From the Ground Up
The infrastructure that distributes AIDS drugs in Uganda grew out of an UNAIDS initiative. From June 1998 through July 2000,
UNAIDS ran a pilot program in Uganda called the Drug Access Intitiative (DAI), whose goal was to provide training, obtain
ARVs from pharma companies at preferential prices, and set up a distribution system for them. The distribution system, Medical
Access Uganda Limited (MAUL), has become an essential part of Ugandan healthcare. The goal of obtaining drugs at a discount
was less successful. According to a report on Uganda by Oxfam International, the price of ARVs in Uganda in 2000 was about
$1,000 a month—and that's in a country where the average adult earns about a dollar a day.
The situation improved as generics became available from Cipla in 2000, but also as the result of the Accelerating Access
Initiative (AAI), a 2002 partnership between the United Nations and five pharma companies (Boehringer Ingelheim, Bristol-Myers
Squibb, GlaxoSmithKline, Hoffman-La Roche, and Merck) to reduce prices in selected developing countries. Prices for many ARVs
in Uganda dropped by 50 percent or more, and the number of patients on therapy tripled at the Joint Clinical Research Center
(JCRC), the national AIDS research center, which had pioneered the use of ARVs in Uganda in 1996.
To a US reader, the names and acronyms of agencies and initiatives may have the comforting sound of established bureaucracies.
On the ground in Kampala, the reality is almost startling in its bare-bones simplicity. Take MAUL, for instance. To get there,
you travel out the same road that leads to Kabalagala, and turn in the gate of the warehouse of the Joint Medical Stores,
a religious not-for-profit supplier of pharmaceuticals. Upstairs, in a tiny office almost overwhelmed by two desks and a couple
of filing cabinets, you'll find Sowedi Muyingo, PharmD, and his assistant. Through their hands pass 70 percent of brand-name
antiretrovirals (and about 25 percent of all ARVs) that come into Uganda—$2 million worth of drugs in 2004.
3questions for Helmut Leuchten
"Far from rotting in warehouses," Muyingo explains, "there is a solid system for distributing drugs." Trucks carry shipments
from Entebbe Airport to Medical Access, where they are unloaded and accounted for. The products then must go through a quality
assurance check by Uganda's National Drug Authority, which takes samples of products before they are sold. Once the quality
is assured, they are priced at a 2-5 percent mark-up to cover MAUL's costs and stored at the Joint Medical Stores warehouse.
Finally, the drugs go off to MAUL's clients: hospitals, clinics, and community based organizations (CBOs). Out front, there's
a line outside the sales office of medical personnel waiting to pick up drugs (holding checks only, for fear of burglars),
while from the fax machine spills an order from Dick Muhwezi, project manager of the ARV program for the AIDS Support Organization
(TASO), the first and largest of the CBOs. With service centers located throughout the country, it provides substantial infrastructure
and has allowed AIDS efforts to progress by moving treatment out of the hospital and into the community. Today, Muhwezi wants
the usual first-line therapies—Combivir (lamivudine/zidovudine), Viramune (nevirapine), Sustiva (efavirenz), Zerit (stavudine),
and Epivir (lamivudine)—for his seven centers accredited to provide ARVs. Because his headquarters is in Kampala, a two-story
building renovated with a Pfizer grant, Muyingo arranges to deliver the order.