Governance of ARV access in Uganda

1
Governance of ARV access in Uganda

• Presentation September 7th 2004 at AIDS Network
  workshop on
• Models for life What can we learn about ARV
  distribution from field experiences in low income
  countries?
• Stine Jessen Haakonsson, ph.d. researcher
• Globalisation and Governance Department
• Danish Institute for International Studies
• and Institute of Geography, University of
  Copenhagen

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Global Governance of trade and aid to AIDS
treatment

• Most research aimed at national/local HIV/AIDS
  programs
• International structures and agents important
  actors in determining ARV access in developing
  countries
• Nation states room for manoeuvre influenced by
  international donors and institutions governing
  international trade
• Political economic perspective on ARV access in
  Uganda

3
Levels of governance in developing countries

• Drugs and drug prices
• global level, governance of trade and AIDS
• ARV treatment programs
• global level, governance of aid to AIDS
• ARV treatment access
• national level, Uganda, various actors

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A broad range of actors some not embedded in
nation states

• Conflicting political and economic interests at
  the different levels of governance of ARVs
• Public health tied to international politics
• Contradicting governance structures within some
  developing countries

5
AID to AIDS

• HIV/AIDS attract donor money
• ARV treatment is entering the agenda of donor
  programs
• Global Fund, PEPFAR, 3 by 5, national donors,
  NGOs etc. political agendas are many and are
  not necessarily bound in the national contexts
• Duplication of and contradictions between donor
  programs
• Disempowerment of national governments in central
  health care (for good and for bad)

6
International aid to AIDS

• Global Fund
• PEPFAR
• 3 by 5
• World Bank

• Donor contributions to UNAIDS 1995.2003
• USA 129 mio.
• NL 114 mio.
• Norway 62 mio
• Sweden 43 mio.
• UK 39 mio.
• Denmark 32 mio.

7
ARV coverage
(WHO 2003, 5)
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Trade and AIDS

• WTO TRIPs Agreement
• Doha Declaration
• Development discourse on free trade and economic
  growth
• Patents and pricing on ARVs

9
Trade agreements and AIDS

• WTO and TRIPs Agreement
• Doha Declaration and compulsory licenses
• Industrial interests vs. ARV access?
• PEPFAR and FDA vs. WHO prequal.
• if we dont apply appropriate scientific
  scrutiny to this vastly expanded flow of AIDS
  medicine, we will run the risk of causing the HIV
  virus to mutate it could leave Africa even worse
  off than it is today (Randall Tobias, 2004)
• Mozambique compulsory license 2004

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UGANDA and donors

• Political stability (!!)
• Donor governance, SAP
• Recognizing AIDS since 1986
• Success story of combating HIV/AIDS
• Advocate for connection between free trade and
  economic growth
• Liberalization gt 7.1 annual growth in late 1990s

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High priority

• 1986 AIDS Control Programme
• 1990 multi layer strategy to combat HIV/AIDS
• 1.2 - 1.5 mio. people infected of whom 100.000 -
  150.000 need ARVs, 10.000 - 15.000 get it
• ARV access has become a high priority
• all AIDS patients in Uganda, will, in due
  course, be given free drugs, beginning with some
  2.700 this year Min. of Health, June 2004

80 of patients are paying out of their own
pockets Generics 25 - 60 Brands 80 -
560 January 2004
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AIDS funding

• Global Fund PEPFAR World Bank
• 200 mio. 95 mio. 3 mio.
• 33.000 on ARVs 60.000 6.000
• Limitations
• infrastructure and health system capabilities
• donor demands and politics (e.g. duplication)
• sustainability of funding
• trade governance

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Development of ARV prices in Uganda
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Trade and AIDS, Uganda

• ARVs are new products and all patented in Uganda
• Compulsory license
• should not eat the seeds for next season
• donor dependency
• governance consequences of national emergency
• Still generics and competition at the market, but
  funding will buy branded products
• Lack of communication between authorities
• Ministry of Health, HIV/AIDS epidemic
• Min. of Tourism, Trade and Industry, trade
  agreements
• and Min. of Law, Industrial property / patent law

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Conclusions

• Increase in ARV access gt significant governance
  conflicts
• High funding - low coverage (2 in Africa)
• Donors need to consider how to upgrade national
  governance of ARVs as well as national health
  systems
• Increase awareness of public health in global
  governance

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Thank you

• If you are interested in receiving our full
  paper, please contact
• Stine Haakonsson stj_at_diis.dk
• Lisa Richey Richey_at_ruc.dk