In the name of God the Most Gracious Most Merciful Faith-based organizations and Government Partnerships: experience from Uganda on the successes and challenges in implementing the Global Plan to eliminate New HIV infections among children. Presentation From Uganda Presenter: Prof. Magid Kagimu, MBChB, M.Med, MSc, PhD. Chairman, Islamic Medical Association of Uganda (IMAU), and Director, Postgraduate Programme, Department of Medicine, Makerere University College of Health Sciences. Best Teacher Award 2010/2011 1

Introduction Uganda is implementing option B+ and HIV Treatment for eMTCT through the Public Private Partnerships for Health (PPPH) approach Public Health Sector (Central & District Local Governments) Private Not For Profit health providers (PNFP-FBOs) Private Health Practitioners (PHP) “Traditional and Complimentary Medicine Practitioners (TCMP)” The health sector Faith Based Organization fall under four umbrella organisations Uganda Catholic Medical Bureau (UCMB), Uganda Protestant Medical Bureau (UPMB), Uganda Muslim Medical Bureau (UMMB), and Uganda Orthodox Medical Bureau (UOMB). Together these bureaus represent over 75% of the 863 PNFP health units while the remainder fall under other humanitarian organisations and community-based health care organisations.

Introduction The FBOs provide health services to the population from established static health units/facilities and work with communities and other counterparts to provide non-facility-based health services and technical assistance. The FBO-PNFP sector presently has over 863 health units (64 Hospitals, 15 HC IVs, 264 HC IIIs and 520 HC IIs). These facilities are largely found in the rural areas (86%). 3

Introduction MoH operates 2,844 (63 Hospitals, 170 HC IVs, 916 HC IIISs and 1695 HC IIs). Of the 48 health training schools in the country, 20 are operated by FBO-PNFP organisations. GOU through MoH seconds Staffs to FBOs 4

Introduction HIV/AIDS Funding to the private sector is largely through the AIDS Development Partners GOU through the National Ware house (Joint Medical Stores, and Medical Access Uganda Limited), provides ARVs, HIV test kits and lab Reagents free of charges to the private sector In addition GOU supports non-facility based services through national programmes such as Community and Environmental Health and Communicable Diseases Control. 5

Experiences with service delivery Models used by the FBOs incorporate Faith as an important component of HIV/AIDS prevention, treatment and care. An example from IMAU is the “Faith-based approach to accelerating delivery of comprehensive HIV/AIDS Prevention, Treatment and Care services (FABAPTCA)”. This contributes to all four prongs of PMTCT: 1.Prevention of HIV infections among potential and actual mothers and fathers 2. Prevention of unwanted pregnancies among HIV positive women 3.Prevention of HIV transmission from HIV positive mother to the child 4. Prevention of AIDS- related illness and death among HIV positive mothers and their children 6

The Problem HIV new infections continue to rise every year from 84,000 in 1994 to 130,000 in HIV prevalence rose from 6.4% in 2005 to 7.3% in HIV/AIDS is the leading cause of adult deaths. Everyday 353 new HIV infections and 175 deaths. Every one death, 2 new HIV infections occur Mulago Ward 4A, where I work, death certificate books from Jan – July 2012 showed 134/194 (69%) deaths due to AIDS, majority 81/134 (60%) women. 7 Faith-based Approach to accelerating delivery of comprehensive HIV/AIDS Prevention, Treatment and Care Services (FABAPTCA)

Benefits of 5-pillar faith-based approach to HIV/AIDS prevention Each of its five pillars has empirical scientific data supporting it from our research study done among year old youth in response to the challenge that the FBAA was unscientific and not evidence based. (1) Believing in God and His messengers (The Messengers of God include Angels, Prophets, Parents and Religious leaders) Feeling guided by God in daily activities is associated with lower HIV infections. Parental guidance is associated with lower HIV infections. (2) Learning Scientific information: Higher levels of religiosity are associated with lower HIV infections. 8

Benefits of FBAA ( 3) Using faith teachings: Frequent prayers are associated with lower HIV infections (4) Forming partnerships with religious leaders: Listening to or watching religious programs on radio and TV is associated with low HIV risk behaviors. (5) Using concept of self-control: Fasting as a means of self-control is associated with lower HIV infections  All these components contribute to the socialization process of an individual from the religious perspective and have a big role to play in HIV prevention and control  There is data from our research study among the year old youth which supports the role of religiosity in HIV prevention 9

Association between religiosity and HIV among Christians (Epidemic Stoppers) Dimension Cases n (%) Controls n (%) Odds ratio 95% CIp-value Daily spiritual experiences Feeling guided by God in daily activities High (many times a day) Moderate Feeling thankful for God’s blessings High (many times a day) Moderate 14 (13) 92 (22) 18 (14) 88 (22) 95 (87) 328 (78) 112 (86) 311 (78)

Association between religiosity and HIV among Christians Private religious practices Praying privately other than at church High (several times a day) Moderate 51 (16) 54 (27) 276 (84) 145 (73) Dimension Cases n (%) Controls n (%) Odds ratio 95% CIp-value 11

Association between religiosity and HIV among Christians Religious commitment Trying hard to be patient in dealings with oneself and others High (strongly agree) Moderate Trying hard to love God with all one’s heart, soul and mind High (strongly agree) Moderate 26 (15) 80 (23) 44 (16) 62 (24) 153 (85) 270 (77) 223 (84) 200 (76) DimensionCases n (%) Controls n (%) Odds ratio 95% CIp- value 12

Significant association between religiosity and HIV among Muslims (Epidemic Stoppers) CharacteristicHIV Positive N(%) HIV Negative N(%) Odds ratio 95% CIp-value Fasting High (≥ 1 month per year) Moderate Sujda Yes No 21(2) 8(5) 6(1) 22(3) 1,009(98) 156(95) 487(99) 651(97) Parental Existence Both parents alive One or both parents died 9(1) 19(4) 720(99) 470(94)

Association between religiosity, HIV-risk behaviours and HIV infections on bivariate analysis of combined Muslim and Christian youth CharacteristicHigh religiosity N(%) Moderate religiosity N(%) Low religiosity p-value Ever had sex No (abstaining = A) Yes Ever drank alcohol No Yes 94 (28) 240(72) 192(58) 140(42) 34(14) 210(86) 98(40) 145(60) 1 (6) 17(94) 6 (33) 12(67) <0.001 HIV status Negative (controls) Positive (cases) Ever used narcotics Yes No 282(84) 52 (16) 9 (3) 322(97) 183(75) 61(25) 22 (9) 218(91) 15 (83) 3 (17) 1 (6) 17(94)

Collaboration between Government and FBO  FBOs participate in Policy formulation, revisions and dissemination and in High level fora such as Health Policy and Advisory Committee, Country Coordinating mechanism, UAC Board, etc Govt. supports FBOs service delivery through: 1. Primary health care funds 2. Training health workers – in-service 3. Supervision of health facility 4. Antiretroviral and Anti-TB medicines 5. M & E and IEC materials. 15

Factors responsible for success in FBOs Service Delivery: 1. For God and my country ( Uganda motto),On God’s selfless health service (IMAU mot to), imitate the healing ministry of Christ (UCMB & UPMB) 2. Religious leaders support 3. Local council leaders support 4. Faith teachings 5. Training religious leaders 6. Incentives for volunteers e.g. Bicycles, lunch allowance. 7. Supportive supervision through monthly meetings 8. Interreligious collaboration 9. Funding for infrastructure, human resources and logistics 10. Accountability to community and donors. 16

Factors responsible for success in Govt/FBO collaboration -1: 1. An enabling environment of Public Private Partnership for health that allows for effective coordination of efforts among all partners 2. Every year the FBO sector qualifies between 500 and 600 nurses/midwives (over 60 % of the total Country annual output). These staff are deployed in both Public and Private sectors. 3. The FBO-PNFP operates 40% of all hospitals and 20% of all lower-level health centres, and currently employs approximately 34% of the facility-based heath workers in the country. 17

Factors responsible for success in Govt/FBO collaboration: 4. The partnership has enabled the country to mobilize additional resources to improve the health of the population (from abroad, through user fees, and through various local initiatives for income generation) 5.The total contribution of government of Uganda to the FB-PNFP has been increasing over the years from Uganda Shillings 3bn in 1998 to Uganda Shillings 18bn in Cooperative Government officers 7. Accountability and trust. 18

Challenges FBOs model of service delivery challenges : 1. Inadequate funds to sustain volunteer motivation, through training, supervision and other incentives, and for regular supply of commodities. 2. High expectations from religious leaders and communities of sustained funding of activities because of poverty. 3. Inadequate scaling up of FBO models for greater impact 19

Challenges in Govt/FBO collaboration: 4.Bureaucracy causing delays in receiving government support 5.Heavy burden of Parallel M & E Systems 6.Human resource inadequacies & mal-distribution between urban and rural settings and attrition of qualified staff from PNFPs to public facilities and private practice continues to be a problem. 7.Poor infrastructure especially inadequate laboratory services (EID, CD4, Viral load) 8.User fees increasing with rising cost of service delivery 9. Infrequent and poor Technical Assistance by the public sector 10. Doctrinal stand of the FBOs on certain services e.g. FP and some so called human rights approaches 20

Recommendations 1. Govt and FBOs should recognize and accept the value of the faith-based approach to HIV prevention and allow each partner to perform their role in accordance with their belief system. 2. Govt and FBOs should plan, implement and monitor the HIV/AIDS response together. 3. Govt and FBOs should scale up faith-based approaches to HIV prevention such as: i. Five pillar faith-based approach to HIV prevention ii. FABAPTCA model of health service delivery ii. Move beyond the ABC strategy to ABCDE. D=Diini ( religiosity), E= Education 21

Recommmendations 4. Govt and FBOs should mobilize funds for activities to support religious leaders and their assistants including: i. Training and refresher training in HIV/AIDS service delivery ii. Incentives – transport, communication, allowances iii Funding the Religious leaders activities as well, since they contribute to HIVAIDS service delivery and not stop at the religious health institutions iv. Support supervision v. IEC materials, media activities vi. Income generating activities to address PID (Poverty, Ignorance and Disease) 22

Recommendations 5. Govt and FBOs should mobilize funds to support Health care workers especially providing performance related allowances 6. Govt and FBOs should mobilize resources to support FBOs to champion the faith-based approach to HIV/AIDS activities of: a) Advocacy b) Coordination c) Information, education and communication d) Training e) Health service delivery f) Monitoring and evaluation e.g. setting up surveillance sites to monitor the outcome and impact of the faith- based approach to HIV/AIDS on HIV prevention. 23

HIV Prevention is better than cure 24

Supporting faith with knowledge The second Epistle General of Peter Chapter 1 verse 5: And beside this, giving all diligence, add to your faith virtue; and to virtue knowledge. 25

Govt/FBO collaboration in knowledge generation 26

Govt/FBO collaboration in Knowledge generation 27