Health in Uganda

Ugandan patients at the Out-Patient Department of Apac Hospital in northern Uganda. The majority are mothers of children under 5 years old with malaria.

As a developing country, health in Uganda lags behind many other countries but is at par with the countries in the WHO AFRO region. Recent statistics show that life expectancy at birth in Uganda is around 54 years. Child mortality (death before the age of five years) occurs in 90 of every 1000 live births. Total health expenditure as a percentage of GDP was 8% in 2012.[1]

Uganda was hit very hard by the outbreak of the HIV/AIDS epidemic in East Africa. In the early 1990s, 13% of Ugandan residents had HIV; this had fallen to 4.1% by the end of 2003, the most effective national response to AIDS of any African country (see AIDS in Africa).

Uganda is home to the Uganda Virus Research Institute (UVRI), considered one of the most advanced viral research facilities in East Africa and one of the three countries where the randomised controlled trials for Male circumcision were conducted to inform the WHO decision on the Voluntar medical circumcision as a policy.

Reproductive Health in Uganda

Reproductive health is a state of complete physical, mental and social well-being in all matters relating to the reproductive system and to its functions and processes. It implies that people have the capability to reproduce and the freedom to decide if, when and how often to do so. Implicit in this is the right of men and women to be informed and to have access to safe, effective, affordable and acceptable methods of family planning of their choice, as well as other methods of their choice for regulation of fertility, which are not against the law, and the right of access to health-care services that will enable women to go safely through pregnancy and childbirth. Reproductive health care also includes sexual health, the purpose of which is the enhancement of life and personal relations.[2][3]

Within the RH rights are certain human rights already recognized by the Ugandan laws. However, rights of LGBT men and women are not recognized and their activities are outlawed and punishable. The ensuring of RH rights apart from couples and individuals decide freely and responsibly about reproduction with information and means, they should also ensure the ability and in fact attainment of the highest standard of SRH. This may be limited in Uganda because women empowerment (proper gender relations on equitable terms) in the rural areas still lacks significantly and domestic violence hampers this for women.

Further information: Reproductive health

Fertility

Uganda has one of the highest fertility rates in the Eastern Africa region, with a woman on average having about 6.2 children in her reproductive lifetime with prevailing rates.[4][5][6] There has been no significant decline in fertility for the last several years.[7][8][9] There is a critical mass of young women because of a very young population, and therefore the population growth as a result is set to keep increasing steadily even if fertility was to decline in the next few years. The Age Specific Fertility Rates indicate fertility peaks when women are aged between 20 to 29 years as opposed to the high income countries. Women thus start to have children early and go on to have them till later ages. The declines in fertility however have been realized in the urban areas and among the women with higher levels of education.[4] However a critical mass of women still live in the rural areas where majority of the general population is based. HIV has not had an influence on the fertility trends since it was discovered in Uganda. Fertility rates were high before HIV and continue to hover over above the 6 children figure even with the drops in annual HIV deaths. The graph below right portrays HIV deaths over the time since 1990 to 2011 for Uganda and its TFR over the same period. This is in comparison with selected regional countries and South African where HIV deaths are much higher but TFR is low. Interventions targeting lowering fertility through family planning are ongoing in Uganda since seeveral decades ago. Thirty percent of married women are using a method of contraception in Uganda (CPR) but with much lower figures for modern methods (mCPR). This is an improvement from as low as 5% in 1988. However, there is still a huge gap between the demand for family planning and the met need with more than one third of women having a need to use family planning but are not doing anything.[4] This gap is what in population studies is referred to as the unmet need for FP. This is an opportunity to address the unwanted pregnancies. Several organisations are providing health education and contraceptive services but this gap is not yet fully addressed. There are several factors why some women may have access but still not use contraceptives.[10]

Antenatal care, Facility deliveries and postnatal care

Further information: Maternal health in Uganda

ANC coverage in Uganda by 2011 was almost universal with above 95% of women attending at least one visit. However the rates drop to only 48% when you consider the recommended 4 visits. ANC attendance has stagnated for the last few years since 2006.[11] Health facility deliveries in Uganda are about 56% of all deliveries, way below the number that attends at least one ANC visit. The silver lining is that the proportion rose from 41% over a 5-year period and should rise further over time if current trends hold. Postnatal care on the other hand is even less common than facility delivery care. only a third of women actually received this care in the first 2 days post delivery. The health workers are also overwhelmed by the numbers that this could affect postnatal care. for example in 2011, only 2% got PNC check up in the first hour for births in 2 years before the 2011 UDHS.[4]

The primary health-care system as recommended from the ICPD plan of action to most (but not all) individuals is existing in the country include some family planning counselling, IEC services, and services for prenatal care, safe delivery and post-natal care. However, post abortion as specified in the programme of action is not existing in Uganda because abortion is illegal except in clearly outlined conditions to save a mothers life.

Table: Uganda Trends in Selected SRH indicators

Indicator 1980 1995 2000 2006 2011
Births attended by skilled health staff (% of total) 38 39 42 58
Maternal Mortality Ratio 435 561 505 435 438
Contraceptive Prevalence rate 19 24 30
Unmet Need for FP 35 41 34
Total fertility rate 7.1 7.1 6.9 6.7 6.2
HIV Prevalence (% of Adult Population) 10.2 7.3 6.7 7.3
Percentage of men (15-59) circumcised 25 27

Sexual Health

Sexual health in Uganda is affected by the high prevalence of HIV with a generalized epidemic and several STIs, the poor health seeking behaviours regarding STIs, violence and some practices such as FGM that affect female sexuality in isolated communities north east parts of the country Uganda has a prevalence of 7.3 in the adult population aged 15 – 59 years (MOH and ORC Macro, 2012). This has increased from 6.7 in 2005. There are several possible explanations including the increased coverage of ARVs that have prolonged the lives of people living with HIV but also a surge in risky sexual behaviours with increased multiple sexual partnerships among people in stable relationships citation Needed. Prevention has now included a new measure of male circumcision (Government of Uganda MOH, 2010) although sexual behaviors among circumcised men need more understanding[12]

Further information: HIV/AIDS in Uganda

Gender Based Violence

Domestic Violence is a key issue in reproductive health and rights and most of the DV is gender-based.[13] Domestic violence is prevalent in Uganda especially among women. Physical violence is the most prevalent with one quarter of women reporting it. Intimate partner violence is the most common form of violence in Uganda that could affect reproductive health right. more than 60% of women who were ever married report having experienced emotional, physical, or sexual violence from a spouse and several of them have experienced physical injuries as a result. reporting for domestic violence is not a common thing in Uganda. In 2011, about 2% of women reported to have undergone FGM, a practice that is dying away in the areas where it was more practiced.[4]

Men's Health

Men have been more or less ignored in Uganda in sexual and Reproductive health. However there are issues that affect men including violence, sexually transmitted diseases, prostate cancers, infertility, HIV specifically, other NCDs that affect sexual performance. a lot needs to be explored in this area especially with men having poor health seeking behvaiours even for other non RH related illnesses. The latest intervention that could improve men's sexual health is male circumcision. This could also have benefits on the women's health in the long run with reduced HIV prevalence among men if population interventions are successful.

Maternal and child health

A maternal health nurse in Karamoja

In June 2011, the United Nations Population Fund released a report on "The State of the World's Midwifery".[14] It contained new data on the midwifery workforce and policies relating to newborn and maternal mortality for 58 countries. The 2010 maternal mortality rate per 100,000 births for Uganda is 430. This is compared with 352.3 in 2008 and 571 in 1990. The under-five mortality rate, per 1,000 births is 130 and the neonatal mortality as a percentage of under-fives' mortality is 24. The aim of this report is to highlight ways in which the Millennium Development Goals can be achieved, particularly Goal 4 – Reduce child mortality and Goal 5 – improve maternal death. In Uganda, the number of midwives per 1,000 live births is 7 and 1 in 35 is the lifetime risk of death for pregnant women.[15]

Further information: Child health in Uganda
Further information: Maternal health in Uganda

Maternal Health

A nurse in Uganda monitoring a patient's heart rate with a Pinard horn stethoscope.

The World Health Organization (WHO) defines maternal health as the health of women during pregnancy, childbirth and the postpartum period.[16] According to estimates from UNICEF, Uganda’s maternal mortality ratio, the annual number of deaths of women from pregnancy-related causes per 100,000 live births,[17] stands at 435 [18] after allowing for adjustments. Women die as a result of complications during and following pregnancy and childbirth and the major complications include severe bleeding, infections, unsafe abortion and obstructed labour.

Uganda is slow in its progress in the fifth goal of improving maternal health in its Millennium Development Goals. With the 2015 target for maternal mortality ratio at 131 per 100,000 births and proportion of births attended by skilled health personnel set at 100%,[19] Uganda has a long battle in reaching its intended goals. Moreover, the methodology used and the sample sizes implemented by the Uganda Demographic Health Survey (UDHS) do not allow for precise estimates of maternal mortality.[19] This suggests that the estimates collated are erroneous and it is conceivable that the actual rates could be much higher than those reported.

High maternal mortality rates persist in Uganda due to an overall low use of contraceptives, limited capacity of health facilities to manage abortion/miscarriage complications and prevalence of HIV/AIDS among pregnant women. Despite malaria being one of the leading causes of morbidity in pregnant women, prevention and prophylaxis services are not well established.

In rural areas, conceiving pregnant women seek the help of traditional birth attendants (TBAs) due to difficulty in accessing formal health services and also high transportation or treatment costs. TBAs are trusted as they embody the cultural and social life of the community. However, the TBAs’ lack of knowledge and training and the use of traditional practices have led to risky medical procedures resulting in high maternal mortalities.

Almost all women in developing countries have at least four antenatal care visits, are attended to by a skilled health worker during childbirth and receive postpartum care. In contrast, only 47% of Ugandan women receive antenatal care coverage and only 42% [18] of births are attended by skilled health personnel. Among the poorest 20% of the population, the share of births attended by skill health personnel was 29% in 2005/2006 as compared to 77% among the wealthiest 20% of the population.[19] The case of Jennifer Anguko,[20] a popular elected official who bled slowly to death in the maternity ward in a major hospital, aptly exemplifies the poor state of maternal health care that is provided to women, even in major urban healthcare facilities.

Despite the national policy of promoting maternal health through promoting informed choice, service accessibility and improved quality of care through the national Safe Motherhood Programme (SMP), it remains a challenge to the Ugandan government as to how it would achieve its 2015 Millennium Development Goals of reducing maternal mortality rates and 100% births attended to by skilled health personnel. In order to achieve future economic growth, it is vital that the population remains healthy.

The Health System in Uganda

A health system denotes all the people and actions whose primary purpose it is to produce health.[21] This includes formal health services provided by health clinics and traditional healers; health promotion and disease prevention; and community-based and home management of illnesses. In line with this broad definition, Uganda’s health system comprises health services delivered in the public sector, by private providers and by traditional and complementary health practitioners. It also includes community-based health care and health promotion activities. The aim of Uganda’s health system is to deliver the Uganda National Minimum Health Care Package (UNMHCP). Uganda runs a decentralized health system with national and district levels.[22]

Structure of Uganda's Health System – A tale of two levels

Uganda’s health system is divided into national and district-based levels. At the national level are the National Referral Hospitals, Regional Referral Hospitals and semi-autonomous institutions including the Uganda Blood Transfusion Services, the National Medical Stores, the Uganda Public Health Laboratories and the Uganda National Health Research Organization (UNHRO).[22]

The lowest rung of the district-based health system consists of Village Health Teams (VHTs). These are volunteer community health workers who deliver predominantly health education, preventive services and simple curative services in communities. They constitute level 1 health services. The next level is Health Center II which is an out patient service run by a nurse. It is intended to service 5,000 population. Next in level to HC II is Health Center III (HCIII) which services 10,000 people and provides in addition to HC II services, in patient, simple diagnostic and maternal health services. It is managed by a clinical officer. Above a HC III is the Health Center IV, run by a medical doctor and providing surgical services in addition to all the services provided at HC III. HC IV is also intended to provide blood transfusion services and comprehensive emergency obstetric care.[23]

The table below summarizes the district-based health system(4)

Health System Reforms

At the turn of the millennium the Government of Uganda began implementing a series of health sector reforms that were aimed at improving the poor health indicators prevailing at the time. A Sector-Wide Approach (SWAp) was introduced in 2001 to consolidate health financing.[24][25] Another demand side reform introduced in the same year was the abolition of user fees at public health facilities, which triggered a surge in outpatient attendances across the country.[26]

Decentralization of health services began in the mid-1990s alongside wider devolution of all public administration, and was sealed in 1998 with the definition of the health sub district.[27] Implementation of the health sub district concept extended into the early 2000s.[28] The aim of decentralization was to improve the management and delivery of health services at the local level.

To improve medicines management and availability, the Government of Uganda made medicines available to private-not-for-profit (PNFP) providers. With decentralization of health services, a ‘pull’ system was instituted in which district and health facility managers were granted autonomy to procure medicines they needed in the required quantities from the national medical stores, within pre-set financial earmarks. The result was better availability of medicines.[29]

Health System Performance

A comprehensive review of Uganda’s Health System conducted in 2011 uncovered strengths and weaknesses of the health system, organized around the six technical building blocks of health system that were defined by the WHO.[30] In summary the assessment found that whereas significant efforts are being implemented to qualitatively and quantitatively improve health in Uganda, more needs to be done to a)focus on the poor; b) improve engagement of the private-for-profit sector; c) enhance efficiency; d) strengthen stakeholder coordination; e) improve service quality; and f)stimulate consumer-based advocacy for better health.

The Ministry of Health (MOH) also conducts annual health sector performance appraisals that assess health system performance and monitor progress in delivery of the UNMHCP

Health Workforce – Not enough, not well spread

A Human Resources for Health Policy is in place to guide recruitment, deployment and retention of health staff. In spite of this, shortages of health workers persist. There is one doctor for every 7,272 Ugandans. The related statistic is 1:36,810 for nurse/midwifery professionals. The shortages are worse in rural areas where 80% of the population resides, as 70% of all doctors are practicing in urban areas.[31]

Health Financing

Total health expenditure per capita is estimated at $51, below the WHO recommendation of $60.[32] Public financing for health is at 8.4%, below the Abuja target of 15%.[33] The graph shows trends in government health financing in comparison to the regional target.

Figure 1: Trends in Public Expenditure on Health in Uganda

Health Information Systems

The country has transitioned to a computerized web-based system in 2013 (DHIS 2). This is expected to improve use of real-time data for planning and budgeting.[33]

Service Delivery

Seventy seven percent of Ugandans live within 5 km of a health facility.[34] The health sector is on track to meet three out of eight core health service indicators in the Health Sector Strategic Investment Plan (HSSIP). Targets for antenatal care attendance, delivery in a health center, malaria prophylaxis in pregnancy and early infant diagnosis of HIV are lagging behind national targets.

Medical Products, Vaccines and Technologies: Work in progress

Management of essential medicines and supplies is a weak point of Uganda’s health system. Drug shortages are prevalent. In 2012/13 51% of health facilities faced stockout of tracer medicines monitored by the ministry of health.[33]

Governance and Stewardship

All relevant policies and regulations are in place. The MOH is currently implementing the HSSIP, which is the third iteration of health sector strategies. The MOH coordinates stakeholders and is responsible for planning, budgeting, policy formulation and regulation.

The health sector at the district and sub district level is governed by the district health management team (DHMT). The DHMT is led by the District Health Officer (DHO) and consists of managers of various health departments in the district. The heads of health sub districts (HC IV managers) are included on the DHMT. The DHMT oversees implementation of health services in the district, ensuring coherence with national policies. A Health Unit Management Committee (HUMC) composed of health staff, civil society and community leaders is charged with linking health facility governance with community needs.

References

References

  1. ↑ The World Bank. "Health expenditure, total (% of GDP)". http://data.worldbank.org/indicator/SH.XPD.TOTL.ZS?order=wbapi_data_value_2012+wbapi_data_value+wbapi_data_value-last&sort=asc''.
  2. ↑ World Health Organisation. "Reproductive health". http://www.who.int/topics/reproductive_health/en/''.
  3. ↑ UNFPA. "Summary of the ICPD Programme of Action". http://www.unfpa.org/public/cache/offonce/home/sitemap/icpd/International-Conference-on-Population-and-Development/ICPD-Summary;jsessionid=601A58E091A75BA2A74F1ADBD79C0589.jahia01#chapter7''. Retrieved September 2014.
  4. ↑ 4.0 4.1 4.2 4.3 4.4 Uganda Bureau of Statistics (UBOS) and ICF International Inc. "Uganda Demographic and Health Survey 2011. Kampala, Uganda:". http://dhsprogram.com/pubs/pdf/PR18/PR18.pdf''. UBOS and Calverton, Maryland: ICF International Inc.
  5. ↑ http://www.prb.org/wpds/2014/
  6. ↑ Population reference Bureau. "2014 World Population Data Sheet". http://www.prb.org/wpds/2014/''. PRB.
  7. ↑ http://www.prb.org/Publications/Datasheets/2013/2013-world-population-data-sheet.aspx
  8. ↑ http://www.prb.org/Publications/Datasheets/2012/world-population-data-sheet.aspx
  9. ↑ http://www.ubos.org/.../ubos/pdf%20documents/UDHS2006Preliminaryreport.pdf
  10. ↑ Nalwadda, Gorrette; Mirembe, Florence; Byamugisha, Josephat; Faxelid, Elisabeth (2010). "Persistent high fertility in Uganda: young people recount obstacles and enabling factors to use of contraceptives" (PDF). BMC Public Health 10 (30). doi:10.1186/1471-2458-10-530.
  11. ↑ Uganda Bureau of Statistics (UBOS) and ICF International Inc.2007. "Uganda Demographic and Health Survey 2006" (PDF). dhsprogram.com/pubs/pdf/FR194/FR194.pdf. UBOS and ICF International Inc.
  12. ↑ Kibira, Simon Peter; Nansubuga, Elizabeth; Tumwesigye, Nazarius; Atuyambe, Lynn; Makumbi, Fredrick (2014). "Differences in risky sexual behaviors and HIV prevalence of circumcised and uncircumcised men in Uganda: evidence from a 2011 cross-sectional national survey" (PDF). Reproductive Health 11 (25). doi:10.1186/1742-4755-11-25. Retrieved 3 September 2014.
  13. ↑ http://www.who.int/topics/gender_based_violence/en/
  14. ↑ The State of the World's Midwifery
  15. ↑ "The State Of The World's Midwifery". United Nations Population Fund. Retrieved August 2011.
  16. ↑ "World Health Organization: Maternal Health". World Health Organization. Retrieved 20 February 2012.
  17. ↑ "Women; Definitions". UNICEF. Retrieved 20 February 2012.
  18. ↑ 18.0 18.1 "Uganda; Statistics". UNICEF. Retrieved 20 February 2012.
  19. ↑ 19.0 19.1 19.2 "Millennium Development Goals Report for Uganda 2010" (PDF). United Nations. Retrieved 20 February 2012.
  20. ↑ Dugger, Celia (29 July 2011). "Promising Care: Maternal Deaths Focus Harsh Light on Uganda". The New York Times. Retrieved 20 February 2012.
  21. ↑ 1. World Health Organization. The world health report 2000 - Health systems: improving performance. Geneva, Switzerland, 2000.
  22. ↑ 22.0 22.1 2. Ministry of Health, Government of Uganda. The Second National Health Policy. Promoting People's Health to Enhance Socio-Economic Development. Kampala, Uganda July 2011
  23. ↑ 3. Ministry of Health, Government of Uganda. Health Sector Strategic Plan 2000/01 – 2004/05. Kampala, Uganda. 2000
  24. ↑ 5. HDPG. 2002. SWAp Mechanisms and Structures. Mimeo. Health Development Partners Group, Kampala, Uganda.
  25. ↑ 6. Jeppsson A. 2002. SWAp dynamics in a decentralized context: experiences from Uganda. Social Science and Medicine, 55 (11): 2053–60.
  26. ↑ 7. Yates R, Kirunga-Tashobya C, Cruz v, McPake B, Ssengooba F, Murindwa G, Lochoro P, Bataringaya J, Nazerali H and Omaswa F. The Ugandan health systems reforms: miracle or mirage? In: Kirunga-Tashobya C, Ssengooba F, Cruz V, editors. Health Systems Reforms in Uganda: Processes and Outputs. Health Systems Development Program, London School of Hygiene & Tropical Medicine, UK.2006. Available from http://docs.mak.ac.ug/sites/default/files/Health%20Sytems.pdf
  27. ↑ 8. Ministry of Health, Government of Uganda. The Health sub-district Strategy. Kampala, Uganda. 1998.
  28. ↑ 9. Murindwa G, Kirunga-Tashobya C, Kyabaggu JH, Rutebemberwa E and Nabyonga J. Meeting the challenges of decentralized health service delivery in Uganda as a component of broader health sector reforms. In: Kirunga-Tashobya C, Ssengooba F, Cruz V, editors. Health Systems Reforms in Uganda: Processes and Outputs. Health Systems Development Program, London School of Hygiene & Tropical Medicine, UK.2006. Available from http://docs.mak.ac.ug/sites/default/files/Health%20Sytems.pdf
  29. ↑ 10. Nabyonga J, Desmet M, Karamagi H, Kadama PY. Omaswa FG, Walker O. 2005. Abolition of cost-sharing is pro-poor: evidence from Uganda. Health Policy and Planning, 20 (2): 100–8.
  30. ↑ 11. Ministry of Health, Health Systems 20/20 and Makerere University School of Public Health. Uganda Health System Assessment 2011. Kampala, Uganda and Bethesda, MD. 2012
  31. ↑ 12. Global Health Workforce Alliance and WHO. Human Resources for Health Country Profile for Uganda. Geneva, Switzerland. 2009. Available from http://www.who.int/workforcealliance/knowledge/resources/hrh_profile_uganda/en/
  32. ↑ 13. World Bank. World Development Indicators [Internet]. Available from http://data.worldbank.org/indicator/SH.XPD.PCAP?order=wbapi_data_value_2009%20wbapi_data_value%20wbapi_data_value-first&sort=asc
  33. ↑ 33.0 33.1 33.2 The Republic of Uganda, Ministry of Health. Annual Health Sector Performance Report Financial Year 2012 / 2013. Kampala, Uganda. 2013
  34. ↑ 15. Uganda Bureau of Statistics. Uganda National Household Survey 2012/2013. Kampala, Uganda. 2013

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