There is growing research evidence pointing to substantial levels of functional impairment among older adults in the SSA, partly attributable to the chronic disease burden. Older adults with functional disabilities have limited ability to carry out essential tasks of daily living independently. There is  thus a huge need  for long-term care (LTC) for older adults in SSA and this need can only be expected to rise further as the region’s chronic disease burden increases. LTC has been defined by the WHO as ‘activities undertaken by others to ensure that older adults with a significant ongoing loss of intrinsic capacity can maintain a level of functional ability consistent with their basic rights, fundamental freedoms and human dignity.’  As such the premises upon which LTC for older adults should be provided include fairness to those who require care and those who provide it; enabling dependent older people to continue doing what they value while living their lives in dignity; being viable and sustainable in the long run and finally, a firm sub-Saharan grounding in broader development and human rights agendas.

Against this backdrop, the African Population and Health Research Center (APHRC) hosted  the   2^nd Africa Region International Association of Gerontology and Geriatrics (IAGG) conference in Nairobi, Kenya, from 6-8 December.   The conference focused on setting the agenda for LTC systems in Africa. The conference, a structured policy-research-practice dialogue, attracted researchers and experts on ageing from all over the world, be it government representatives, staff from international organisations, non-governmental organisations, academia or civil society.

The field of research on ageing issues in Africa is still very young – by way of example, the youngest generation of researchers is only the third. Conference discussions and presentations  can be accessed on the IAGG website, in the rest of this article I will present my personal reflections and lessons learnt while interacting with a vast body of “ageing experts” (pun intended).

On ageism

The term “elderly” itself is ageist. It is more dignified to refer to people who are advanced in age as ‘older adults’.  Hidden in ageist terminology like ‘elderly’ are discriminatory prejudicial attitudes that portray older adults as frail, leading to a lack of respect for their autonomy and dignity. Even global health policy isn’t immune for institutional ageism.

Although ageism is pervasive in society, today’s older adults play a significant role in SSA settings. Roles include taking care of children orphaned by AIDS, being agriculturalists, mentoring younger generations in agriculture or actively participating in politics with one standing example of Nelson Mandela who began his political career at the cool age of 75 years (at least at the highest level). True, older statesmen aren’t always as exemplary as Mandela, but let’s not go into that.

Will families continue to care for older adults?

Traditionally, families gladly took care of frail older adults as a reciprocal act of human kindness (Ubuntu). However, families become overburdened, financially and physically, by the pressure of caregiving, especially if the care is to be provided over long periods of time single handedly. Many scholars now argue that the family structure has changed due to rural-urban migration, emigration,  missing generations in families (due to the HIV/AIDS scourge) and urbanization and modernization trends. Care giving roles are thus more likely to disproportionately fall on young females whose education and employment prospects are, as a consequence, often negatively affected. Therefore there is a need for formal LTC systems to alleviate some of the burden and pressures of caregiving from the families. However, in several African settings, “formal long-term care systems” are unfairly equated to residential homes for older adults without any further in-depth analysis of the premises for the need of these. For example, South Africa’s President Zuma worried about the institutionalization of care outside the home, “As Africans, long before the arrival of religion and [the] gospel, we had our own ways of doing things. Those were times that the religious people refer to as dark days but we know that, during those times, there were no orphans or old-age homes. Christianity has brought along these things.”

As much as Zuma’s cry resonates with many Africans, which busy employed person would not be happy to know that the care “their” older adult is receiving is of the best possible standards? That while they are away, it is possible for their older adults to receive quality care from a day center? Wouldn’t it be great to occasionally relieve a busy or tired family member from a caregiving responsibility? And who wouldn’t be at ease knowing that health institutions in Africa are well equipped to handle chronic diseases attributable to older age?

Most African countries do not have policies on ageing, and those that do have no clear-cut policy on long term care for older adults with functional disabilities. Different issues of ageing for older adults such as the need for financial support and health care are often handled separately in a rather uncoordinated way. It is therefore imperative for family care to be seen as part of a broader care system that spans both informal and formal spectrums with the needs of older adults at the center of the care, and with overall stewardship being provided by individual governments.

Last but not least: on the emigration of Africans, and the interface between LTC and broader development agendas

Curiously, Africans leave Africa and many (health staff) end up in the Western world’s care sector, but most return to Africa when they themselves are old and frail, and with little care options. There needs to be a way, somehow, to pass on these newly acquired caregiving skills to benefit them and future generations.

Within broader development agendas, human rights frameworks as enshrined in the Sustainable Development Goals (SDGs) for example dictate that older adults are entitled to the right to health and the right to age in a friendly environment – rights not based on an individual’s ability to contribute to the economy. Having said that, even in the (generally lofty) SDG agenda, older adults still fall prey to ageist approaches, see for example the concept of premature mortality, an approach that is clearly discriminatory against older adults, as has been pointed by scholars. Also, it’s good to keep in mind a holistic lens: everything is connected with everything in the SDG agenda. In SSA, younger women responsible for caregiving suffer increasing gender inequalities in terms of education and employment; and yet, a woman’s education status is known to be a key predictor for the health of her children. In addition, given the fact that there is a high burden of youth unemployment all over the SSA region, does LTC for older adults provide an employment opportunity into which the younger generations can venture?

In conclusion, LTC provision like other forms of care is a risk but how much of that risk should go to the government? How much should go to the societies and what will be the effects of failure to enshrine ageing and LTC agendas into the development prospects of young economies in Africa?  All remain unanswered questions, for the moment.  Let’s hope this week’s High-Level Ministerial Meeting on Health Employment and Economic Growth in Geneva provided some answers, as time is running out.

In Uganda, most clinics and wards are overcrowded and intern doctors are often the first medical professionals a patient will come in contact with. In many cases they are the only doctors patients will ever see when visiting a hospital. The often overworked young doctors, functioning under poor working conditions, prevalent in most health care facilities in Uganda find (some) solace in knowing that they will receive a pay check for their hard work. However, the notion that hard work pays might not hold any water for several of the new interns whose first-ever pay-check dream might remain just that – a dream – due to a recent exploitative and short-sighted policy suggested by the government.

The short-sighted policy and its genesis

Social unrest in the health sector is not new in Uganda. Over the last 10 years, Uganda has witnessed more than seven strikes by medical professionals, mostly by intern and postgraduate doctors. The strikes have been attributed to poor or delayed pay as well as poor working conditions. In 2005, a strike by postgraduate doctors who were later joined by consultants left the main national referral hospital paralyzed and able to only handle emergency cases.

An intern strike preceding the current strike happened in May this year, and was led by the batch of interns scheduled to complete their internship in August 2016. The sit-down strike was to protest against cumulative unpaid allowances which the government attributed to bureaucracy.

The wave of strikes over the past decade made the government realize that Uganda’s health system was threatened. After 2006, the government strategically expedited the opening of three more publicly funded medical schools. At the same time, a number of private medical schools popped up which were registered by the government. Ten years have elapsed since and we now have a cohort of one thousand brand new medical students who are expected to start their internship. The government does not feel equipped to pay these interns, saying there is simply no money to pay such a large number of interns.

Word has it that the government is only prepared to pay previously government sponsored students at the universities leaving masses of privately sponsored students without income during their internship.  The rationale behind this new, exploitative policy is that if the students were government sponsored, then it is the responsibility of the government to continue to financially support their internship. This “implies” that for the once privately sponsored students, it is the obligation of their sponsors to continue sponsoring them. Well, at least according to the government.

Secondly the government wants to pre-empt potential health worker migration by taking a conservative approach of binding government sponsored medical students to a government health facility for two years. For those government sponsored interns who were thinking of fleeing Uganda for greener pastures immediately after receiving their medical license, the government’s message is clear – they should not even think about it until their two-year “shift” is complete .

It was in defiance of this proposed, discriminatory and binding policy that a group of one thousand brand new intern doctors held coordinated marches on the 31^st of August this year, marching on the streets of Kampala, Mbarara and Gulu. The doctors will not agree to start their internship unless the policy is reversed.

Does Uganda really have many doctors?

Uganda has a doctor patient ratio of 1: 24,000 which is a far cry from the WHO recommended ratio of 1:1000. Despite the severe shortage of doctors in Uganda, the ministry of foreign affairs surprised the whole world in 2015 when it came up with a plan to export doctors to Trinidad and Tobago. The scheme was envisaged as a pathway to strengthen diplomatic ties between the two countries. Other arguments for the plan included giving doctors an opportunity to improve their technical skills, earn more money – pretty much like a government-funded opportunity for medical professionals to move, medics who were destined to move out in any case. Stunning plan, in short. The ministry of health was quick to distance itself from having played any role in this dubious “export” plan. The plan to “export” doctors and other health workers greatly angered Ugandans and attracted heavy criticism from outside leading to government litigation. It was quickly abandoned. The recent turn of events points to the fact that Uganda does not have an excess of doctors, but limited fiscal space for the health sector.  But fiscal space for health is never carved in stone.

The current state of affairs

For the moment though, medical graduates and current interns, unhappy about the proposed policies are not about to give up their (more than justified) demand for fair pay and freedom of movement after completion of their internship. They are aggrieved by the fact that money is available for other sectors in Uganda and that health is not a priority – a situation not unfamiliar in other developing countries either! They are particularly dismayed by the fact that Uganda can spend at the same time an exorbitant two billion shillings (US$ 590,754) on legislators attending a three-day Uganda convention in America.

In a meeting between the government, intern representatives and representatives from the Uganda Medical Association (of which I am a member), the government argued that the current budget is not able to accommodate the influx of interns.  The minister of health has recently informed the parliament that medical interns will take a screening exam and only those government-sponsored interns who pass with flying colours will qualify for the internship placement, and therefore salary. However negotiations are still ongoing to find an amicable solution.

The government also argues that the two-year bond for the government-sponsored students’ policy is not yet fixed. The medical representatives have suggested that the allowances for government-sponsored interns could be reduced from 600,000 UGX (US$177) to 350,000 UGX (US$103), a reduction aimed at redistribution of the available budget in a fair way amongst all the interns regardless of who  funded their medical education. Even with this improvised budgetary redistribution, the Ministry of Finance would need to release an additional 3.4bn UGX (US$1,004,283) in order to be able to pay all the interns. If the cuts occur, it will in fact be the second time intern allowances have been trimmed this year – allowances were already slashed from US$257 to US$177 earlier this year. This ever increasing slashing of internship allowances by the Ugandan government – in some sort of B rated slasher movie – is in itself likely to escalate the ongoing strike and spark future resistance.

The way forward

There is no question that the health system in Uganda at the moment cannot function properly without interns although some ministry of health officials unrealistically deny this fact.  It is critical for Uganda to increase its financing of the health sector as recommended by the African Union (see the ‘Africa Scorecard on Domestic Financing for Health’). This isn’t as easy as it sounds, particularly with the dwindling donor funds even though the Ugandan government proudly claims it can survive without donor funds. But in essence, the limited fiscal space for the health sector (which includes the wage bill ceilings) in Uganda is a ‘political’ decision and the result of a (never ending) ideological battle on resource distribution and allocation. To put it bluntly, it is a consequence of a (rather awful) political ideology and vested interests that prioritise other sectors over health and that should be challenged. Uganda should learn from  nearby countries like Ethiopia that have already demonstrated that such disastrous ideology can be shed, which can in turn lead to significant improvements in the health workforce – and I’m saying this fully aware of the fact that the Ethiopian government is not without its flaws either.

Expansion of the fiscal space for the health sector will not only require proper taxation systems, but also curbing of corruption in all its forms and prioritization of the health sector. This might mean redistribution of finances from sectors like defence, which is over financed in many countries, to the health sector. After all, the inequities that arise from poor provision of health services to the poor can trigger security threats too and can therefore be seen as “defence” issues as well (for the “iron men” among you). It might also mean cutting down on the exorbitant expenditures that Ugandan tax payers have to incur due to an unnecessarily large parliament.  Anyhow, the government cannot continue to underestimate grievances in the health workforce as it is increasingly recognized that the impact of a productive health work force goes far beyond health outcomes – HRH is not only a cost, but it also contributes to economic growth and wellbeing.   As you might know, the UN High-Level Commission on Health Employment and Economic Growth will present its report on 20 September, in New York, along these lines.

The inability of the Ugandan government to plan appropriately for interns despite the vital role they play in the health system, together with downright silly plans like the exportation of (the already scarce) specialists overseas remains a paradox and points to a national priority setting exercise gone badly wrong. Nonetheless, it is my sincere hope that the supplementary budget of 3.4bn UGX will be found in this fiscal year and interns will be budgeted for in the years to come because no intern deserves to work in poor conditions without remuneration. Regarding implementation of the two-year bond, it is my sincere hope that this will be implemented only if there is an absolute respect for people’s right to free movement.

Similarly in psychiatry there is a group of anxiety disorders called “specific phobias”. A specific phobia is defined as an overwhelming irrational fear of an object or situation that poses little or no danger. Phobias are characterised by an uncontrolled form of anxiety when exposed to the source of the phobia; avoidance of the cause of the phobia at all costs; overwhelming fear of the phobia that affects the person’s ability to function properly; overt awareness of the irrational fear and inability to control the fear.

During the course of the 20^th century, a group of words has been coined to join the phobia family. These include xenophobia, homophobia and islamophobia.  Unfortunately these newly coined forms of phobia do not fit the definition of a true phobia, as psychiatrists know it.  They are reflections of mere lack of tolerance, hatred and feelings of disgust. Unlike the malaria misnomer whereby those affected by the disease get the treatment they deserve, sufferers of the emerging groups of phobias do not get the treatment they deserve.  They hide behind the sugar coating of a genuine psychiatric disorder and are treated as victims of the illness they have. The time has come for us to see the face of hatred for what it is and call it by its real name because hate by any name is still hate. If these emerging phobias are truly phobia, then why are there no policies to ensure that persons affected by them get the psychiatric help and therapy that they need?

Now everyone has been greatly made uncomfortable by something that they clearly do not like at some point of time, but does that give them the right to call that something a phobia? By labelling feelings of disgust, dislike or disagreement, a phobia – potentially criminal behaviour is justified as an innocent psychiatric condition that requires treatment other than the criminal discriminative behaviour that it is.

In Nairobi, thousands of worshippers braved the rain and lined up in the streets to catch a glimpse of pope Francis, a very remarkable pope to say the least (in football terms you could call him “The Special One”). In addition to playing his usual pastoral role, the purpose of the Pontiff’s visit was also to draw focus on Africa as a continent of hope and not just a hotbed of terror and disease as it has all too often been referred to in the western media (admittedly interspersed with some ‘Africa rising’ rhetoric in magazines like The Economist in recent years). As a Ugandan researcher and SDGs optimist, working closely with people in the slums in Nairobi and eagerly waiting for the day when Kenya and Uganda will harness their so called “demographic dividend” (a state whereby birth rates fall due to a significant decline in infant and child mortality thus leading to increased life expectancy and an increased proportion of the productive age-group of a nation), I think some important lessons can (and should) be drawn by the global health community from the Pontiff’s views as reflected in his multiple messages to Kenyan and Ugandan audiences, in rainy and more sunny circumstances. Furthermore, the Pontiff’s messages related to national policies in the two countries offer some more lessons for national decision makers as well. If they heed the gist of his messages, East African governments could work together with the church (as they have long done in several other sectors) to ensure the achievement of sustainable development and harness the demographic dividend.

Below you find a summary of the Pontiff’s –  sometimes hard-hitting – messages and statements.

On social inclusiveness

The Pontiff spoke forcefully against “practices which foster arrogance in men, hurt or demean women, and threaten the life of the innocent unborn”; also, the elderly shouldn’t be neglected, he insisted. In line with his strong beliefs and the teachings of Jesus, he also encouraged catholics to care for the poor and vulnerable.

On conflict and violence

The Pontiff identified the failure to address poverty as the key driver of conflicts, violence, and terrorism. He blamed high levels of youth unemployment for making youth vulnerable to being recruited into terrorist activities. In his view, key mechanisms for conflict and violence are mistrust, fear, despair and frustration. While acknowledging that our societies experience divisions, based on ethnicity, religion and socioeconomic status, he expressed his strong conviction that reconciliation and interfaith dialogue are not an option but a dire necessity.

On the refugee crisis

He was deeply touched by Uganda’s exemplary behaviour in welcoming refugees  in the East African region and called for fair treatment of refugees all over the world. ““How we deal with them is a test of our humanity, our respect for human dignity, and above all our solidarity with our brothers and sisters in need”.

On urbanisation

He emphasized that urbanization should be effectively planned and condemned the level of indifference shown to the destruction caused by rapid ineffective urbanization. He noted that social breakdown as commonly occurs in the informal slum settlements increases violence. He acknowledged that as the land inhabited by the poor gets swallowed up by cities and towns, the youth tend to loose their identity and resort to new forms of social aggression including vices such as drug abuse and trafficking. The Pontiff challenged the government to ensure that urbanization is used as a means for development and integrated with the basic human right to live in dignified conditions: the very basics of life such as water, sanitation, education, housing and health care should be preserved and guaranteed. Pope Francis also condemned the practice of land grabbing, especially with respect to public spaces, as private corporations have been depriving schools of playgrounds and forcing poor people into even more tightly packed slum settings where criminal behavior is on the rise. Speaking in a shantytown, he even likened the injustices the poor people in Kenya are faced with, to new forms of colonialism. He called for equitable elimination of urban poverty by the governments with tangible plans to provide good housing for all.

On environmental preservation and carbon emissions

Also in Nairobi, the pope warned, just days before the start of COP 21 in Paris, that the world is facing a “grave environmental crisis” and spoke eloquently about the intersection between social justice and nature conservation.    In line with the key messages in his Encyclical Laudato Si (“On Care for our Common Home”) from earlier this year, he acknowledged the intimate connection between man and nature and reminded the world’s citizens of their responsibility to pass on the beauty of nature in all its integrity to the generations to come. He urged the nations to be responsible stewards of the rich natural resources they are blessed with.  He was saddened by the fact that many large cities today are in fact health threats (or even traps) with very poor air quality, urban chaos, poor transport systems, visual and noise pollution. He condemned the non-recycling consumerist culture, wasteful use of resources in production of food and other goods that has led to high greenhouse gas emissions. He called for the adoption of low-carbon energy systems and sustainable consumption and production patterns in order to prevent degradation of the ecosystem and catastrophic climate change. As you can imagine, Francis didn’t spare the ivory poachers and diamond smugglers in both Uganda and Kenya.

On governance

Although the Pontiff believes that corruption has infiltrated several institutions all over the world (including the Vatican, he acknowledged, with a smirk), he advised the crowds and particularly the youth in Africa to refrain from idolizing corruption, tribalism and other devastating effects of corruption. Using a somewhat global health-stylish metaphor, he emphasized: “Corruption is something that eats you inside like sugar. It’s sweet, we like it, it’s easy. And then we end up sick and poor. So much sugar that we either end up being diabetic or own country ends up being diabetic.”

On HIV/AIDS and condoms

As the world was gearing up for World AIDS day, celebrated every year on the 1^st of December, Pope Francis took some time to visit a hospital for HIV infected children while in Uganda. Nonetheless, on his return to the Vatican, when asked about the role of condoms in the fight against AIDS during an in-flight press conference, the pope was quick to point out that there are more important issues confronting the world such as malnutrition, environmental exploitation and lack of clean safe drinking water. At the very least, a bit funny timing for this sort of stance.

On LGBT rights

Last but not least, although Ugandan homosexuals were eagerly hoping for an opportunity to meet  pope Francis who has recently shown sympathy for sexual minority groups, he remained silent on this rather contentious issue in the East African Region. Whilst harnessing the demographic dividend that many countries aspire for depends on controlling  unplanned population growth, the issue of population control was not addressed by the Pontiff…

In conclusion, the pontiff’s messages related to policies in East Africa cut across several areas addressed by the SDGs and expressed principles that underpin the global health challenges of today, even if the pope he still has his flaws (just like his predecessors).  His views provide practical lessons that can be used to address some of the most pressing global health and security issues of today.

Suffice to say, his view of what real ‘global health security’, a truly ‘rising Africa’ and inclusiveness require seems rather different from that of the ‘powers that be’.

Dr Wayengera

Shortly after finishing his medical internship in 2005, Dr. Wayengera joined graduate training in Bio-entrepreneurship at the Medical and Related Sciences (MaRS) discovery district, University Health Network (UHN), University of Toronto to gain skills that would enable him to accomplish his dreams, which included inventing an HIV-1 cure and rapid tuberculosis diagnostics. On his return to Uganda in 2008, Dr. Wayengera embarked on his journey of innovation. He kicked off his research with the Ebola virus disease (EVD) RDT under start-up (2008) biotech Restrizymes Biotherapeutics (U) Limited; the idea was to come up with a simple and accurate test which would be able to detect several strains of Ebola in less than 15 minutes for use at the community level.  It has always been known that containing an Ebola outbreak through case management can prove to be futile unless cases are picked up rapidly, but progress in the invention of effective point-of-care rapid diagnostic tests has been sluggish, at least till the outbreak in West Africa.

Despite the dire need for a rapid EVD RDT, Dr. Wayengera’s efforts were constrained by the lack of funds. It took two full years for the President’s office to respond to a letter he wrote in 2008 requesting for financial support. In response to his letter, the President’s Office acknowledged the importance of his research for biodefense and pledged to offer all the necessary support. Yet, despite the fact that the President of Uganda decried the fact that it had taken two years for the letter to get to his office, Dr. Wayengera’s follow-up efforts fell on deaf ears. He attributes the delay and neglect to the lack of clear structure and focus on research within the President’s office and the inability to look beyond self-interests.

Undeterred, Dr Wayengera then resorted to applying for funding from Grand Challenges Canada in 2013;  he was awarded a grant worth CAN$100,000. In addition, Grand Challenges Canada was willing to award to him an extra one million dollars for his research, if matched by financial commitment [of any value] to the project by his home Government. Subsequent efforts to secure local funding from the Ugandan government through follow up letters and social media pressure were futile. Luckily, in a rare turn of events, a breach of the prevailing rules and in a show of trust, Grand Challenges Canada offered Dr. Wayengera and his research team CAN$1.5 million, possibly due to the devastating EVD in West Africa and beyond.  The money enabled Dr. Wayengera and his team to continue with their research which led to a breakthrough innovation. His RDT for EVD is able to detect Ebola recombinant antigens in less than five minutes; he has already filed a patent with both the World Intellectual Property Oganisation (WIPO) and the African Regional Intellectual Property Organisation (ARIPO).

Dr Wayengera’s troubles underscore the plight faced by many young researchers in Africa, missed opportunities and the lack of political commitment towards innovation, research and development.

It is no secret that innovation can boost economic growth. It is equally important to support innovative approaches in health relevant to the local context and resources. Low-income countries have to take increasing responsibility for their own health financing, including investing in innovation and intellectual property. Innovations are more likely to be taken up when there is a window of opportunity. The Ugandan government claims it is committed to science and innovation, demonstrating this by sponsoring science students over arts students at the universities; and has been lately encouraging its citizens to be patriotic (as in ‘assist in steering national development’) through a proposed patriotism bill due for discussion by the Parliament.

However, had this young scientist received support for his research in due time, the country, indeed the world would probably have benefitted from a rapid diagnostic test for Ebola, when the disease hit West Africa. It is unclear as to why a government that is allegedly pro-patriotism, pro-science and pro-innovation, and governing a country that has repeatedly been struck by haemorrhagic fevers was not able to invest a single dime in an Ebola RDT.

Dr. Wayengera now strongly believes that the most sustainable way to manufacture and scale up the RDT will be through engaging with a North American Partner. “If my government never showed interest while we were in the tunnels, I don’t think they deserve much of the benefits thereafter. The systems here are broken, infiltrated by naivety and intrigue, let alone corruption and are not favourable to the local innovators. Don’t get me wrong, the Ugandans deserve pride for this innovation, but someone must stand up and tell the leadership that their planning is mis-directed and short sighted, and detrimental for the local economy. This is my way of fighting the forces that drive brain-drain” Dr. Wayengera remarked (in a personal conversation). “I will stay and continue my work on other things including an HIV cure, but if the trends continue, then the tax benefits of that too will go elsewhere. We must assume some level of investment and ownership if we are to claim partnership in an innovation; this is not like the case where the donor simply gives and does not expect any benefit in return”.

Well, we wish Dr. Wayengera good luck and hope that the Ugandan government will be more responsive in the future, if only to live up to its own rhetoric.