Uganda: Private Players in Reproductive Health

The assistant commissioner in charge of reproductive health in the Ministry of Health and an associate professor of public health at Uganda Christian University, Dr Mbonye will be researching on involving the Private Sector in the Prevention of Mother-to-Child Transmission of HIV in Uganda. He talked to Kakaire A. Kirunda on his upcoming three-year-study and PMTCT in general.

Tell us about your upcoming research.

In simple terms, most HIV testing and antiretroviral treatment is done in the public sector. But now we want to involve the private sector. Our theory is that since most reproductive health indicators are stagnating, can we use the private sector to improve our health status? And these include maternal mortality, post natal care, HIV prevalence, STD management and treatment, contraceptive prevalence, deliveries at health units and antenatal care. There is a government policy on public-private partnership but how do we operationalise this policy to improve the health status of our population?

Can private midwives, if trained in HIV counselling and testing, family planning and antiretroviral treatment (ART) improve the health of especially pregnant women? Can we use these midwives to reduce mother-to-child transmission of HIV (PMTCT) by training them to give the necessary drug to HIV-positive pregnant women?

The driving force of the private sector is to make money. How do you ensure they will not exploit the poor?

We know the private sector charges money. And in the last demographic and health survey, women were asked what constraints limit them to use health services. Their number one response was cost, number two was distance to health units, and number three was availability of drugs and supplies.

So if number one was cost, how do we address this?

In this study, we want to introduce the voucher system. We want to discuss with the private mid wives and agree that if a woman went to them for antenatal care for four visits and she returned to deliver, how much will you charge? Say they charge Shs5,000, we shall agree and give the women in the surrounding community vouchers to get antenatal and delivery services. We shall then relay the results to the government.

But we shall also do a cost effective analysis. We shall know what it costs to save a mother and her child. Using our example, if a mid wife helps 20 women to deliver in a month, she will earn Shs100,000 which is just $50. The most important thing is that this midwife will have protected the life of a mother and a child.

Why is the uptake of PMTCT still very low yet many people know that it is available and free?

The answer to that is the very reason why only 42 per cent of women deliver at health facilities, is the same reason that only 23 per cent of women use contraceptives, is the same reason that only 46 per cent of our children are immunised against the killer diseases.

The reason is the barriers I told you earlier. The real barrier is cost of accessing services. Services in government health units are free but there is the cost of moving from your home to the health unit. On average, a boda boda ride from a rural area (for 10 kilometres) to reach the health facility costs between Shs7,000 and Shs10,000 to and fro.

And you are talking of spending a whole day at the centre because there is waiting time. We are talking of going there and being told there are no drugs and one has to buy them, and also lunch. There is also what we call opportunity cost of time. If I am a pregnant woman, then leave home and spend a whole day away, who will look after my children?

How much farm work am I forfeiting? People wonder who will look after their animals and shambas, and then they promise themselves to go next time. So the priority is not their health. But they are not alone. Does the government prioritise health in expenditure, infrastructure, motivating health workers, paying them a good salary? Yet there is real poverty in Uganda that even if an individual prioritised health, they would not afford.

HIV testing is vital to PMTCT but research in some parts of this country has indicated that women who test positive never accept their results. Isn't this affecting PMTCT?

That goes to the quality of counselling. If a client voluntarily goes to a health facility, what kind of counselling has this person received especially on acceptability of results and the impact of the results? But also, there is a problem of stigma. It's still high.

Uganda: Private Players in Reproductive Health

AIDS/HIV