Chapter Nine - Interview with Dr Samuel Okware

Dr Samuel Okware, health commissioner at the Uganda Ministry of Health and former director of the Uganda AIDS Control Programme

Questions put by Rex Winsbury

RW: There is some controversy about priorities in health. When money is limited, as it is for everybody, is a blood transfusion service worth the expense? It's not cheap.

SO: Blood transfusion is absolutely, absolutely a priority, because it is the only area where we can actually control the epidemic 100 per cent. Once you have a safe blood supply then you are sure that there will be no infection. So there is no question of having second thoughts about that. But over and above that we must continue with IEC, health promotion, and ensuring that behaviour changes constantly.

RW: Turning to the AIDS Information Centre and the concept of mass voluntary testing - there's some controversy about that also. The WHO so far has not formally recommended large scale anonymous voluntary testing as one way of combating AIDS. Your centre here in Uganda is not the only one of its kind, but it is one of the best examples. Do you feel the AIC also makes a valuable contribution?

SO: I think it has been a valuable contribution. Why? First of all, people want to know their serostatus before they take certain decisions. Second, it gives an important opportunity for counselling those people who are spreading the infection or who are likely to get infected. Thirdly, the seropositivity among blood donors in Kampala, and the blood taken and then discarded because it is infected, has actually gone down. This was a collateral advantage that we had not expected.

RW: There is debate about the extent to which a blood transfusion service should be centrally organised, with a very strong centre as you have here in Uganda.

SO: With a disease like AIDS, the central aspects of the problem must be very strong. Why? First of all, you need to make sure that quality assurance is important and, two, make sure there is always a reserve stock, and third, it needs a lot of input initially which the units on the periphery cannot cope with. So it's better to get a centralised system which ensures that blood can be received when wanted, and wholesome blood. At the beginning we had an experience of having it done by each hospital but then we found out that because of the poor facilities available at these small units the tests left a lot to be desired. So it was necessary for us to centralise the blood transfusion and then make sure they improved transportation for the collection of this blood and also distribution.

RW: You were the director of the AIDS control programme in those early days. So you watched the UBTS develop from the beginning. What factors would you pick out to explain why the blood transfusion service got going very quickly.

SO: I think the major reasons were, one, the fear and the whole momentum of the AIDS problem. Secondly, there was nothing before, really nothing. The Nakasero building has been disused and was overgrown and there were no facilities at that time. Thirdly, there was the issue of management. I think Dr Watson-Williams ought to be congratulated. He did a tremendous job. It was through his force that we were able to put up that facility. And lastly, we obviously needed money, and we were lucky, money at that time was available for the blood transfusion service in this country and I think it was properly applied and that has been sustained.

RW: The structure of the health service in Uganda is now going through reform. Essentially, de-centralisation. Some people say, how can you have a centralised blood transfusion service if the general structure is being pushed down to the districts.

SO: The overall activities, planning, and so on, are done in the district. Fine. But the hospitals still remain the property of the Ministry of Health. So by having all the hospitals in the Ministry of Health we will be able to make sure that there is quality assurance for drugs, quality assurance for blood, quality assurance for staff and personnel in terms of qualification, training and so on. The local authorities have got their own mandate, their mandate is to do the planning at their level. But we are working very, very closely together. What is happening is that the management has been shifted from this end to the other end. That's number one.

Number two is that blood transfusion is a central project, just like there are some development projects which are centrally organised which are cheaper to handle centralised. It is not even a Ministry of Health activity. The blood bank is a sort of a quasi-NGO. So it can stand the test of time.

RW: There is much debate whether a project like the blood transfusion service will always need exterior financial support, or whether it's realistic to suppose that the government of Uganda, or any other government in Africa, should or could aim to take over the full responsibility for it after a period of time.

SO: Without AIDS, yes, the government could take over, but with the AIDS problem as it is right now and because of the costs that are involved, I think we will need some support from outside for some time, because the cost of the blood tests is very high. If you had to put that cost in the central budget among competing priorities, you might find that the blood bank would take 10 to 20 per cent of the budget. So I think in the long run the government will take over. But in the short run there is a need for international support.

Dr. Sam Okware

RW: If people from other countries ask you about your blood transfusion service because they don't have one themselves, what would be the main advice you would give to them?

SO: The first question is, who should organise the blood transfusion service? Those who are nearest the problem should be the ones who provide the know-how, like the Ministry of Health, which has a vested interest in ensuring that blood is wholesome. So it is important to tie a blood transfusion service in with a government agency, maybe a ministry, so there is accountability, both political accountability and technical accountability. If you make it into an NGO, sometimes it can easily go into outer space and get lost. Of course it is important for everyone to be involved, but you must have a Ministry and you must have a Minister who is accountable.

Number two, it is very urgent that they must set up the service as quickly as possible. But how should the whole thing be started? I think the best way to start is to strengthen a central point, because quality assurance is very important. There is no point in testing blood when you know very well that half of it is not accurately tested. So quality assurance, starting from the central level going downward, is where you start from. I know that with most activities, the ideal is to start from the bottom working upwards. But with this one, you start with a good tertiary institution at the centre, and then work downwards.

RW: How would you sum up the benefits of the rehabilitation of the UBTS to the health care system in Uganda?

SO: First, it has helped to strengthen the health care infrastructure at both central and district levels. Strengthening the blood bank in this integrated way means that hospitals have benefited by having their laboratories updated and equiped. Second, this has promoted general protective measures for infection control. Third, the operational level courses conducted by the UBTS have provided additional training for health care workers.

RW: So what is your general verdict?

SO: The UBTS is perhaps the most successful of our development projects so far. The budget has been modest, and a lot has been achieved. Quality Assurance has been prominent in all its activities. This was possible because of dedicated leadership from Dr Watson-Williams and his counterparts. There was a detailed plan with specific targets right from the beginning. Regular evaluations have greatly assisted in assessing and improving progress.