Honorable Ministers of Government;
Members of Parliament;
Deputy Vice Chancellor Lilliane Tibatemwa-Ekirikubinza;
Deputy Principal Celestino Obua;
Professor Seggane Musisi;
Leaders of the Makerere University College of Health Sciences;
Health Development Partners;
Future Health Care Professionals of Uganda;
All protocols observed –

Good afternoon! I am delighted to be here today with all of you as we mark World Health Day and the partnership between the U.S. Government and the People of Uganda. Together, we have done so much to create a healthier future for the citizens of this nation and we have even more to do to ensure that Uganda will have the healthy population it needs to take the country into a prosperous and productive future.

We have been partners in health for a very long time – USAID and the U.S. Peace Corps have been working in Uganda since its independence; the U.S. Centers for Disease Control has been collaborating with the Government of Uganda for over 20 years; the National Institutes of Health has been supporting collaborative research with Ugandan scientists since the 1960s and the Walter Reed Army Institute of Research, part of our Department of Defense, has been working in-country since the late 1990s.

Our partnership took on a new dimension, however, in 2009 when President Obama announced the Global Health Initiative – or GHI – a six-year, $63 billion worldwide effort that builds upon and moves significantly beyond existing disease-specific programs, such as the U.S. President’s Emergency Plan for AIDS Relief (better known as PEPFAR) and the President’s Malaria Initiative.

The Global Health Initiative incorporates a range of health concerns including nutrition, family planning, reproductive and maternal health, and newborn and child care, into an integrated approach that recognizes all these interventions must be supported by strong and effective health care delivery systems.

Through this comprehensive engagement, the GHI seeks to achieve significant health improvements and foster sustainable effective, efficient and country-led public health programs. At its core, GHI sees a future where there is a continuum of care and engagement. We begin with good ante-natal care and better baby delivery practices that protect mothers’ lives and produce healthy babies. Then we continue with nutrition programs and a strong child health focus that helps those children grow into adults living long and productive lives and contributing to their societies.

I believe that President Obama’s global vision of healthy children and families with adequate nutrition and good medical care is one that Ugandans share. And, as we work together on our GHI programs, I know we will move closer toward our shared goal of a healthy, prosperous, secure, and democratic Uganda.

However, to achieve this ambitious agenda, particularly in an environment constrained by challenging fiscal realities, we must ensure that we remain focused on high impact interventions that are proven to save lives and prevent diseases. Equally, we know that our interventions must be in harmony with those of the government; our goals and our vision must be shared to maximize our prospects for progress and success. And, given the serious and diverse challenges we face, working together to prioritize our efforts is critical.

Let me just highlight a few of the daunting facts we must consider:
HIV, malaria and tuberculosis continue to be the leading causes of death and disability in Uganda even though all three are preventable and treatable. Uganda’s HIV prevalence rate has increased to 7.3 percent; making Uganda the only country in sub-Saharan Africa with a rising prevalence rate. It is estimated that nearly 1.4 million Ugandans are living with HIV and each year over 64,000 Ugandans die from AIDS-related causes. There are an estimated 1.2 million orphans due to AIDS deaths.

Malaria? Well malaria prevalence in Uganda is among the highest in Africa, killing 320 of your fellow-citizens every day, or one person every five minutes, and causing almost 20 percent of the deaths among children under five years old.

And what about TB. It is a disease that gets far less attention than HIV or malaria, but nonetheless one in six Ugandans are reported to suffer from it and it causes 27000 deaths per year.

In addition, maternal and newborn mortality remain high. Every day, an average of 16 Ugandan women die in childbirth. That means in the course of our time together today discussing the future of a healthy Uganda, another family will mourn the death of a mother on what should have been a joyous occasion. And three more women will die before you have your supper tonight
Unfortunately, the story only becomes more troubling and the challenges even greater as this nation’s population grows at a breakneck pace.

With an estimated population over 35 million, a total fertility rate of 6.2 births per woman, and a population growth rate of 3.2 percent, Uganda’s population could double within 20 years and reach100 million people by 2050. Meanwhile only 26 percent of married Uganda women use a modern method of contraception, and although more than one third of married women wish to postpone their next pregnancy or stop bearing children, they cannot access contraception. This unmet need is one of the highest in sub-Saharan Africa. Sustained high fertility rates over decades have exacerbated poverty, strained public services such as health and education, and created a youth bulge with half of the population under the age of 15 years.

These facts are illustrative of the challenges the young medical professionals here will face. But we need to remember that behind these statistics lie real stories; stories of mourning families, devastated communities, and needless death and loss.
It does not have to be this way. We can and we must do better by working together, in an integrated fashion to implement strategies that have been proven to work. Doing so, I believe that can achieve our shared vision of a healthy and productive Uganda society.

The U.S. Government is committed to this vision. Every year we invest over $430 million, approximately 1.1 trillion shillings, to address these critical health issues in Uganda. One of my greatest frustrations, however, is when a Ugandan on my Facebook page says things like “thank you for the assistance, Ambassador, but you know that the money never reaches the people because it is eaten by corrupt officials and NGOs.”

Statements like that are, quite simply, wrong. Dead wrong. These concerns are perhaps understandable given the challenges of corruption and the recent reports on the misuse and theft of donor funds. I know, however, that my government’s assistance is making a difference and I know that every day we are touching the lives of Ugandan families and, in partnership with the government, changing their futures for the better.

Let us look, for example, at the fight against HIV/AIDS. Through the President’s Emergency Plan for AIDS Relief, or PEPFAR, the U.S. Government currently provides 700,000 Ugandans with care and support. We have tested and counseled 5.5 million people, including over a million pregnant women. PEPFAR also provides funding to eliminate mother to child HIV transmission to over 68,000 HIV-positive pregnant women, allowing countless Ugandan babies to be born HIV-free.

And every day 364,000 HIV positive Ugandans — including mothers who are there to raise and nurture their children and fathers who are there to be role models and to bring home wages — live healthy and productive lives because the people of the United States fund and support their antiretroviral treatment. Those 364,000 Ugandans represent over 80 percent of the total number of people who are on HIV treatment today in Uganda. We are so very proud to know that for those families, our engagement has made all the difference.

Other examples of our partnership can be found right here at Makerere University. Through PEPFAR, we are supporting the Baylor College of Medicine Children’s Foundation – Uganda as well the Infectious Diseases Institute. Earlier today I had the privilege to tour both facilities and learn more about the impact they are having on the lives of fathers, mothers, and children infected with HIV.

US Ambassador to Uganda, Scott DeLisi

However, perhaps the most important contribution we are making in this particular battle is through our support for the combination-prevention approach the Government of Uganda has chosen to pursue. HIV combination-prevention remains the single most powerful weapon in our fight for an AIDS-free generation. This approach is equal parts education and science, and the PEPFAR program contributes significantly to the evidence-based, bio-medical interventions that are a key part of the science component of the government’s strategy.

We are, for example, working in full partnership with the Ministry of Health on the prevention of mother-to-child transmission of HIV. We believe that Option B+, recently launched by the First Lady, has the potential to be one of the most critical bio-medical interventions in the fight against the epidemic. As the First Lady said, Option B+, if scaled up and implemented effectively across Uganda can be the key to actually eliminating mother-to child transmission of HIV and to realizing the dream of an HIV-free generation.

Another critical intervention where we know our resources will truly have impact is our joint effort with the Ministry of Health to increase significantly the number of HIV positive individuals who are receiving anti-retroviral therapy. It is clear that if those individuals who are HIV positive are not engaged, treated and counseled, they will continue to spread this disease and undercut our efforts. So scaling up treatment as a key to prevention only makes sense and we are fully engaged in this effort as well.

We also support strongly the government’s prioritization of Safe Male Circumcision as another important and effective tool to fight HIV/AIDS. Rigorous scientific research, some of it conducted right here at Makerere, shows conclusively that adult medical male circumcision reduces men’s risk of HIV infection from an HIV-infected female partner by approximately 60 percent. The government’s goal is to have 1 million Ugandan men circumcised this year and, through PEPFAR, we will fund and support the procedure for 750,000 men in that target group.

Safe male circumcision is a one-time, relatively quick procedure that confers a lifetime of reduced HIV infection risk on heterosexual men. Young men who choose circumcision are not only helping to protect themselves and their families but they are also demonstrating the personal responsibility we must all assume to contribute to the nation’s efforts to combat HIV. We need to make sure that all Ugandans understand the benefits of this procedure and ensure that Safe Male Circumcision is available to every man who wants it.

We must also ensure, however, that we provide them the counseling to understand that, as President Museveni has said, circumcision does not “make them metal.” It reduces greatly, but does not eliminate, the risk of HIV transmission a point that must be clearly made.

And this brings us back to the critical link between bio-medical interventions and education. We applaud the efforts that are being made by the government, religious leaders, and HIV activists to advance the education component of the combination-prevention strategy through renewed emphasis on the ABCs of HIV prevention: Abstinence, Being Faithful and Condom use. The challenge, however, is to ensure that this important education message is delivered in a way that supports, rather than undercuts, the evidence-based interventions that are also part of the government strategy.

For example, in HIV counseling people are told to use condoms, but in other fora condoms are condemned as encouraging promiscuity. Young men are urged to consider medical circumcision to reduce the risk of contracting HIV, but other voices suggest that circumcision only encourages them to act irresponsibly afterwards. A billboard in Kampala advising people cheating in a relationship to use condoms to protect themselves and their partners is taken down because it is viewed as promoting infidelity.

Ladies and gentlemen, these mixed messages hurt us all and they seriously undercut our efforts. These conflicting signals engender uncertainty and lessen the ability of people to protect themselves from the threat of HIV/AIDS and contribute to the increase in the prevalence rate. No one condones cheating. None of us want to encourage promiscuity. But we cannot pretend that these behaviors are not common in society and we must educate people to protect themselves and protect their partners from risky conduct even as we try to change their behaviors.

I believe we can do better when it comes to messaging on these issues and indeed we must. We can be firm and determined in calling for responsible sexual behavior, but let’s not allow condom use and circumcision to be miscast as unhelpful when, with proper guidance and counseling, they actually are part of the behavior models we encourage and when documented scientific evidence clearly shows they are key interventions for fighting HIV.

People need and deserve the best information possible to enable them to make informed decisions about their health and the health of their families. Let us find a way to ensure that they get it and that, in the process, we respect the importance of both behavior change and biomedical interventions.

Ultimately the goal we all share is an AIDS-free generation. We can only get there if we educate all Ugandans about what they can do to prevent HIV through messaging that is clear, consistent and embraces both components of our strategy.

Let me address next how our partnership with the Government of Uganda is also producing real results in tackling the single greatest killer in Uganda today: malaria. As with HIV/AIDs, the United States is working in close alignment with the government’s malaria strategy to address this threat and we also are proud to have the strong partnership of the United Kingdom’s Department for International Development in this effort. And, as with our HIV prevention and treatment interventions, I am confident that our assistance is helping to change lives and to save lives. Since 2006, nearly 3 million people in 10 districts in Northern Uganda have been protected from malaria through US-funded Indoor Residual Spraying, a proven effective method that reduces malaria transmission.

We have procured and distributed over four million Long Lasting Insecticide treated Nets and we have provided over 160,000 malaria-in-pregnancy treatments. We have also trained over 6,000 health workers in administration, case management, and improved diagnostics for Intermittent Preventive Treatment of Malaria in Pregnancy.

The story behind these numbers is what matters to me, though. What these interventions mean is that pregnant women will not keep falling ill with malaria – a disease that could potentially jeopardize their lives and those of their unborn babies. They mean that fewer children under five years of age, who are so vulnerable to this disease, will die. They mean that, together, we are helping to create healthy and prosperous communities and building a new future for Uganda.

There is, however, still much work to be done to prevent and control malaria. We need to ensure that every mother receives Intermittent Preventive Treatment of Malaria and that every household receives a Long Lasting Insecticide treated bed net. These two simple interventions will save hundreds of thousands of lives and that is a result worth fighting for.

The U.S. Government’s partnership with Uganda also extends to the global health security threats we face due to pandemic contagious diseases such as Ebola, Plague and Marburg. Over the last decade, the U.S. Government has supported Uganda in numerous outbreak responses and is committed to building capacity for long-term health impact through surveillance, epidemiological investigation, laboratory diagnostics and response support.

Another major focus of U.S. health assistance to Uganda is family planning and maternal and newborn health. The U.S. Government, in collaboration with the Government of Uganda, supports programs to reduce maternal deaths and reduce unmet need for family planning. We focus on proven, effective, high-impact interventions that save mothers’ and newborns’ lives, including increasing access to voluntary family planning, birth spacing, antenatal care, skilled care at birth, and emergency obstetric and newborn care. And the work is more critical than ever given that maternal mortality rates in Uganda have risen to 438 deaths per 100,000 live births instead of dropping. I fear that the target of bringing this number down to 131 deaths per 100,000 births by 2015 seems an elusive dream. That is all the more reason, however, for us to commit to this effort.

Studies have shown that the easiest and most cost effective way to save a mother’s life is to reduce the number of pregnancies she has. If she is not pregnant, she will not die in childbirth and it is clear that a mother giving birth to her seventh child in a ten year span is at far greater risk than a mother who has had the chance to make carefully considered decisions about what will be best for her health, her body and her family. Birth spacing is, quite simply, essential to all women’s health, and I join the First Lady in her call for men to be more engaged and more responsible participants and partners in decision-making about health care issues and the family’s future.

Also in the maternal health arena, we are working with the Government of Uganda and private sector partners to implement the Saving Mothers, Giving Life (SMGL) program in four districts in western Uganda. Through this joint effort we hope to significantly reduce maternal deaths in these districts by finding solutions that keep mothers alive during labor, delivery, and the 24 hours following delivery. Similar interventions are being implemented by the government throughout the country and we look forward to expanding our partnership in maternal health in the months ahead.

The critical consideration shaping our engagement in these issues of maternal health is the basic premise that every woman should be given the right to choose when she wants to have a baby and how many babies she will have. Voluntary family planning allows women, and their partners, to make informed choices and It is essential that women be provided information on all available family planning methods and be allowed to choose the appropriate method for her and her family. I know that there are cultural and societal values that influence these decisions and as a non-Ugandan there is little I can appropriately add to that discussion.

I do believe, however, that there are concerns here that transcend a cultural context and I believe that we must also look honestly and thoughtfully at the implications of unchecked population growth for the nation’s economic future, for its health, and the life of the women of this country. One respected and influential traditional leader in Zambia, Chief Mumena, recently offered some very thoughtful words in this regard. He said “culture is not set in concrete; it is dynamic. …What is the purpose of holding on to a culture that is going to see you extinct? This is not about culture; it is about survival.”

I cannot tell you whether or how your culture should change but I think those words are telling. Whether talking about family planning, HIV, circumcision, or condom use we must strip away the myths and confusion that surround these issues and have thoughtful, honest and focused discussions about these challenges that Uganda struggles with today and that you will suffer from even more tomorrow if they are not effectively addressed.

As I said at the outset, at the core of President Obama’s Global Health Initiative is the recognition that effective health care delivery systems are essential to the implementation of all the programs I have discussed today. It goes without saying that health professionals must have access to basic but essential tools: things like soap, clean water, and electricity are critical, but too often unavailable. And what about transport and blood supply? These too must be readily available.

In essence, the government must find ways to provide the fundamental tools that skilled health workers need to do their jobs, for without them how do any of our well-conceived plans and programs ever reach the people who need them?

For the future medical professionals in the audience today, I can assure you that the U.S. Government is dedicated to working with the Government of Uganda to strengthen essential health services. We believe it is vital to ensure that all Ugandans have access to the care they need and that you have the support you need to carry out your work.

U.S. Government assistance for health systems is broad and we work not only with government but with private sector partners as well. Our support extends to human resources for health, including recruitment, retention and motivation; performance improvement; targeted pre-service training; and comprehensive in-service training. We also provide considerable support for supply chain management, building laboratory capacity, ensuring blood safety, and strengthening information systems and governance.

In fact, I just returned yesterday from Fort Portal where we dedicated a new Blood Bank funded through our PEPFAR program that is a result of a robust and ongoing partnership between our Centers for Disease Control Office and the Uganda Blood Transfusion Service. And I would note that one of the leading causes of maternal mortality is hemorrhaging and blood loss. Continued strengthening of the Blood Transfusion Service is critical to all our interventions and I hope that the Government will match, and ultimately take a full leadership role in funding this vital need.

Our work on health systems also provides desperately needed support for human resource development. With assistance from the U.S. Government, approximately 500 doctors, nurses and laboratory technicians completed their training in the last three years and another 5,000 staff will complete training in the next five years. Over 330 district health staff in 58 districts were trained in medicines management supervision and stores management.

And I am pleased to note that the Ministry of Health recruitment for Health Centers III and IV has been successful. 5519 new health workers have reported to work as of last week, which is 70% of those who were offered positions. Furthermore we hope to have up to 7000 new health workers in HC III and HC IV, before the end of this financial year.

To the young health professionals here today I say that we are investing in you because we believe in you. We know that you are critical to achieving our vision of a healthy Uganda and we want you to succeed. We want you to have the tools and resources you need to provide life-saving and life-enhancing services so that you can be the first one to touch a newborn’s life and bring that child into this world safely.

However, responsibility for the transformation of the Uganda health care system lies not with U.S. assistance and international donor funding. The transformation belongs to you and your fellow citizens. You must stand up and ensure that your voices are heard in shaping the priorities of your government. You must insist on transparency and accountability in Uganda’s health systems and as taxpayers and citizens you deserve. You must demand more, not just for yourself but for your families and your children, and your children’s children. You are the key to building a health care system of which your nation will be proud.

We will work with you for a shared vision of a healthy Uganda. Where no baby is born with HIV and no child dies of malaria. Where no women give birth on a hospital floor because of inadequate facilities or dies in childbirth because she couldn’t pay for treatment that should be available without discrimination to all.

We hope for a Uganda where all citizens have the information they need to make healthy choices. We will work together for a Uganda where clinics have the medicines and supplies they need to save lives. Where there are enough medical staff to treat each and every Ugandan who walks in the door. And we will work together for a Uganda where the future health care professionals, like those in the audience today, have the training they want and need to serve your communities and your nation.

You are the future of health care in Uganda. You will care for your fellow-citizens, you will save lives, you will strengthen health systems and you will shape the policies of the future. Your skills will be important, but so will your vision and your values, which ultimately will define who you are and how you will serve.

As we celebrate World Health Day, think about where you want to start. And think of where you want to end up. Of why you serve and why you care. Knowing that; knowing what matters to you is at the heart of everything.

And that is why my government and the American People are so engaged, why we stand with you. Because we know what matters to us. For us, helping the people of Uganda to grow strong, to be healthy, and to be successful models for East Africa matters. It is good not only for the people of Uganda but for us all. So, as you begin your journey as medical professionals, know that the people of the United States of America stand ready and willing to be your partners on that journey as you shape your destiny and the destiny of Uganda.

As we have for so many years and in so many ways, let us continue to work together to build a better, brighter and healthier future for all Ugandans. I look forward to being part of that effort with you.

Thank you.