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A private-public partnership is gaining ground in the fight against the disease in the city’s slums.<\/p>\n<\/section>\n
\"Confronting <\/a><\/figure>\n

Down a side street in Kawempe division, one of five districts that make up\u00a0Uganda\u2019s capital city, Kampala, two women chat behind a ramshackle wooden structure displaying baskets of tomatoes and bananas. Flies surround the fruit but the women take no notice. Twenty steps further down the dirt road of the city slum, Sarah Najjuka unrolls a woven green and pink mat, kneels and watches as her six-year-old son emulates her movements.<\/p>\n

\u201cI used to wrap a cloth around his head before school because when it was cold he would cough so much,\u201d she says in a soft but steady voice, gesturing at her own headscarf in explanation.<\/p>\n

The 22-year-old single mother looks down at her son, Hethiri Bukenya. He\u2019s inherited her long, full eyelashes and smooth complexion.<\/p>\n

\u201cEventually he could no longer go to [nursery] school \u2013 he was too sick.\u201d<\/p>\n

When Hethiri was four he developed a violent cough and began to lose weight. Sarah spent a year and a half taking her son to different clinics and hospitals in Kampala, both public and private, without any improvement in her son\u2019s condition.<\/p>\n

\u201cBy this time I was so desperate I decided to go to the village where my mother stays to get some help,\u201d she says, smacking the back of one hand into the palm of the other in frustration.<\/p>\n

In her mother\u2019s village, near the city of Mbarara, almost 300km from Kampala, Hethiri was given herbal medicines by the local traditional healer. But he kept coughing.<\/p>\n

Sarah\u2019s voice cracks and she wipes a falling tear from her cheek with the sleeve of her dress.<\/p>\n

\u201cI decided to come back because everything had failed.\u201d<\/p>\n

Pillar to post<\/strong>
\nSarah went to so many different health facilities that she cannot even remember the number, yet Hethiri was discharged each time with a packet of new and ineffective medicine.<\/p>\n

Although he displayed the classic symptoms of tuberculosis (TB), such as coughing up blood and a dramatic loss of weight, he was not tested for the disease.<\/p>\n

Sarah\u2019s experience, although extreme, is not unusual in Uganda. A 2014 study published in the International Journal of Africa Nursing Sciences<\/em> noted that Ugandan patients often spend more than six months after their symptoms first appear repeatedly going to health facilities before their TB is diagnosed.<\/p>\n

According to Anna Nakanwagi, the Ugandan country director for the International Union Against Tuberculosis and Lung Disease, the reasons for delayed diagnosis in many patients are multifaceted.\u00a0\u201cThere are limited resources in the country for TB control and these are focused in the government facilities,\u201d she says.<\/p>\n

Sixty percent of the population in urban centers access primary health services from the private sector, which does \u201cnot have the know-ledge and skills to detect TB.<\/p>\n

\u201cPeople who come to the private facilities would be treated for other health conditions and the health workers would miss the TB,\u201d Nakanwagi says.\u00a0\u201cAdditionally, people are not aware of TB. It\u2019s not like HIV, which everyone knows about. Communication activities around TB don\u2019t nearly match those of HIV.\u201d<\/p>\n

Even though Uganda has met its millennium development goals for reducing TB-related deaths and new infections, it remains one of 22 countries identified by the World Health Organization that constitute 80% of the global burden of the disease.<\/p>\n

The organization estimates that, globally, one in three TB cases goes undetected every year. This is particularly true in Uganda where 60\u00a0000 cases are expected but only 44\u00a0000 are found, according to Frank Mugabe, the acting TB and leprosy manager for the country\u2019s health ministry.\u00a0\u201cThis leaves about 16\u00a0000 people undetected, who we expect to be spreading the disease in their communities,\u201d he says.<\/p>\n

Missed cases<\/strong>
\nLucica Ditiu, an international TB expert from the Geneva-based organization Stop TB Partnership, says the reason for the missed cases is largely historical. \u201cOur approach for many decades has been what we call \u2018passive case finding\u2019, where the doctor or nurse waits for the patient to come to them.\u201d<\/p>\n

This \u201cmedicalised\u201d approach has had the largest impact on \u201cvulnerable groups\u201d who may not have the means or knowledge to seek appropriate care.<\/p>\n

According to Ditiu, \u201cwe will never find this third of missing cases\u201d unless efforts are made to go into communities to find potential TB infections \u2013 what she calls \u201cactive case finding\u201d.<\/p>\n

One evening, after Sarah\u2019s return to Kampala from her mother\u2019s village, sitting in her tiny rented room with ailing Hethiri, she heard a loud voice outside.\u00a0 The voice belonged to village health team volunteer John Kisembo who, using a megaphone, was informing the slum community that there would be a health camp the following day at a nearby playground, with testing for HIV and TB.\u00a0\u201cShe asked me if the services would be free of charge because she didn\u2019t have the money,\u201d Kisembo recalls.<\/p>\n

To earn a living, Sarah helps to prepare potato chips at a slum shop where she makes about 5\u00a0000 Ugandan shillings a day (US $ 1.68) .\u00a0\u201cI said: \u2018Yes, it is free; please come.\u2019\u201d<\/p>\n

Kisembo says that, at that stage, Hethiri was \u201cvery tiny, very thin\u201d and \u201cyou could see he was living a miserable life. People were scared of him; children would run away; the mother was telling people she has taken this child everywhere, he is not improving and she doesn\u2019t know why.\u201d<\/p>\n

The following day Hethiri gave a sample of his sputum (mucus coughed up from the lungs) to the health workers at the camp and it was sent for TB testing.\u00a0 It came back positive.<\/p>\n

The health camps, which take place every month in each of the five districts in Kampala, are part of an initiative started in 2011 called Slum Partnerships to Actively Respond to TB in Kampala (Spark TB) implemented by the International Union Against Tuberculosis and Lung Disease.<\/p>\n

\u201cThis project is about trying to find the missing and hard-to-reach cases,\u201d says Paula Fujiwara, scientific director for the union. \u201cWe work in urban slums because this is where people don\u2019t have access to TB services.\u201d<\/p>\n

The union\u2019s Nakanwagi says government facilities, with expertise in TB diagnosis and that provide free anti-TB drugs, are few and are often located far from people living in urban slums, a particularly vulnerable group. She says this group is at a high risk of TB infection because slums are densely populated and many of the homes don\u2019t have good ventilation, making transmission of the airborne disease likely.<\/p>\n

Though there are few public facilities in the slums, there are more than 1\u00a0000 private clinics in Kampala, constituting about 80% of the city\u2019s total healthcare services, Nakanwagi says.<\/p>\n

\u201cTwenty-five percent of the urban population of Uganda is here in Kampala and the majority of them are poor,\u201d she says.<\/p>\n

High price<\/strong>
\nBut people are still willing to pay for health services because government facilities are few, far from slums, overcrowded and people \u201cperceive that the quality of care isn\u2019t good in the public sector\u201d, she says.<\/p>\n

The health ministry\u2019s Mugabe says that, although these facilities may provide good health services closer to patients\u2019 homes, they were detrimental to TB control.<\/p>\n

\u201cA few years ago I would estimate that not more than 5% of private facilities even knew the definition or diagnosis of TB \u2013 never mind the treatment regimen,\u201d he says.<\/p>\n

But from 2011, private healthcare facilities in Kampala slowly started to provide TB services through public-private partnerships with the health ministry.<\/p>\n

As part of Spark TB, health workers at a number of private clinics have been trained to diagnose and treat the disease and, to date, 1?700 TB patients in Kampala have been diagnosed and treated through this route \u2013 Hethiri being one of them.<\/p>\n

\"\"Medical staff explain the challenges of ongoing TB to journalists at the Pillars Medical Centrein Kawempe, Kampala.<\/i><\/p>\n

Pillars Medical Center, a private clinic in Kawempe division near Sarah\u2019s home, is one example. \u201cWe didn\u2019t have the expertise to identify TB so if we had a suspected case we would refer them to a government facility but after that we would lose them; we wouldn\u2019t know if they had been tested or treated. It was a problem,\u201d says Kasawuli Mahmoud, who runs Pillars.<\/p>\n

But currently, if Pillars receives a suspected TB case it can test, diagnose and receive free anti-TB drugs from the government\u2019s national medical store. Patients pay 5\u00a0000 Ugandan shillings (R21) to be tested but get their medication for free.\u00a0 Hethiri, now cured, was diagnosed and treated at Pillars early in 2014.<\/p>\n

As part of the agreement with government, private facilities must record and report TB cases to the health ministry.\u00a0 Only 14 clinics have been approved to receive medication from the national store but these in turn support five or six clinics close to them, forming a network of about 70 private facilities in Kampala, says Nakanwagi.<\/p>\n

These \u201csupported\u201d clinics report cases and receive medication through the accredited 14.\u00a0 Village health teams\u00a0across the country have been assigned to the slum clinics to help with adherence to the many months of treatment.<\/p>\n

\u201c[Village health team members] live in the localities where we\u2019re operating and are closer to the community,\u201d says Mahmoud. \u201cThey follow up with patients in their homes if they do not come to get their next month of medication.\u201d<\/p>\n

TB treatment in Uganda consists of an eight-month course of four drugs. However, the country is in the process of switching to the global standard of six months of treatment, which all new patients are given.<\/p>\n

\u201cThe problem with TB treatment is that after about two weeks on the drugs, coughing calms down and the general condition improves so many patients stop taking their medication thinking they are cured,\u201d Mahmoud says.<\/p>\n

The village health team members, volunteers who receive a minimal cost-covering stipend from organizations or the state, try to make sure this doesn\u2019t happen by checking up on individual patients in their localities.\u00a0 Because private clinics are usually closer to slum populations, they are \u201clikely to be visited more often\u201d, are more \u201cpatient-centered\u201d and are likely to be open after business hours, unlike public facilities, says Mugabe.<\/p>\n

\u201cWe are thinking that this can be a very good model for us to scale up in the other urban areas.\u201d\u00a0But he has reservations. \u201cOur challenge is providing incentives for private facilities, which we can\u2019t do much of, being a programme that is ill-resourced.\u201d<\/p>\n

Motivated<\/strong>
\nWithout incentives he does not believe the model is sustainable. \u201cBut those that have come on board so far seem motivated. Ultimately we want a win-win situation for government, private facilities and, of course, patients.\u201d<\/p>\n

Globally the number of new TB cases is decreasing by just over 1% a year but Ditiu says this is no reason to \u201crelax\u201d.<\/p>\n

\u201cIt\u2019s going down but it\u2019s a snail walk. If we want to see any real impact the number of new cases needs to decrease by seven to 10%.\u201d<\/p>\n

If TB cases continue to decrease at the current rate, in 180 years Uganda will have a global level of TB comparable with that in developed countries, she says.\u00a0 \u201cIf we continue with a passive approach to detecting the disease we won\u2019t hear the words \u2018TB-eliminated\u2019 in 180 years \u2013 it\u2019s terrifying.\u201d<\/p>\n

According to Jacob Creswell from the Stop TB Partnership, this public-private partnership for TB control is an example of \u201cthinking outside the box\u201d. Uganda is the only country on the continent, other than Nigeria, to use this type of model.<\/p>\n

He says that creative and country-specific strategies such as\u00a0this need to be developed across the globe to decrease the large number of undetected cases.<\/p>\n

Outside Sarah\u2019s home a light drizzle falls, bringing the smell of sewage into the air. She opens the red metal door and holds the white lace curtain behind it aside for Hethiri to enter the dark room.<\/p>\n

The rectangular, cement-floored space accommodates a bed on one side and a wash room with a bucket on the other. \u00a0Sarah reaches below an old television set and pulls out a framed photograph of Hethiri in a black gown.<\/p>\n

\u201cHe just graduated kindergarten,\u201d she says, with a shy smile. Sitting on the edge of the bed, she motions for Hethiri to join her. He grabs some paper from beneath the television and sits down next her. He is now eligible to start primary school and, almost as if to prove it, places the paper on her lap for support. With an old pencil he slowly writes a word. A few minutes earlier on the mat outside she had exclaimed: \u201cMy child was going to die!\u201d<\/p>\n

But in the darkened room Hethiri looks far from death: he scratches his nose and smiles to reveal a pair of growing teeth. Now that he has a chance, what would he like to be when he grows up?<\/p>\n

He thinks for a moment then says: \u201cThe president of Uganda.\u201d<\/p>\n

\"\"Recovered TB patient Hethiri Bukenay (6)\u00a0with his mother Sarah and health worker John Kisembo in Kawempe.\u00a0<\/i><\/p>\n

\n

South Africa lags behind the continent in tackling TB<\/h2>\n

South Africa has the world\u2019s third- highest tuberculosis (TB) burden (after India and China) according to the World Health Organization \u2013 but once the figures are adjusted for population size, South Africa\u2019s infection rate is the highest.<\/p>\n

About 70% of South Africans with TB disease are also infected with HIV \u2013 the highest co-infection rate in the world, according to the health department.<\/p>\n

The targets set by the department in its National Strategic Plan (NSP) for HIV, sexually transmitted infections and TB are to halve the number of new cases as well deaths from the infections and diseases by 2016 and to have no new infections or deaths by 2032.<\/p>\n

Academics and activists criticize government\u2019s response to the epidemic as too slow, especially when compared with TB control in poorer African countries. They doubt whether the department will achieve its targets.<\/p>\n

In an opinion piece in the Mail & Guardian<\/em> last year, Cape Town doctor Jennifer Hughes wrote: \u201cHow embarrassing for a government to have the means and resources to develop and deliver better treatment to combat a disease that kills but that can be cured, but not to have the political commitment to prioritize it.\u201d<\/p>\n

For example, the TB disease rate in South African prisons is exceptionally high, with 4.3% of all cases coming from correctional facilities in 2012, according to Health Minister Aaron Motsoaledi.<\/p>\n

In 2012, Dudley Lee won a case in the Constitutional Court against the minister of correctional services for contracting TB while awaiting trial at Pollsmoor in the Western Cape from 1999 to 2004. He sued the minister for R270\u00a0000 because he contracted and developed TB as a result of being held in overcrowded and poorly ventilated cells.<\/p>\n

After the case, the health department started a screening campaign in prisons, checking inmates for TB on entry, twice during incarceration and again on release.<\/p>\n

But according to a 2014 edition of the Treatment Action Campaign\u2019s NSP Review, inmates who tested positive for the disease sometimes did not get treatment. \u201cWithout providing effective access to … treatment, mass screening is not only an expensive exercise but also presents a serious ethical issue.\u201d<\/p>\n

The review noted that only eight doctors were employed by the correctional services department to look after almost 160 000 inmates. This directly affected the treatment of TB because \u201cnurses can prescribe TB treatment but the pharmacy will not dispense without a doctor\u2019s signature\u201d, the review noted.<\/p>\n

Moreover, cases of the multidrug resistant (MDR-TB) form of TB, which is much\u00a0more difficult and expensive to treat, are increasing. According to a 2014 report in the South African Medical Journal<\/em>, the country has the second-highest number of diagnosed MDR-TB cases in the world after India, with almost 15\u00a0000 cases a year.<\/p>\n

The report also noted that 25% of positive TB cases in the country were \u201clost to follow-up before treatment initiation\u201d, which \u201cmay contribute to ongoing transmission and an increased risk of death\u201d. Although the study noted that South Africa had made \u201cnotable progress in improving TB control\u201d, the \u201cburden of TB remained \u2018enormous\u2019 \u201c.<\/p>\n

The article\u2019s authors argued that, for the country to achieve the NSP targets, \u201cadditional strategies\u201d needed to be implemented by the health department, including better access to treatment for special populations such as prisoners as well as focusing on diagnosing and successfully treating MDR-TB.<\/p>\n

On Tuesday, World TB Day, Motsoaledi and Deputy President Cyril Ramaphosa launched a national TB screening campaign in Kanana, near Klerksdorp, in the North West. It aims to have 90% of the country\u2019s 160\u00a0000 inmates and 90% of an estimated 500\u00a0000 miners screened by March 2016.<\/p>\n

\u201cNext year we focus on screening in the metropolitan municipalities; the year after in the provinces with the highest burden of TB,\u201d said the department\u2019s deputy director general Yogan Pillay.\u00a0\u2013<\/p>\n

 <\/p>\n

M&G:

A private-public partnership is gaining ground in the fight against the disease in the city’s slums. Down a side street in Kawempe division, one of five districts that make up\u00a0Uganda\u2019s capital city, Kampala, two women chat behind a ramshackle wooden…<\/span><\/p>\n

Read more ›<\/a><\/div>\n

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