What Dilemmas of Reproductive Health Suggest for Scaling-Up ARVs in Uganda

1. What Dilemmas of Reproductive Health Suggest for Scaling-Up ARVs in Uganda Lisa Ann Richey, Ph.D. Roskilde Univ. Denmark Richey@ruc.dk

2. Reproductive Health Dilemmas • Uganda has been presented as the first African “success” story in the fight against HIV/AIDS, and boasts one of the most effective women’s movements in Africa. • Yet, Uganda has experienced no decline in fertility rates, infant mortality rates have risen, and access to reproductive health services is limited.

3. Reproductive Health Lessons Learned • Effective policy responses to the new realities of AIDS treatment will require a well-funded, capable state with goals of health equity. • These are the same requirements for implementing the other aspects of the reproductive health agenda. • Download this paper on reproductive health and HIV/AIDS policies in Uganda at http://www.cdr.dk/working_papers/wp-03-8.pdf

4. Official commitment to access • The World Bank, donors, governments and civil society groups are all struggling to wed access to anti-retroviral drugs to the improved health-care capacity necessary to deliver these treatments. • However, access requires more than just drugs. • It must encompass rational selection, guidelines for use, training, monitoring, and diagnostics together with strong health systems and sustainable funding.

5. In African countries, access to ARVs is bound together with important questions about the relationship between: • civil society • for-profit pharmaceutical companies • international donors and lenders • African governments

6. Politics of Access • Who gets to define AIDS? Treatment? • Participants demanding access from the same governments, researchers and industry whom they have been struggling against in the past • Kenyan and Malawian politicians told them in the 90s to ”pack up your AIDS and go home.”

7. Importance of the State • From doctrinaire neo-liberalism to a vigorous developmentalist response by the African state • Even in the U.S. where private insurance is most extensive, HIV/AIDS care is largely financed through the public sector

8. Market Share? • Developing countries comprise 80% of the world’s population but only 21% of global medicine sales • ”Africa will soon be the largest ARV drug user in the world”—Dr. Peter Mugyenyi (JCRC)

9. Together with the Private Sector • At the same time as promoting expanded state capacity, the roles of business and civil society have become increasingly central in grappling with public health problems in developing countries.

10. Why Private Sector is becoming more important in public health • 1. growth and influence of non-governmental organizations in international health has expanded • 2. private foundations have become increasingly active in creating and funding public-private partnerships • 3. new technologies are brought quickly to global markets, and their rapid spread across rich countries and to the rich citizens of poor countries brings issues of unequal access to the forefront. • 4. traditional public health groups are confronted by limited financial resources, rapid disease transmission across national borders, complex social and behavioural problems, and reduced state capacities

11. Points of Debate on Public-Private Partnerships • Can they create“new problem-solving institutions that can work creatively and flexibly outside the existing bureaucratic framework” as described by Reich 2002? • Or does the involvement of business interests serves to fragment international cooperation in health and to undermine struggles for public accountability? • Uganda as example of success

12. Uganda was among the first recipients of the World Bank’s MAP I funding in January 2001 • The $500 million Multi-Country HIV/AIDS Program (MAP) for Africa is one of the largest potential funding sources for access to HIV/AIDS treatment. • This fund provides loans for HIV/AIDS prevention and treatment with an emphasis on vulnerable groups, communities and civil society organizations in Africa. • Yet, in Uganda, initial refusal to buy ARVs and cash-flow problem

13. Are ARVs a burden on public health or an opportunity? • The concentration on relatively narrow issues, such as access to HIV/AIDS drugs, may have a negative impact on global inequalities by directing the focus of international development away from more difficult problems of systemic poverty analysis.

14. Constraints for Scaling Up ARVs (adapted from Collins and Rau 2000) • 1. lack of political will: political commitment is more than rhetoric from officials, and must include functioning policies and programmes which provide space in which donors, activists and specialists can work

15. Constraints for Scaling Up ARVs (adapted from Collins and Rau 2000) • 2. donor-driven models and bureaucratic standards: speed of implementation, emphasis on participation of target groups (including the poor), flexibility in adjusting to local realities are all critical for implementation success

16. Constraints for Scaling Up ARVs (adapted from Collins and Rau 2000) • 3. expert-driven programmes: experts, primarily in public health, have been allocated responsibility to determine the scope and character of interventions, and the terms by which they will be judged, and while lip-service has been given to community involvement, practitioners are sceptical about involving communities in program design and implementation work

17. Constraints for Scaling Up ARVs (adapted from Collins and Rau 2000) • 4. crumbling state capacity: the institutional framework required to implement an effective response to HIV/AIDS has been fractured under pressure from donors and as a result of structural adjustment ramifications.

18. We are at a critical juncture when the “problem” of HIV/AIDS is being reformulated in a rapidly changing context of multi-national pharmaceutical companies, plummeting life expectancy and promises from donor countries.

19. At this time when problems are being delineated, there may be an opening for social science contributions to become particularly policy relevant.

20. Even when international and national barriers are overcome and anti-retrovirals make their way into African clinics, who gets them, under what circumstances and with what kind of regularity?

21. How does access to anti-retrovirals reconfigure power relations of local health care? • Is the focus on expensive pharmaceuticals shifting attention and resources away from the necessary investments in rebuilding public health care systems? • Do anti-retrovirals bring with them additional funding for health care improvements in training and infrastructure that are beneficial for larger local health care provision?

22. Governance, Politics and Access • Preferential access to anti-retrovirals, where some senior members of the government and army are provided with free or subsidized AIDS treatment, provides strong incentives for staying in office, leading to deleterious governance implications (De Waal 2003, 15). • Local media reports confirm the political significance of treatment access noting that “Ugandan government gives ARV’s to LRA commanders to persuade them to denounce rebellion” (New Vision 20/11/02).

23. As treatment options expand, coordination between treatments and their providers, integration of various types of care for AIDS-related illnesses, and referrals (both vertically and horizontally) will not be possible without a stronger, more focused and effective government role.

24. While the Ugandan government has been successful in taking credit for its laissez-faire approach toward reducing its HIV prevalence rates, it faces different challenges as the nature of the epidemic is altered according to the realities of treatment.

25. AIDS as a Critical Reproductive Health Issue • Given that the predominant mode of HIV transmission is through heterosexual intercourse and the almost universal nature of childbearing in Uganda, a meaningful reproductive health agenda must incorporate issues of HIV/AIDS in a gender sensitive way.

26. Access to Reproductive Health Care Includes Treatment for HIV/AIDS • HIV/AIDS prevention and treatment, • reproductive health services, • and family planning provision based on choice, not imposition, • together form the minimal interventions necessary for promoting a reproductive health and rights agenda in Uganda.