Health in Uganda

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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. As of 2013, disease expectancy at birth in Uganda was 58 years, lower than any other country in the East African Community except Burundi.[1] As of 2015, the probability of a child dying before reaching age five was 5.5 percent (55 deaths for every 1,000 live births).[2] Total health expenditure as a percentage of gross domestic product (GDP) was 7.2 percent in 2014.[3]

Uganda was hit very hard by the outbreak of the HIV/AIDS epidemic in East Africa. In 2015, an estimated 1.5 million people in Uganda were infected with HIV,[4] and the HIV prevalence rate in the country was 7.2 percent.[5]

Uganda is home to the Uganda Virus Research Institute, considered one of the most advanced viral research facilities in East Africa.[citation needed] Uganda is one of the three countries where randomised controlled trials for male circumcision were conducted to inform the WHO policy decision on voluntary medical circumcision.[6]

Common illnesses and treatments[edit]

Patients in Uganda

As of 2015, the average life expectancy in Uganda was 64 years for women and 60 years for men.[7] The leading causes of death in Uganda include communicable diseases such as HIV/AIDSmalariarespiratory infections, and diarrheal disease. The risk factors most responsible for death and disability include child and maternal malnutritionunprotected sexual activity, contaminated water and poor sanitation, and air pollution.[21]

HIV treatment in Uganda has centered on human antiretroviral therapy through task shifting, or increasing the scope of health workers who can administer treatment (ie. community health workers, nurses, etc).[8] This shift in treatment occurred through the World Health Organization's 2004 "Integrated Management of Adult and Adolescent Illness" guide.[8] A study from 2006 of HIV-infected adults in Uganda showed risky sexual behavior to have declined, contributing to the decline in HIV incidence.[9] From 1990 to 2004, HIV rates have declined by 70% and casual sex by 60%.[10] Health communication was also listed as a potential cause of inducing behavioral changes in the Ugandan population.[10] Current barriers to reducing HIV incidence include food insecurity in rural areas and stigma against HIV counseling and testing.[10][11]

In 2013, 16 million cases of malaria and 10,500 deaths were reported in Uganda.[12] In 2002, the Ugandan government formalized the process of treating fevers through home-based care.[13] Mothers were able to better recognize symptoms of malaria and as a result took their children to a community medicine distributor early on in the illness.[13] The Integrated Management of Childhood Illness allowed for better recognition of malaria's symptoms.[13] Treatment either involved immediately taking the child to see a nearby healthcare worker or acquiring the treatment of chloroquine and SP, also known as HOMAPAK.[13] However, resistance to HOMAPAK emerged, and drug recommendations by the WHO changed to artemisinin combination therapy (ACT).[13] After the midterm review in 2014 of the national plan for malaria reduction and the malaria programme review in 2010, the national strategy to reduce malaria is being redesigned.[14] Currently, Uganda is treating malaria through distribution of insecticide-treated nets, indoor spraying of insecticides, and preventative therapy for pregnant women.[15] The disease burden of malaria, however, remains high and is further strengthened by inadequate resources, understanding of malaria, and increased resistance to drugs.[15]

Health infrastructure[edit]

Uganda's health system is composed of 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.

Structure of health system[edit]

The not-for-profit providers are run on a national and local basis and 78% are religiously based.[8] Three main providers include the Uganda Catholic Medical Bureau, Uganda Protestant Medical Bureau, and the Uganda Muslin Medical Bureau.[8] Nongovernmental organizations have emerged as prominent not-for-profit organizations for HIV/AIDS counseling and treatment. [7]The for-profit providers include clinics and informal drug stores. Formal providers include medical and dental practitioners, nurses and midwives, pharmacies, and allied health professionals.[7]Traditional providers include herbalistsspiritual healerstraditional birth attendantshydro therapists, etc.[7][8]

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).[16] The aim of Uganda’s health system is to deliver the national minimum health care package. Uganda runs a decentralized health system with national and district levels.[16]

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 serve 5,000 peoole. Next in level is Health Center III (HCIII) which serves 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 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.[17]

In terms of governance, 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.[18]

According to a 2006 published report, 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.[18]

Health system reforms[edit]

At the beginning of the 21st century, 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.[19] 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.[20][21]

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. Implementation of the health sub district concept extended into the early 2000s.[18]

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.[22]

Health system performance[edit]

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. 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 focus on the poor, improve engagement of the private-for-profit sector, enhance efficiency, strengthen stakeholder coordination, improve service quality, and 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.[22]

A number of factors affect the quality of services in Uganda, including the shortage of healthcare workers and lack of trust in them, a lack of needed treatments, high costs, and long distances to facilities.[23] In 2009, a survey conducted of Ugandan patients indicated a decline in the performance of the public sector health services. These were indicated through comments about poor sanitation, a lack of professionals and drugs and equipment, long wait times, inadequate preventative care, a poor referral system, rude health workers, and lack of services for vulnerable populations like the poor and elderly.[23] The quality of services affects utilization in different ways, including preventing patients from seeking out delivery services or leading them to see traditional providers, self medicate, and decide not to seek formal care or seeing private providers.[23]

Health workforce[edit]

There is a significant shortage of health workers in Uganda. 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. According to a 2009 published report, 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 percent of the population resides, as 70 percent of all doctors are practicing in urban areas.[24] There are 61 institutions that train health workers, with five medical colleges, twenty-seven allied health training schools, and twenty nine nursing schools.

Community health worker training has increased since the 2000s. The Ugandan Ministry of Health implemented the Village Health Teams (VHT) Training Program to develop community health workers who connect rural communities to health facilities and aid in the spread of preventative knowledge about malariapneumonia, worm infestations, diarrhea, and neglected tropical disease.[17] VHTs have also aided in health campaigns and disease surveillance. Nongovernmental organizations, such as Health Child Uganda and Omni Med, have also been working with the Ministry of Health to train and maintain VHTs.[18]

An assessment of VHT abilities led to the creation of a Community Health Extension Worker (CHEW) Program, which involves the training of health workers for a year in all districts of the nation.[17]Unlike VHTs, CHEWs will possess elevated skills in addressing the health needs of their communities, will be based at the Health Center II level.[17] The CHEW program is planned for implementation in 2017 and 2018.[17]

Health financing[edit]

Total public and private health expenditure per capita was US$59 in 2013.[25] Public financing for health was 4.3 percent of GDP in 2013,[26] well below the target of 15 percent set in the 2001 Abuja Declaration.[27]

Service delivery[edit]

In 2006, there were 3,237 health facilities in Uganda.[7] Seventy one percent were public entities, 21 percent were not-for-profit organizations, and 9 percent were for-profit.[7] The doubling in public and not-for-profit facilities was primarily driven by the government’s initiative to improve access to services.[7] However, 68% of these services are located in the capital Kampala and the surrounding central region, while rural areas face a gross shortage of such facilities.[7]

According to the Uganda National Household Survey 2012/2013, the majority of those who sought health care first visited a private hospital orclinic (37 percent) or a government health centre (35 percent). Twenty-two percent of the urban population used government health centers, while that proportion rose to 39 percent in the rural areas. Thirty-five percent of government health centers visited by persons who fell sick were within a radius of 5 kilometres (3 mi) from the population.[28]

Reproductive health[edit]

Reproductive health (RH) 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. RH care also includes sexual health, the purpose of which is the enhancement of life and personal relations.[29]

Fertility rate and family planning[edit]

Uganda has the second-highest fertility rate in the East African Community, behind only Burundi. According to 2014 data, a Ugandan woman, on average, gives birth to 5.8 children during her lifetime compared to 7.1 in 1969 and 6.8 in 2001.[30] The age-specific fertility rates indicate that fertility peaks when women are aged between 20 and 24 years and then declines slowly until age 34. According to 2011 data, the fertility rate in urban areas (3.8 per woman) was significantly lower than in rural areas (6.7 per woman).[31]

Based on 2012 data, 30 percent of married Ugandan women are using some method of contraception, with 26 percent using modern contraceptive methods (MCM), such as female and male sterilization, pill, intrauterine device, injectables, implants, male condom, diaphragm, and the lactational amenorrhea method. MCM were used by only 8 percent of married Ugandan women in 1995.[31] There is a gap between the demand for contraception and the amount of contraception being made available. Several organisations are providing health education and contraceptive services.[32]

Antenatal care, facility deliveries, and postnatal care[edit]

Antenatal care (ANC) coverage in Uganda in 2011 was almost universal with more than 95 percent of women attending at least one visit. Only 48 percent of women, however, attended the recommended four visits. Deliveries in health facilities accounted for about 57 percent of all deliveries, far below the number of women who attend at least one ANC visit. That percentage had risen from 41 percent between 2006 and 2011.[31]

Only one-third of women received postnatal care (PCN) in the first two days after delivery. In 2011, only two percent of mothers received a PNC check up in the first hour for all births in two years before the 2011 Uganda Demographic Household Survey.[31]

Table: Uganda Trends in Selected SRH indicators[31]

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[edit]

Sexual health in Uganda is affected by the prevalence of HIV, sexually transmitted infections (STI), the poor health-seeking behaviours regarding STIs, violence, and female genital mutilation that affect female sexuality in isolated communities in the north-eastern part of the country. As of 2015, Uganda's national HIV prevalence rate was 7.2 percent among adults aged 15 – 59 years, representing an increase from 6.7 percent in 2005. Prevention now includes voluntary male circumcision, although sexual behaviors among circumcised men need more understanding.[33]

Men's health[edit]

Issues affecting men including violence, sexually transmitted diseases, prostate cancers, infertility, HIV, and non-communicable diseases that affect sexual performance. The latest intervention that could improve men's sexual health is male circumcision.[34]

Maternal and child health[edit]

A maternal health nurse in Karamoja.

The 2010 maternal mortality rate per 100,000 births was 430, compared to 352.3 in 2008 and 571 in 1990.[citation needed] The under-five mortality rate, per 1,000 births is 130, and the neonatal mortality as a percentage of under-fives' mortality is 24.[citation needed] 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.[citation needed]

Maternal health[edit]

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.[35] According to UNICEF, Uganda's maternal mortality ratio, the annual number of deaths of women from pregnancy-related causes per 100,000 live births,[36] was 440 from 2008 to 2012.[37] The Millennium Development Goal (MDG) for 2015 concerning the maternal mortality ratio was 131 per 100,000 births. The MDG also set a goal for all births to be attended by a skilled health professional,[38]

In rural areas, conceiving pregnant women seek the help of traditional birth attendants (TBAs) because of the difficulty in accessing formal health services and high transportation or treatment costs. TBAs are trusted as they embody the cultural and social life of the community. The TBAs' lack of knowledge and training and the use of traditional practices, however, have led to risky medical procedures resulting in high maternal mortality rates. Those rates also persist because of an overall low use of contraceptives, the limited capacity of health facilities to manage abortion/miscarriage complications, and the 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 according to a 2013 published report.[39]

Only 47 percent of Ugandan women receive the recommended four antenatal care visits, and only 42 percent[37] of births are attended by skilled health personnel. Among the poorest 20 percent of the population, the share of births attended by skill health personnel was 29 percent in 2005/2006 compared to 77 percent among the wealthiest 20 percent of the population.[38]

Gender based violence[edit]

Domestic violence (DV) is a key issue in reproductive health and rights. Most of the DV is gender-based.[40] Physical violence is the most prevalent type of DV in Uganda, with one quarter of women reporting it. More than 60 percent of women who have ever been married have reported experiencing emotional, physical, or sexual violence from a spouse.[41]

In 2011, about 2 percent of women reported to have undergone female genital mutilation, a practice that is dying away in the areas where it was more frequently practiced.[31]

Health in the Northern Region[edit]

Northern Uganda is one of the four major administrative regions in Uganda. The region was devastated by a protracted civil war between the government of Uganda and the Lords Resistance Army as well as the cattle rustling conflict that lasted for 20 years.[42][43]

Since the war ended in 2006, the internally displaced person camps have been destroyed and people have resettled back to their former homesteads. The region, however, still has many health challenges, such as poor health care infrastructure and inadequate staffing at all levels (2008 published report);[44] lack of access to the national electricity grid (2007 published report);[45] an inability to attract and retain qualified staff;[citation needed] frequent stock outs in the hospitals and health facilities;[citation needed] emerging and re-emerging diseases such as Ebola, nodding syndrome, onchocerciasis, and tuberculosis;[46] malaria epidemics;[citation needed] reintegration of former abducted child soldiers who returned home (2007 study);[47] lack of safe drinking water as most boreholes were destroyed during the war;[citation needed] the HIV/AIDS epidemic (2004 published report);[48] poor education standards with high failure rates in primary and secondary school national examinations (2015 published report);[49] and poverty (2013 published report).[50]

Health indicators[edit]

According to the 2015 Uganda Bureau of Statistics (UBOS) report:[51]

  • The region has one of the highest HIV prevalence rates of 8 percent in the country, second only to Kampala.
  • The region leads in poverty with 80 percent of households living below poverty line compared to only 20 percent of the country in general living in poverty. The region has the lowest per capita house hold expenditure of UGX:21,000 compared to UGX:30,000 of the general population. Up to 26 percent of people are chronically poor
  • The region leads in illiteracy with only 60 percent of the population aged 10 years and above being literate compared to 71 percent of the general country population.
  • Most districts in the region lack clean piped water supply with the exception of a few town centers like Gulu, Lira, Arua, and Soroti. The pit latrine coverage ranges from 4 to 84 percent in some districts, the worst in the country.
  • The region has the lowest numbers of health facilities compared to other regions of the country. Of the total 5,229 health facilities in Uganda (2,867 operated by the government, 874 operated by non-governmental organizations (NGOs), and 1,488 private facilities), there are only 788 health facilities in the Northern Region (664 operated by government, 122 operated by NGOs, and 2 private facilities). Health facility deliveries range from 7 percent in Amudat, to 81 percent in Gulu.[51]
  • The region has the highest total fertility rate of 7.9 children per woman compared to the nationwide 6.1 rate.[31]
  • The Karamoja sub-region has high maternal mortality ratios.[52] According to the 2001 Uganda Demographic and Health Survey, the Northern Region was the worst in infant child mortality indicators (under age 5 mortality: 178 deaths per 1000 live births) (under age 1 mortality: 105 deaths per 1000 live births) (neonatal mortality: 42 deaths within the first month of life per 1000 live births).[38] For purposes of the 2011 Uganda Demographic and Health Survey, the Northern Region was subdivided into West Nile, North, and Karamoja, with the other three regions having seven subdivisions, for a total of ten subdivisions nationwide. Karamoja's under age 5 mortality rate (153 deaths per 1000 live births) was the worst in the country, with West Nile's rate (125) the third worst and the North's rate (105) the fourth best. West Nile's under age 1 mortality rate (88) was the worst in the country, with Karamoja's rate (87) the second worst and the North's rate (66) the fifth best. West Nile's under one month mortality rate (38) was the second worst in the country, with the North's rate (31) tied for fourth worst and Karamoja's rate (29) being the fourth best.[38]
  • Nodding syndrome hit the region during the early to mid-2000s, although the international community did not become aware of it until 2009 when the WHO and the US Centers for Disease Control and Prevention first investigated it.[53] The disease affected children aged 5–15 years, mainly in the Acholi sub-region and a few in the Lango sub-region.[54] Over 3,000 confirmed cases were documented as of 2012, with Uganda having the highest number of cases in the world.[55] The disease has profound health effects on children, families, and communities.[56] The children who were previously healthy and growing well are observed by the parents to nod mainly at meal times initially, progressing to head nod when it is cold, etc. These children eventually develop various forms of epileptic seizures as well as disabilities such as severe malnutrition, burns, contractures, severe kyphosis, cognitive impairment, and wandering away from homes.[57] Since the interventions began in 2012, there have been no new cases reported in the region. The exact cause of this disease has not been found, although there is strong association with oncocerchiasis. Communities believe their children could have been exposed to chemicals during the war, particularly when they were displaced into internally displaced persons camps because they observed that their children became sick only when in the camps.[58]
Sub County Nodding S Nodding S Epilepsy Epilepsy
Male Female Male Female
Awere 230 188 231 198
Atanga 144 129 95 84
Lapul 34 32 23 22
Agagura 119 108 70 64
Laguti 172 164 115 110
Acholi Bur 03 04 18 23
Puranga 13 12 148 146
Pader 13 11 21 16
Total 728 648 721 663

See also[edit]


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