Lacor hospital’s approach to the vertical funding dilemma

12 September 2011

The AIDS epidemic brought challenges that give some idea of the complexity of international aid. Uganda was one of the earliest and worst affected countries. In certain areas, almost 30% of the population was infected. The government faced the challenge immediately with health and education campaigns, the only options available at the time. Now the 6% prevalence of AIDS in Uganda is one of the lowest in sub-Saharan Africa.

Rapid death from HIV/AIDS is now no longer inevitable: the disease can be controlled, but at a cost that is still too high for the population to bear. Drugs are expensive, but so also is the complex structure that must be put in place in order to adequately treat patients. Luckily, some large international organisations have covered these costs.

Perhaps it was inevitable that ‘vertical’ or disease-specific projects created exclusively for the treatment of AIDS would be formulated without considering the often very harsh impact on local health systems. The country’s health systems – which can be described as ‘horizontal’, because they offer general, accessible health services to the population without discrimination – had already been severely affected by the brain drain and the lack of financial resources forced upon them by dozens of years of structural adjustment policies enforced by rich countries to reduce debt. The Ugandan health system, and our hospital, experienced an acceleration of this brain drain towards these rich vertical projects.

At the time, Northern Uganda was undergoing a violent, 20-year-long civil conflict, and many people were dying from curable conditions. In 2003, 759 under-sixes died at the hospital. Of these, 698 deaths were caused by just six conditions: pneumonia, malaria, septicaemia, malnutrition, anaemia and diarrhoea. Lacor needed a general referral hospital.

It was in this context that Lacor Hospital was faced with a choice: it could remain a struggling and underfunded general hospital serving the whole community, it could become an AIDS hospital, or it could opt to have a dedicated, independent AIDS unit. Choosing either of the latter two would have allowed access, at least in the short term, to a wealth of funding – a temptation that can be very hard to resist.

A dedicated unit would have created a much ‘richer’ independent section within the hospital, with better-paid staff and greater availability of diagnostic means and drugs. In the greater part of the hospital, the ‘poor’ part, patients would be at risk of dying from treatable diseases as a result of shortages of essential drugs and treatment. And staff here would be paid much lower salaries than those working in the AIDS unit. This would have created iniquities and severely destabilised the functioning of the hospital.

The hospital therefore set itself the difficult goal of providing antiretroviral treatment for AIDS patients without neglecting the other, much more numerous patients with common diseases, who were just as much at risk of dying. In addition, we wanted to prevent the disruptive effect of having an external organisation manage a section of the staff and hospital structure.

I think this shows that, with care, respect and consideration for local priorities, rich vertical projects can be integrated into horizontal health systems without severely destabilising the latter.

It was an achievement to resist being swallowed up by gigantic projects so rich in resources. Today, as vertical projects are experiencing donor fatigue, we believe that our choice was far-sighted: care for AIDS patients that is integrated into a general hospital is less expensive and more sustainable in the long term.

The lesson we learned was that large programmes, even vertical programmes such as the AIDS programmes, are necessary. However, they must not have a negative impact on the other, horizontal, systems that take care of all other aspects of health, from vaccinations to primary health care and general and specialised care. These are just as important to the population.

It is absolutely essential to reflect very cautiously before accepting an aid project that could affect the structure of a hospital or the way it is run. It is important to ask:

• Is the project targeting the hospital’s priorities?
• Is the average poor patient going to benefit from this project?
• Does this project present some organisational risks for a large, complex structure such as a hospital, which relies on a high proportion of highly qualified staff?

Yours sincerely,

Dominique Corti d.corti@fondazionecorti.it
Member of the board of directors of St Mary’s Hospital, Lacor, Uganda

Opira Cyprian opira.cyprian@lacorhospital.org
Executive director of St Mary’s Hospital, Lacor, Uganda

Martin Ogwang ogwang.martin@lacorhospital.org
Institutional director of St Mary’s Hospital, Lacor, Uganda

  

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