A damning report by the Ugandan Auditor General has found that government hospitals and health centres, the frontline in the country's fight against HIV/AIDS, are systematically failing to provide adequate services to patients.
The report, 'Value for Money: An Audit Report on the Management of Programmes of the Health Sector', found that drugs and equipment were being wasted or pilfered by staff, who often also showed a marked lack of commitment to their patients.
"The local person is not getting value for money," Francis Musuba, acting auditor general, told PlusNews. "The funding is inadequate, the drugs are inadequate, the infrastructure is poor, the staffing is poor and the monitoring is poor."
The audit report comes weeks after three former health ministers - Jim Muhwezi, Mike Mukula and Alex Kamugisha - were arrested and charged with misappropriating hundreds of thousands of dollars earmarked for vaccinations. The three ministers lost their jobs in 2006 following separate allegations of misappropriation of grants from the Global Fund to Fight AIDS, Tuberculosis and Malaria.
The Ugandan government spent US$11 on healthcare for every Ugandan in 2005, compared to a United Nations World Health Organization recommendation of between $30 and $40.
"The funding is low, that is an accepted fact, but the way we are using what little funding we have leaves a lot to be desired," Musuba said. "It needs to be well spent and it isn't."
"The AIDS programme is not isolated, it is supposed to be run through the health delivery system," he added. "As the health delivery system is this bad, it gives one an indication of how difficult it is to run AIDS programmes."
A health system in shambles
The auditing team found that drugs, including life-prolonging antiretrovirals, were left to expire in several health centres. In 2006, the National Medical Stores in the capital, Kampala, admitted that 42,555 packs of ARVs, worth $468,000, had passed there use-by date.
The report further found that health centres did not have proper storage facilities and did not comply with national handling procedures, while stock was poorly managed, leading to drugs leaking onto the private market.
The auditors noted that one sub-district of Soroti, in the east of the country, had failed to spend $20,000 - half its annual drug budget – and $13,500 had vanished into a black hole.
Despite so many concerns about corruption, many districts were still failing to review accounts and there was no nationally endorsed book-keeping method.
Every health centre surveyed lacked equipment, and what equipment they did have, including CD-4 machines crucial for ARV provision, were often poorly maintained, "leading to constant breakdown". Over one third of health centres did not have proper inventories of their equipment, an invitation to theft. Staff were also not arriving for work on time, or not arriving at all.
For Beatrice Were, a prominent activist and AIDS coordinator for the anti-poverty group, ActionAid International, the report confirmed what those working in the sector already knew – that AIDS funding was not getting to those that needed it.
"In Bugiri [eastern Uganda], my home district, the ARVs are there, the medicine is there, but there are no health workers qualified to distribute them," she said. "But this isn't about individuals; it's about the system ... what little money that has been coming in has been landing in the pockets of the big shots."
Lessons must be learnt
Were warned that complacency risked reigniting the pandemic. Uganda's HIV prevalence has already crept back up from a low of six percent in 2000 to 6.4 percent in 2006; "We could well have a resurgence of this epidemic, and this time there will be resistance to drugs."
Musuba said it was his hope that the report would allow the health department to learn from its mistakes. "Monitoring and evaluation have to become the focus," he stressed.
The audit was carried out over a five-year period between 2000 and 2005, during a time Uganda's AIDS programmes suffered several setbacks. In 2006, Uganda lost out on a large chunk of expected grants from the Global Fund owing to concerns the government had not acted expeditiously in its handling of senior officials accused of corruption.
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