Page last updated at 23:10 GMT, Sunday, 4 October 2009 00:10 UK

Uganda's misplaced health millions

Two women outside a health centre in Ssekiwumna
This health centre lacks even the most basic equipment

By Jeppe Villadsen
BBC Focus on Africa magazine, Nairobi

On a sun-drenched Sunday after a weekend in the country with his wife and two colleagues, Diego Angemi drives from the Sipi Falls in eastern Uganda towards the capital, Kampala.

He has travelled this stretch of road many times before but this time there is a dramatic turn of events. A hit-and-run accident has left a boy lying unconscious at the side of the road.

They rush the boy to a regional hospital in Mbale, a village about 200km north-east of Kampala, in the hope that they can save his life.

Their hopes are soon dashed. In the hospital's emergency room, apathetic staff must be persuaded even to investigate the boy.

"Unbelievably, the doctor seemed almost annoyed by the fact that we had brought the boy in," Mr Angemi recalls.

The reason for the staff's apparent numbness, however, soon becomes clear.

The plush surroundings of an Aids research centre
In contrast to the health centre, this research centre is worth millions

There is no equipment in the department, not even for basic resuscitation procedures. The emergency room has neither oxygen nor equipment for monitoring blood pressure. There is not even a simple penlight to investigate eye movement.

"While we sat waiting and hoping that the doctor would take responsibility we realised that the boy's hands were turning cold and that his pupils were dilating. He died right there in front of us," Mr Angemi says.

Huge imbalance

Although the emergency room of this local hospital is dysfunctional, right next door is a newly-erected building belonging to Taso, a Ugandan Aids support organisation, which houses medicine and hospital equipment worth millions of dollars.

Nearby is an arm of the Joint Clinical Research Centre (JCRC), the self-governing state institution which researches HIV and Aids. JCRC is the largest provider of anti-retroviral (ARV) medicine in sub-Saharan Africa.

Why then should foreign donors continue to multiply Aids spending but use small change on projects which, for example, provide safe drinking water?
Daniel Halperin, Harvard University

Both these organisations are recipients of multi-million dollar support from the US. One of the main American funders is Pepfar - the President's Emergency Plan for Aids Relief.

In 2008 alone, funding from Pepfar reached $283.6 million - an amount which easily exceeds the entire annual budget for Uganda's ministry of health.

"It makes you wonder whether this assignment of funds is justified when the most frequent cause of death in Uganda is, in fact, malaria," says Mr Angemi.

The Ugandan health ministry acknowledges the imbalance.

"Since ARV medicine is very expensive and HIV testing equally so, expenditure on HIV completely overshadows what is otherwise available in the health system," says the state's head pharmacist, Martin Oteba.

After many trips throughout Africa, Harvard's Daniel Halperin, who has been researching the disease for 15 years, has made the same observations.

"Many people in the West believe that all Africans are impoverished and infected with HIV. Yet the reality is that many countries have stable HIV statistics of under 3%," he says.

But in spite of this, the vast majority of support, particularly from the US, is given specifically to the war on Aids.

"This is because it is a disease that we ourselves have dreaded and have therefore placed it at the top of the global agenda."

Multitude of diseases

Sometimes African health ministries become over-burdened with the huge deliveries of ARV medicine which they do not have the time, finances or manpower to distribute.

Aids: 94,000
Malaria: 41,000
Diarrhoea: 30,000
Tuberculosis: 15,000
Measles: 7,000
Tetanus: 7,000
Source: World Health Organisation, figures from 2002

"The healthcare systems cannot keep up," says Esben Sonderstrup, chief health consultant for Danida, the Danish international development agency.

"Then, there is the serious risk of medicine expiring and becoming unusable."

For Mr Halperin, it is completely mindless to target aid with such a narrow focus on a single disease.

"Why then should foreign donors continue to multiply Aids spending but use small change on projects which, for example, provide safe drinking water?" he asks.

Last year, according to Mr Halperin, the US spent $3bn on Aids programmes in Africa but invested a mere $30m on safe drinking water.

Mr Halperin cites other examples.

One fifth of the world's diarrhoea-related deaths occur in just three countries: the Democratic Republic of Congo, Ethiopia and Nigeria, all of which have relatively low HIV statistics.

Yet diarrhoea, which is relatively straightforward to combat, is largely ignored by donors in favour of Aids programmes.

No-one turned away

At the main Taso centre in Masaka, southern Uganda, there is a new building with a bright, newly furnished office stocking an excess of campaign materials.

We are always able to offer the right medicine to our patients. It has never been necessary to turn anyone away
Martha Nakayma, Taso

Martha Nakayma, a 26-year-old public-relations assistant, relays the demands of a district which has an estimated 80,000 HIV-positive inhabitants.

Already more than 25,000 people have received help from the centre.

Aside from doctors, nurses and social workers, personnel at the Taso centre include nine information technology assistants and two marketing people.

Pepfar is Taso's main donor, providing approximately 60% of the funding.

"We are always able to offer the right medicine to our patients. It has never been necessary to turn anyone away," says Ms Nakayma.

She explains that one day each week is reserved for home calls to those who live far away.

A skills development programme for patients means the hum of sewing machines is often heard. In addition, there is a theatre group for productions on HIV-related topics.

"We also offer massage and special aromatherapy which can help to alleviate pain," she says.

Elsewhere, there are local general medical clinics like the Ssekiwumna Health Centre situated on a dirt track off a main road outside Kampala.

On an average day, up to 30 patients visit the clinic, typically with conditions like malaria, skin infections or diarrhoea.

Its annual budget is just $3,500.

No apologies

One of the biggest problems in institutions like this is the unreliable delivery of medicine and the lack of transport facilities, says Charles Mugyenyi, a health worker at the centre.

His dream is to purchase a motorcycle for the small clinic.

African leaders at a UN summit
African leaders recently announced a joint bid to tackle malaria

All this stands in stark contrast to the large sums pumped into Aids' centres by international donors.

"Of course a lot of money goes to HIV/Aids because it is a terrible illness, but more should go to programmes like vaccination campaigns, tuberculosis and family planning," says Mr Mugyenyi.

So what do the representatives of Pepfar make of the criticism?

Premila Bartlett, Pepfar's coordinator in Uganda, says they have nothing to apologise for.

She argues that, unlike many other international organisations which had "lofty goals" to get people on treatment, Pepfar has actually committed resources to the disease and in doing so has made things happen.

Pepfar, she says, is certainly not trying to undermine the existing system but rather to repair something which "in many cases is in pieces".

One of the problems is government commitment.

"If that isn't there, the system isn't going to get fixed and the people won't get the services they need."

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