Uganda has made progress towards improving the health of children, newborns, adolescent boys and girls, women and men in the country. However, Uganda still ranks among the top 10 countries in the world with high maternal, newborn and child mortality rates. Many policies have been implemented over the last 20 years trying to improve maternal and child health. The related health indicators are progressing but there is still much to do
By Pietro Dionisio
EU health project manager at Medea SRL, Florence, Italy
Degree in Political Science, International Relations Cesare Alfieri School, University of Florence, Italy
Uganda: the Big Challenge of Maternal and Child Health
Over the past two decades, Uganda has made progress in improving Reproductive, Maternal, Newborn, Child and Adolescent Health (RMNCAH) indicators. Nevertheless, RMNCAH conditions currently account for over 60% of years of life lost in Uganda constituting a major public health problem. Maternal mortality rates fell by only 20% over the past 20 years, decreasing too slowly to achieve national targets. The unacceptably high number of maternal deaths annually are mainly caused by hemorrhage, obstructed labor and complications from abortion and account for 2% of the annual maternal deaths globally. Moreover, almost 28% of maternal deaths occur in young women aged 15 – 24 years.
Actually, Uganda realized a steady reduction in child mortality rates between 1995 and 2016 from 156 to 64 per 1,000 live births with the annual rate of reduction increasing dramatically from 1.2% per year to 8.1% per year between 2006 and 2011. Unfortunately, while the infant mortality rates have followed a similar trend, neonatal mortality is decreasing at a slower pace with newborns experiencing a disproportionate burden of deaths among this age group. Under-five mortality is mostly attributable to neonatal conditions as well as three common childhood illnesses: malaria, pneumonia, and diarrhea often in synergy with underlying malnutrition.
The path is still long and a lot has to be done to reach the SDGs target by 2030. As such, according to the “Reproductive, Maternal, Newborn, Child and Adolescent Health Sharpened Plan for Uganda 2016/17 – 2019/20”, the Government is addressing the following topics:
- Improving maternal mortality (including improvement of skilled birth attendance and antenatal care),
- Improving adolescent health,
- Family planning,
- Ending preventable newborn and under-five mortality,
- Improving Universal Health Coverage (UHC),
- Provision of water and sanitation,
- Coverage of RMNCAH Interventions, &
- Malnutrition reduction.
But, how these dominions are treated? What about the outcomes of government directions so far?
As for the first point above, the maternal mortality has dramatically improved. Indeed, it has gone down to 336 per 100,000 live births (687 per 100,000 in 1990). The skilled birth attendance and the antenatal care are being improving, but great disparities persist between urban and rural areas as well as between educated mothers and the non-educated ones. In fact, while skilled attendance at birth rate is 89% in urban area, it is just 53% in the rural zones. Additionally, only 38% of mothers with no education had a skilled attendant at birth, compared to 55% of mothers with primary education and 93% with higher education.
Likewise, things aren’t going well if we consider “adolescent health”. Indeed, Uganda still has one of the highest rates of adolescent pregnancy and HIV incidence among young people in Sub-Saharan Africa. Overall, teenage birth rate or proportion of births per 1,000 women aged 15-19 years decreased from 204 to 111 between 1995 and 2016 with 24% giving birth to their first child before turning 19 years. Additionally, adolescent women are loath to use sexual and reproductive health services because of long waiting time, long queues, and poor quality services. Plans have been implemented and guidelines released (“Adolescent Health Policy Guidelines and Service Standards 2012”) to overtake this situation, but only slow pace progresses are obtained and more efforts should be devoted to adolescents’ health and related strategies.
Concerning family planning, overall, 39% of currently married women are using a method of family planning. Furthermore, the contraceptive prevalence rate among married women generally increases with age, peaking at 40-45 years old women (47%) before declining to 29% among women aged 45-49. Women with no education are less likely (26%) than women with any education (38-51%) to use a contraceptive method. Concerning sexually active unmarried women, 51% are currently using a contraceptive one.
Noteworthy, Uganda is moving towards Universal Health coverage (UHC) and a higher RMNCAH coverage. In fact, the Country has a strong health sector development plan that seeks to, among other goals, “accelerate movement towards UHC with essential health and related services needed for promotion of a healthy and productive life”. Additionally, a health sector monitoring and supervision framework has been set up and health services have been deployed both at national and local level.
Unfortunately, despite strong policies foundation, still a long way has to be covered to achieve UHC. At a time when 72% of the Ugandan population live within 5 km of a health facility, only 13% of health facilities carry out scheduled maintenance of medical equipment, while health workforce density is at 1.55 per 1,000 population and health facilities reporting availability of over 95% of a basket of commodities are only 55%.
What’s more, despite the presence of important and well-articulated programs, the water and sanitation sector is still a little bit tricky for the Country. In fact, almost 61% of Ugandans lack access to safe water and 75% do not have access to improved sanitation facilities. Many are the reasons explaining this state of the art, but the development of the socio-demographic fabric as well as the lack of good and prompt infrastructure are among the most relevant. In fact, since mid-‘90s, Uganda experienced a significant economic growth, leading to large population movements from rural to urban areas. Additionally, the high population growth, coupling with an inadequate infrastructure development, stressed the existing water and sanitation services. Many initiatives are currently on the ground to improve the situation. Among these, the last June, the African Development Bank approved a $62 million concessional loan to finance the Ugandan “Strategic Towns Water Supply and Sanitation Project (STWSSP)”. The project, to be implemented in 10 towns spread across the country over a five-year period, is designed to enable the government to achieve sustainable provision of safe water and sanitation for the urban population by 2030.
These prospects unfortunately couple with the awareness that RMNCAH plan is undermined by a high rate of women abuse cases. The 2016 Uganda Demographic and Health Survey revealed that up to 22% of women aged 15 to 49 in the country had experienced some form of sexual violence. The report also revealed that annually 13% of women aged 15 to 49 report experiencing sexual violence. This translates into more than 1 million women exposed to sexual violence every year in Uganda. Violence against women has recently taken new, more sophisticated forms. An increasing number of women are, for instance, reporting cyber-bullying and abuse through social media and smartphones.
In particular, ineffective laws pose a big challenge to the fight against women abuse. Laws such as the Penal Code (Amendment) Act 2007, the Domestic Violence Act 2010, the Sexual Offences Bill and the Marriage Bill do not address key violence against women. None of these laws criminalize marital rape, for instance. The Domestic Violence Act does not cover cohabiting partners, while the 2004 amendment to the Land Act of 1998 requires spousal consent to sex, but does not recognize coownership of land between spouses. The Land Act also fails to require customary land tenure systems to permit women to act as co-owners/managers of customary land, and creates weak protections for widows who seek to inherit their husband’s land. Additionally, the Employment Act, 2006 restricts punitive action in sexual harassment cases at work to an employer or his representative, saying nothing of physical, sexual and verbal abuse by coworkers.
Poor funding for “stop violence against women” programs also remains a huge challenge.
Things are not running well for malnutrition as well. As a malnutrition consequence, almost one-third of children under 5 years in Uganda are stunted. Stunting increases with age, peaking at 37% among children 18-35 months with a higher prevalence among children in rural (30%) than urban (24%) areas, with some regional variations. Unfortunately, more than 30% of the total population faces some level of chronic food insecurity. The causes of food insecurity in Uganda are multifaceted, often as a result of poverty, landlessness, high fertility, natural disasters, high food prices, lack of education, and the fact that a majority of Ugandans depend on agriculture as a main source of income. Gender inequality worsens food insecurity and poverty.
Admittedly, the Government is fighting this issue and several programs have been implemented (such as the “Uganda Nutrition Action Plan (UNAP)” or the “National Nutrition Planning Guidelines (2015)” and the “Multi-Sectoral Nutrition Action Planning Training Module (2017)”), but more has to be done to reach the national targets in this area.
To conclude, gender equality is not only a fundamental human right, but a pre-condition for sustainable development. Providing women and girls with quality education, health care, decent work, access and ownership rights over property and technology, and an equal participation in political and economic decision-making processes will lead to social, economic and environmental sustainability across the globe.
Uganda is strongly progressing in the protection of women and girls, yet a lot remains to be done. As a matter of fact, at a time when RMNCAH indicators are improving year by year and investments in the sector are growing nationwide and internationally, the overall healthcare and law system is not strong enough to underpin them.
Nevertheless, while discrepancies between what is written and the reality are still huge and time is needed to make further progress, the road is seemingly traced to achieve the foreseen targets by 2030.