It's politics, stupid! A political analysis of the HIV/AIDS Trust Fund in Uganda

The role of trust funds in the practice of and the policy discourse on the sustainable financing for health and HIV is growing. However, there is a paucity of political analyses on implementing trust fund arrangements. Drawing on a novel meta-framework – connecting multiple streams and advocacy coalition frameworks to policy cycle models of analysis – to politically analyse HIV financing policy design, adoption and implementation as well as insights from public finance literature, this article critically analyses the politics of the AIDS Trust Fund (ATF) in Uganda. We find that politics was the most fundamental driver for the establishment of the ATF. Whereas HIV financing is inherently both technical and political, enacting the ATF was largely a geopolitical positioning policy instrument that entailed navigating political economy challenges in managing multiple stakeholder groups’ politics. With the mandated tax revenues earmarked to capitalise the ATF covering only 0.5% of the annual resource needs, we find a very insignificant potential to contribute to financial sustainability of the national HIV response per se. As good ideas and evidence alone often do not necessarily produce desired results, we conclude that systematic and continuous political analysis can bring meaningful insights to our understanding of political economy dimensions of the ATF as an innovative financing policy instrument, thereby helping drive technically sound health financing policy proposals into practice more effectively. For Uganda, while proponents have invested a considerable amount of hope in the ATF as a source of sustainable domestic funding for the HIV response, substantial work remains to be done to address a number of questions that continue to beguile the current ATF architecture. Regarding global health financing policy, the findings suggest the need to pay attention to the position, power and interests of stakeholders as a powerful lever in health financing policy reforms

Traditional processing, microbial and physicochemical changes during fermentation of malwa

A survey was conducted to characterise production methods of malwa; a Ugandan traditional fermented millet beverage, in four divisions of Kampala district using a questionnaire. Lactobacillus and Lactococcus spp and coliforms were enumerated in the raw materials and during fermentation using standard microbiological methods. Changes in chemical parameters were determined using standard methods. Similarities in production methods were observed among the malwa producers. All producers germinated millet grains (2-3 days) to make green malt. The germinated grains were sun-dried for 2-3 days. Moistened millet flour was subjected to solid state pit fermentation for one week to produce acidified fermented dough. The acidified fermented dough was roasted over an open fire to produce roasted acidified dough. The duration of fermentation of malwa varied between 2 and 4 days. Only 5% of the producers practiced back slopping. Producers (90%) reported that consumers preferred sour malwa. Lactobacillus and Lactococcus spp numbers in the sour dough, roasted sour dough and green malt varied between 3.48 and 5.38, 2.02 and 2.60, and 4.45 and 6.25 log cfug–1 respectively. Coliforms in sour dough, roasted sour dough and green malt varied between 1.36 and 5.53 log cfug–1. Lactobacillus spp increased from 2.73 to 6.60 log cfu mL–1 whereas Lactococcus spp increased from 2.67 to 6.22 log cfu mL–1 during 72 h of fermentation. The greatest increase in numbers was observed during the first 24 h. Coliforms decreased from 2.80 to 1.19 log cfu mL–1after 24 h with a slight increase to 1.26 log cfu mL–1 after 48 h due to further addition of green malt. Coliforms were still detectable after 72 h. The pH decreased from 4.3 to 3.65 as titratable acidity increased from 0.69 to 1.47% lactic acid after 72 h of fermentation. Total soluble solids decreased from 17.7 to 7.7 oBrix during 72 h fermentation. Ethanol increased from 1.07 to 12% v\v. Carbohydrates and tannins decreased during germination and fermentation. Apparent increase in protein contentwas observed. The high numbers of Lactobacillus and Lactococcus spp and coliforms in the sour dough suggest their involvement in the solid state pit fermentation of millet flour. Higher numbers of Lactobacillus and Lactococcus spp in the green malt indicates that these organisms play a big role in the fermentation process of malwa.Key words: Lactococcus, Lactobacillus, Millet, Fermentation, Malw

Improving Incident Detection KPI on SANRAL’s Freeways in Gauteng

The South African National Roads Agency Ltd (SANRAL) primarily relies on CCTV cameras to detect traffic incidents occurring on the Freeway Management System (FMS) network. On the Gauteng FMS network, over 90% of the incidents are detected using CCTV cameras. The operators have to manually pan, tilt and zoom each camera to detect incidents along the freeway. Traffic incidents are the major cause of severe or fatal injuries, congestion and delays on the freeway. They may also result in secondary incidents such as rear-end or multi-vehicle collision. It is therefore of utmost importance that the incidents are detected and cleared within the shortest time span. In the current contract, SANRAL has set the ‘Incident Detection KPI’ as 3 minutes. In other words, on average, incidents have to be detected within 3 minutes from the time of occurrence of the incident. Once the incident has been detected, the operator would rewind the video footage to determine the ‘occurrence time’ of the incident. However, in most cases (approximately 70%), the occurrence time of the incident is unknown. This is predominantly because the camera was facing away from the incident location (facing the opposite direction). This study aimed at improving CCTV surveillance, given the current infrastructure and resources; thereby increasing the number of incidents with an occurrence time. The study assumed that there would be no changes to the current camera positions, type of camera being used and operational structure. It was also assumed that there would be no additional cameras or human resources. Several surveillance methods were evaluated. The proposed surveillance method was tested using a before and after study. Incident data from May 2017 was used as the “before” and incident data from May 2018 (three months after implementation of the proposed new method) was used as the “after” period. The results of the analysis showed that subsequent to the implementation of the automated pre-set surveillance method, the number of incidents with an occurrence time increased by approximately 15% – an increase of approximately 500 incidents. The paper eludes to some of the shortcomings that still exist in the new method and possible ways of overcoming it.Papers presented at the 38th International Southern African Transport Conference on "Disruptive transport technologies - is South and Southern Africa ready?" held at CSIR International Convention Centre, Pretoria, South Africa on 8th to 11th July 2019

Village Baseline Study: Site Analysis Report for Albertine Rift – Hoima, Uganda

The village baseline study of Kibaire village in the CCAFS benchmark site Hoima in Uganda took place from 13 to 16 July 2011. Forests are exploited at unsustainable levels in Kibaire but deforestation does not appear to be a serious threat because the tree population is still relatively high. Most of the forests have been leased to private individuals as part of the privatisation policy being implemented in Uganda. Wetlands are also increasingly subjected to overexploitation and pollution from brewing and other activities. Farming at both subsistence and commercial level is increasing at the expense of forests. Community access to forest resources is restricted. Participants identified 29 organisations working in the community, two-third of them operating from outside the locality. Participants said that they did have plenty of food in the village, and women expressed that they had never had a food crisis. Nonetheless, half of the organisations men and women identified were involved in some form of food security related activity, and notably food availability. Less than one-third of the organisations addressed natural resources management, and most of them were from outside the community. Organisations are the most significant source of information on agriculture. Farmers also get information through the many radio stations in the area that air many programs in local languages

Consensus and contention in the priority setting process: examining the health sector in Uganda.

Health priority setting is a critical and contentious issue in low-income countries because of the high burden of disease relative to the limited resource envelope. Many sophisticated quantitative tools and policy frameworks have been developed to promote transparent priority setting processes and allocative efficiency. However, low-income countries frequently lack effective governance systems or implementation capacity, so high-level priorities are not determined through evidence-based decision-making processes. This study uses qualitative research methods to explore how key actors' priorities differ in low-income countries, using Uganda as a case study. Human resources for health, disease prevention and family planning emerge as the common priorities among actors in the health sector (although the last of these is particularly emphasized by international agencies) because of their contribution to the long-term sustainability of health-care provision. Financing health-care services is the most disputed issue. Participants from the Ugandan Ministry of Health preferentially sought to increase net health expenditure and government ownership of the health sector, while non-state actors prioritized improving the efficiency of resource use. Ultimately it is apparent that the power to influence national health outcomes lies with only a handful of decision-makers within key institutions in the health sector, such as the Ministries of Health, the largest bilateral donors and the multilateral development agencies. These power relations reinforce the need for ongoing research into the paradigms and strategic interests of these actors

Women living with HIV, diabetes and/or hypertension multi-morbidity in Uganda: a qualitative exploration of experiences accessing an integrated care service

Purpose: Women experience a triple burden of ill-health spanning non-communicable diseases (NCDs), reproductive and maternal health conditions and human immunodeficiency virus (HIV) in sub-Saharan Africa. Whilst there is research on integrated service experiences of women living with HIV (WLHIV) and cancer, little is known regarding those of WLHIV, diabetes and/or hypertension when accessing integrated care. Our research responds to this gap. Design/methodology/approach: The INTE-AFRICA project conducted a pragmatic parallel arm cluster randomised trial to scale up and evaluate “one-stop” integrated care clinics for HIV-infection, diabetes and hypertension at selected primary care centres in Uganda. A qualitative process evaluation explored and documented patient experiences of integrated care for HIV, diabetes and/or hypertension. In-depth interviews were conducted using a phenomenological approach with six WLHIV with diabetes and/or hypertension accessing a “one stop” clinic. Thematic analysis of narratives revealed five themes: lay health knowledge and alternative medicine, community stigma, experiences of integrated care, navigating personal challenges and health service constraints. Findings: WLHIV described patient pathways navigating HIV and diabetes/hypertension, with caregiving responsibilities, poverty, travel time and cost and personal ill health impacting on their ability to adhere to multi-morbid integrated treatment. Health service barriers to optimal integrated care included unreliable drug supply for diabetes/hypertension and HIV linked stigma. Comprehensive integrated care is recommended to further consider gender sensitive aspects of care. Originality/value: This study whilst small scale, provides a unique insight into the lived experience of WLHIV navigating care for HIV and diabetes and/or hypertension, and how a “one stop” integrated care clinic can support them (and their children) in their treatment journeys

The experience of “medicine companions” to support adherence to antiretroviral therapy: quantitative and qualitative data from a trial population in Uganda

Good adherence is critical for antiretroviral therapy (ART) in sub-Saharan Africa. We report on the characteristics of medicine companions (MCs) chosen by Ugandan patients enrolling on ART, and on how MCs were chosen, and what roles they played. Baseline data on MCs of 1453 participants in a randomized controlled trial comparing facility and home-based delivery of ART in Jinja, Uganda were analyzed. Textual data on experience with MCs were collected through in-depth interviews among a subsample of 40 trial participants equally divided by sex and trial arm. Significantly more women (71%) than men (29%) were recruited. The majority (75%) of women participants were either widowed (51%) or separated or divorced (24%), whereas most of the men (66%) were married. Women were most likely to choose a child as their MC while men were most likely to choose their spouse; 41% of women chose an MC under 21 compared with only 14% of men. Only 31% of married women chose their husband, compared with 66% of married men who chose their wife. Qualitative interviews suggested MCs proved useful for reminding and other supportive tasks in the first three months but were generally less essential by six months and beyond. Convenience, reliability, and trust were key considerations in choosing an MC. Children provided the only alternative for many unmarried women, but even some married women felt children made more reliable MCs than husbands. Participants who had disclosed their serostatus usually received drug-taking reminders from multiple household members. One participant in the qualitative sample with poor family relations delayed starting treatment due to unwillingness to identify an MC. MCs were generally welcome and useful in supporting early adherence. However, disclosure to an MC should not be a condition of obtaining treatment

Lack of effectiveness of adherence counselling in reversing virological failure among patients on long-term antiretroviral therapy in rural Uganda.

OBJECTIVES: The current World Health Organization and Uganda Ministry of Health HIV treatment guidelines recommend that asymptomatic patients who have a viral load (VL) ≥ 1000 HIV-1 RNA copies/mL should receive adherence counselling and repeat VL testing before switching to second-line therapy. We evaluated the effectiveness of this strategy in a large HIV treatment programme of The AIDS Support Organisation Jinja in Jinja, Uganda. METHODS: We measured the HIV VL at enrolment, and for participants with VL ≥ 1000 copies/mL we informed them of their result, offered enhanced adherence counselling and repeated the VL measurement after 3 months. All blood samples with VL ≥ 1000 copies/mL were sequenced in the polymerase (pol) region, a 1257-bp fragment spanning the protease and reverse transcriptase genes. RESULTS: One thousand and ninety-one participants were enrolled in the study; 74.7% were female and the median age was 44 years [interquartile range (IQR) 39-50 years]. The median time on antiretroviral therapy (ART) at enrolment was 6.75 years (IQR 5.3-7.6 years) and the median CD4 cell count was 494 cells/μL (IQR 351-691 cells/μL). A total of 113 participants (10.4%) had VLs ≥ 1000 copies/mL and were informed of the VL result and its implications and given adherence counselling. Of these 113 participants, 102 completed 3 months of follow-up and 93 (91%) still had VLs ≥ 1000 copies/mL. We successfully genotyped HIV for 105 patients (93%) and found that 103 (98%) had at least one mutation: eight (7.6%) had only one mutation, 94 (89.5%) had two mutations and one sample (1%) had three mutations. CONCLUSIONS: In this study, enhanced adherence counselling was not effective in reversing virologically defined treatment failure for patients on long-term ART who had not previously had a VL test

Women's Experiences and Views about Costs of Seeking Malaria Chemoprevention and other Antenatal Services: A Qualitative Study from two Districts in Rural Tanzania.

The Tanzanian government recommends women who attend antenatal care (ANC) clinics to accept receiving intermittent preventive treatment against malaria during pregnancy (IPTp) and vouchers for insecticide-treated nets (ITNs) at subsidized prices. Little emphasis has been paid to investigate the ability of pregnant women to access and effectively utilize these services. To describe the experience and perceptions of pregnant women about costs and cost barriers for accessing ANC services with emphasis on IPTp in rural Tanzania. Qualitative data were collected in the districts of Mufindi in Iringa Region and Mkuranga in Coast Region through 1) focus group discussions (FGDs) with pregnant women and mothers to infants and 2) exit-interviews with pregnant women identified at ANC clinics. Data were analyzed manually using qualitative content analysis methodology. FGD participants and interview respondents identified the following key limiting factors for women's use of ANC services: 1) costs in terms of money and time associated with accessing ANC clinics, 2) the presence of more or less official user-fees for some services within the ANC package, and 3) service providers' application of fines, penalties and blame when failing to adhere to service schedules. Interestingly, the time associated with travelling long distances to ANC clinics and ITN retailers and with waiting for services at clinic-level was a major factor of discouragement in the health seeking behaviour of pregnant women because it seriously affected their domestic responsibilities. A variety of resource-related factors were shown to affect the health seeking behaviour of pregnant women in rural Tanzania. Thus, accessibility to ANC services was hampered by direct and indirect costs, travel distances and waiting time. Strengthening of user-fee exemption practices and bringing services closer to the users, for example by promoting community-directed control of selected public health services, including IPTp, are urgently needed measures for increasing equity in health services in Tanzania