Campaign—a consortium of 172 organizations, with representation from labor unions, religious groups, health advocates, housing activists, environmentalists, small businesses and others, urging passage of a Wall Street sales tax.

Experts are saying that we have the science we need to end the global AIDS crisis, yet everyone agrees that this will not be possible without a considerable increase in resources. In his 2016 fiscal year budget, the President proposed over $400 million in cuts to spending on the global AIDS response. To put this into perspective, this is less than 0.15 percent of the total estimated yearly revenue that Rep. Ellison’s financial transactions tax would generate

April 4, 2015 marks 47 years since Dr. Martin Luther King, Jr. was murdered while conducting a national campaign against socio-economic inequality. On April 8, we will honor the legacy of Dr. King by calling on Congressional representatives to take action in the fight against economic inequality by supporting a Robin Hood Tax to advance social justice. Robin Hood Tax Campaign supporters around the country, including Health GAP and the Student Global AIDS Campaign, will hold vigils outside Congressional offices.

To find out about a vigil happening near you, click here or email Michael Tikili at michael@healthgap.org.


Gilead Anti-Diversion Program for Hep C Medicines Throws Patient Rights under the IP Bus

Professor Brook K. Baker, Health GAP senior policy analyst

March 24, 2015

MSF has leaked information concerning Gilead's licensing negotiation with 11 Indian generic companies that have received authorization to manufacture and sell Gilead's promising new oral hepatitis C medicines in 91 designated countries. The latest negotiations involve an "anti-diversion" demand from Gilead that generic licensees collect personal information on patients receiving the Hep C medicines including name, proof of residence, and proof of citizenship as a condition of dispensing the medicine.

Ordinarily, drug companies do not gain access to confidential patient information merely because they have patent rights and marketing rights for their medicines. Ordinarily, like in the U.S., individualized patient information is highly confidential and neither medical providers or pharmacists can supply this kind private information to third parties. So what gives - why is Gilead seeking this information and can it get away with it?

Gilead's licenses at present allow sales in particular countries/territories. This is consistent with the nature of patent rights themselves, which are territorial. Patent rights don't give companies to right to decide who gets to buy a medicine in a country. Foreigners and non-citizens in the country can buy, as can persons with no fixed address. By requiring proof of identity, address, and citizenship, Gilead appears to be setting the stage to deny or limit sales to to non-citizens and/or to medical tourists, who they hope to exploit for higher prices in their home countries. Of course, the Gilead provision also adversely affects many displaced persons, migrants, legal outsiders, and unhoused persons who might lack the required information.

In addition to requiring privileged and confidential information from medical providers up front, Gilead is also trying to require generics to ensure that licensed distributors dispense only one bottle of Hep C treatment at a time to personally identified patients, even though the normal course of treatment requires 3-6 bottles. So patients need to return the empty bottle physically or by courier in order to receive the next month's treatment. These "verification of use" procedures undermine both patient autonomy and patients' adherence to treatment. Of course, these requirements also help to weed out medical tourists who might find it unaffordable to stay 6-12 weeks in another country merely to get treatment, even highly discounted treatment.

In sum, through its draconian anti-diversion policies, Gilead is throwing patient rights under their IP bus. With what should be forbidden information, Gilead is hoping to prevent treatment access for richer patients from other countries and all other forms of product diversion to rich markets. Patients get caught under the wheels as their privacy and autonomy rights are sacrificed on the alter of Gilead's search for profits rich- and middle-income country markets.

There are solutions. Generic companies could simply refuse to collude in this unethical practice. Moreover, licensing terms are also reviewable at least in some countries with respect to the reasonableness and anti-competitive impact of licensing terms. These terms might also be challengeable in many countries pursuant to the medical information confidentiality laws. Finally, public pressure can and should be brought to bear against Gilead for this ghastly infringement of patient rights.


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