In Uganda, The HIV and AIDS Health Epidemic Should Be Tackled Through Taxation

Context and background introduction

In September 2012 a working paper was released entitled ‘ Justification for Increased and Sustainable Financing for HIV in Uganda’ which looks to set out an innovative solution to funding HIV and AIDS prevention. Similar models have been proposed throughout the East African Community (EAC). The proposal suggests levying small taxes on petrol, telephone calls, beer, soft drinks and electricity which will be collected in a fund and used solely to tackle the disease in Uganda.

But is this a realistic and viable proposal? Let’s discuss!

Agree 1: It will reduce Uganda’s reliance on international support

Developing strategies that will enable Uganda to become less reliant on foreign aid will be supported by both Ugandans and the donor community. It will be a starting point from which Uganda can build from, with the goal of becoming less dependent on aid [1]. This is the next stage in Uganda’s development as it seeks to develop a health service that provides for the needs of its people without over reliance on external support.

Counterpoint: Not enough revenue will be raised

It is unlikely that the money raised will reach the $336 million given by donors in 2010-2011. As recently as September 2012 Barack Obama gave $10.75 million [2] to three NGOs working to prevent HIV and AIDS in Uganda. The HIV and AIDS fund will not be able to generate that amount of money in the near future although it hopes to raise $1 billion [3] in the longer term. However it will not create enough revenue to provide adequate funding in the short-term.

Disagree 1: The poorer pay proportionally more

The tax would not differentiate on earnings but on usage of things such as telephone calls, electricity and the purchase of certain goods (tobacco, alcohol and fuel). There is a danger that the tax could be seen as placing a greater burden on the poorer [11] in society as the margins are much finer at the and that the state is once again taking more without offering anything significant in return. There is the possibility that the tax would be seen as further entrenching the divide between rich and poor in Uganda.

Counterpoint: It is a tax on luxury items

The tax is mainly on luxury items and therefore the amount of usage is a choice and in fact the wealthy will contribute more as they use more, and spend more, on items like phone calls/electricity/goods. Furthermore it will be those less well-off who will benefit most from the fund as the money will be mainly directed at helping them not those from wealthier backgrounds who often have the choice of paying for their healthcare privately.

Agree 2: Reduced strain on health and education sectors

A fund devoted solely to HIV and AIDS protection will enable a clear strategy to be developed with regards to the issue, specifically in terms of health and education approaches. It will also free up funds in both health and education budgets which can be used to tackle other outstanding issues of which there are many in Uganda: Maternity units in some of Kampala’s main hospitals are ill-equipped and ambulances in a state of disrepair are not uncommon . [4]

Counterpoint:

The government may see the HIV and AIDS tax not as addition to the current budget to fight the disease but a way of reducing the health and education budgets so that funds can be reallocated to other sectors, most probably security sector reform. In the 2012/2013 financial year the budget for health was reduced from 814 billion to 761 billion Ugandan shillings [5]. And there is a strong possibility that funding would continue to decline as the funds revenues began to increase.

Disagree 2: Corruption will be an inescapable feature

Corruption continues to be a major issue at the level of national politics in Uganda. Convincing them to part with more money for government initiatives would be met with anger and claims that it too will be misappropriated. Current debates over the National Oil and Gas Bill reflect the demand for greater transparency [12] and pose the question of how will the money be dispersed and to whom. These are questions that would need to be asked of the HIV and AIDS Tax Fund. Theft of HIV funds [13] has taken place in Uganda so why would this measure not have the same results?

Counterpoint: It is the role of the state to deliver services for its citizens

It is the responsibility of the state to reflect the will of its people and ultimately, it is the primary actor tasked with delivering services that improve the lives of citizens. It should be given the chance to do so. Fear of corruption should not prevent the generation of new ideas that have the possibility to impact positively on reducing HIV and AIDS in society. Museveni has recently spoken about the need for Uganda to keep up the fight [14].

Agree 3: A way of re-engaging citizens in discussing the issue

By taxing citizens on items such as telephone calls it will serve as a daily reminder of the HIV and AIDS issue that needs to be tackled. Increased civic engagement may lead to greater interest and involvement on the issue at the community level and ultimately projects that can have impact at that level are often the most likely to be sustainable and successful. Secondly with a significant proportion of Uganda’s population being youth – the median age of Ugandans is 15.5 years [6] – it is crucial to ensure their engagement and the fund will be able to do this by at least ensuring that they maintain awareness of the disease.

Counterpoint: It might make citizens resentful of helping HIV and AIDS victims

Citizens who are forced to give up a small portion of their income to contribute to the financing of the fund may grow resentful that HIV and AIDS is an issue which is being raised above other causes such as better healthcare or improving roads. If they are aware of how to protect themselves against HIV and AIDS why should they help people who are less careful and who have failed to listen to the numerous warnings [7] that have been issued previously?

Disagree 3: Ineffective Strategy

It is time to review the ABC (Abstinence, Be Careful and Condom) approach and adopt new and innovative strategies and ways of thinking to tackle the issues more in tune with the Ugandan youth of today. It is not the amount of money being spent on HIV and AIDS prevention which is the problem but the methods being championed. For example the issue of homosexuality remains one completely ignored by any strategy [15] and its continued criminalisation does not help the fight against HIV and AIDS in Uganda. A positive development is Ugandan civil society joining force to draw up a 10 point plan [16] setting out practical ways forward.

Counterpoint: Funding and Strategy are not the same

Even if new strategies are needed that is no reason not to try and come up with new ways of funding HIV and AIDS prevention. They are two separate, although connected, issues. It appears that stagnant thinking may have played a part in the gradually increasing infection rates since 2005 [17] and therefore it is important to demonstrate innovative thinking in sourcing funds to tackle HIV and AIDS. The proposed fund shows that the Ugandan state is aware of the problem and is addressing the issue but recent legal provisions have been criticised [18].

Agree 4: Moral obligation to fulfill Human Rights and MDG Pledges

Millennium Development Goal 6 requires states to have universal access to HIV and AIDS treatment [8] and to have begun the reversal and spread of the disease by 2015. This fund will assist Uganda in achieving those goals as since 2005 there has been a slight increase in infection rates and there is still a continued need for greater access to treatment. More broadly, it will assist the Ugandan government in promoting and protecting human rights

Counterpoint: Is the State morally obliged to provide healthcare?

Concentrating on the lofty goals of ‘human rights obligations’ when it concerns healthcare provision misses the broader more practical challenge: Uganda’s health-care brain drain. The flight of Ugandan nurses is principally fuelled by nursing shortages in wealthy nations. While rich countries average 222 doctors per 100,000 people, Uganda has fewer than 6. Put another way, Uganda has 3,000 practicing doctors to treat 34.9 million people [9]. Medical professionals are being poached by wealthier countries at an alarming rate. In addition, Uganda trains very few doctors [10] because of the cost burden in medical school education. Focusing on the rhetoric of ‘human rights obligations’ from wealthy countries that distracts from the brain drain problem they help maintain.

Disagree 4: Complacency not underfunding

It has been suggested that a relaxed attitude towards the disease amongst both citizens and the state has played a crucial role in the gradually rising rates on HIV and AIDS infection. Uganda had such great success in lowering its rates from 1991 to 2005 that a degree of complacency has begun to undermine the great strides previously made. The need is not for greater funding but for a change in attitude towards tackling the disease.

Counterpoint: Funding addresses awareness as well as financial aspect

The fact that the government is proposing this HIV and AIDS fund, and has made it publicly available so that discussions can be held about its suitability, shows that it is keen to generate public dialogue on the issue. This is an effort to bring the issue back into focus –that the way the proposed fund might work increases public engagement and may also have the effect of changing attitudes through inescapable engagement.

However, two years after the research was completed and generated momentum for the HIV and AIDS fund things have gradually stalled.

References & Background Reading

Aids: 20 Ugandans who Made a Difference by Shifa Mwesigye (Dec 2, 2012) The Observer (Uganda)

Corruption and HIV AIDS in Uganda by How does corruption affect the fight against HIV/AIDs unit 9 learning module(2009) (for HTML link) World Bank Institute Professional Development Programs for Parliamentarians & Parliamentary Staff

AIDS pandemic at ‘beginning of the end’, say campaigners by Catharine Paddock PhD (Dec 1, 2014) Medical News Today

[1] Malik Fal — Advocacy for Small-Medium Enterprises on Poverty Cure website

[2] US gives Uganda 27b to fight HIV/AIDS by John Odyek (Sept 27, 2012) New Vision

[3] Uganda: HIV trust fund in the works (Oct 3, 2012) IRIN

[4] Maternal Deaths Focus Harsh Light on Uganda by Celia W. Dugger (July 29, 2011) New York Times

[5] Experts divided over HIV strategy by Rukiya Makuma (Sept 9, 2012) The Independent (Uganda)

[6] Median ages in Africa infographic tweeted by @GlobalPost (Jan 1, 2015) Twitter

[7] Uganda’s Soaring HIV Infection Rate Linked to Infidelity by Hilary Heuler (April 19, 2013) Voice of America (USA)

[8] Goal 6: Combat HIV/AIDs, Malaria and other diseases by United Nations

[9] Uganda, fueling the brain drain, sends MD’s to Trinidad (Dec 30, 2014) Black Star News (USA)

[10] Why is Uganda exporting doctors it doesn’t have? by Flavia Nassaka and Haggai Matsiko (Dec 8, 2014) The Independent (Uganda)

[11] Towards taxation for development: challenges and opportunities – the case of Uganda (Nov, 2010) SEATINI. See pages 12 and 13.

[12] Oil in Uganda website

[13] Uganda: Global Fund probe reveals massive graft by (April 3, 2006) IRIN

[14] Return to abstinence, Museveni tells youth by Flavia Lanyero (Dec 3, 2012) Daily Monitor (Uganda)

[15] Uganda: HIV trust fund in the works (Oct 3, 2012) IRIN

[16] The ten point plan to kick HIV out of Uganda (Dec 3, 2012) New Vision (Uganda)

[17] Uganda losing fight against HIV/AIDs, UN official says (May 18, 2013) by Daily Monitor (Uganda)

[18] Uganda: New Law Criminalizes HIV/AIDS Transmission, Requires Pregnant Women to Undergo HIV Testing by Hanibal Goitom (Sept 17, 2014) Library of Congress (USA)