Florence Mirembe, Freddie Ssengooba, and Rosalind Lubanga

Map of Uganda 2

Summary 3

Background 5

Reproductive Health Policies and Programs 8

Funding for Health Services 21

Policy Implications 25

Recommendations 29

Endnotes 30

Appendix 31

Tables and Figures: — Recurrent health expenditures, 1994-98, Uganda 21 — Total health sector development expenditures, 1994-97, Uganda 22 — Reproductive health funding by USAID, 1995-98, Uganda 22 — Reproductive health budget allocation, Kabarole District, 1997-98 23 — Client charges by service and level of care (in US$) 24

Florence Mirembe, Freddie Ssengooba, and Rosalind Lubanga September 1998 The Republic of Uganda is located in East Africa and lies on 47 percent of the population is under age 15, while 23 percent are the equator (see map). It is a landlocked country bordered by Kenya, women of reproductive age (ages 15 to 49). About 90 percent of Tanzania, Rwanda, Democratic Republic of Congo, and Sudan. the Ugandan population lives in rural areas and depends on agricul- Uganda has an area of 241,038 square kilometers, with 18 percent ture. About 66 percent of the population—a large proportion of open water and 12 percent forest reserve and game parks. Uganda whom are women—lives below the poverty level. Per capita GNP is mainly tropical forest and savanna woodlands. Uganda has is US$300. 54 tribes of Bantu, Nilotic, Nilo-hamitic and Sudanese origin. The case study covers four districts, shown in highlights Uganda had an estimated population of 21 million people in here: Kampala, Jinja, Lira, and Kabarole, in the central (capital), 1998 with a growth rate of 2.6 percent. It is estimated that eastern, northern, and western regions of the country, respectively. UGANDA Summary

nly recently emerging from the devasta- IMPROVEMENTS IN REPRODUCTIVE O tion of a major civil war, the Ugandan HEALTH SERVICES government is committed to improving Family planning programs have helped to increase the health and well-being of its population by using contraceptive use from 5 percent of married couples the country’s available resources. Uganda faces in 1990 to 15 percent of married couples in 1995. major reproductive health problems that include The rate is thought to be much higher today. Family high infant and maternal mortality, high fertility, and planning programs have also begun to provide more high rates of teenage pregnancies and unsafe abor- comprehensive services, including care for STIs, tions. It is estimated that between prenatal care, and childhood 1.5 million and 2 million Ugan- immunizations, as opposed to dans are infected with HIV/AIDS. As a result of “vertical” contraceptive services In the last five years, Uganda alone. This has led to obvious has undergone many political, legal, massive information, increases in service use, especially and institutional changes that have education, and among under-served client groups influenced all development activi- such as men and adolescents. ties. Some changes have been communication Uganda has also adopted a conducive to improving the status campaigns, as well as multisectoral strategy to fight the of women and reproductive health. high prevalence of HIV and STIs. These include the new constitu- research and voluntary The open government policy on tion, which guarantees women’s counseling and testing, the HIV problem has enabled political representation, and several national and international efforts national policies in the areas of more than 90 percent to innovate and organize to population, gender equality, and of adults know address the problem at all levels of universal primary education, which society. As a result of massive promotes girls’ education. about HIV/AIDS. IEC campaigns, as well as research Within the broad reproductive and voluntary counseling and health framework adopted at the testing, more than 90 percent of International Conference on Population and adults know about HIV/AIDS. Most current Development (ICPD), the Ministry of Health is programs are targeting behavior change, especially focusing on the major priority programs that most among young people. There are indications of a affect the population. These programs include safe declining trend in HIV incidence and an increase in motherhood and child survival, family planning, condom use in general. prevention and management of sexually transmitted More attention has also been given recently to infections (STIs) and HIV/AIDS, capacity building, safe motherhood, child survival and nutrition, and adolescent health, infrastructure development, postnatal and postabortion care. Efforts to improve and information education and communication these services have included training and retraining (IEC). Though most programs have been in place of providers, equipping health facilities, and mobiliz- since before the ICPD, most have changed focus ing communities. Systems are also being piloted to to incorporate aspects of the ICPD Programme refer pregnant women to hospitals in the event of of Action. life-threatening complications of labor and delivery.

3 Summary

REPRODUCTIVE HEALTH FINANCING and district levels who can implement health-sector The government’s contribution to the health sector reforms and reproductive health programs. The has been increasing, but is still low given the low available manpower is not deployed in favor of the tax base in the country (per capita income is only primary health care system that serves the majority about US$300). The government spends only about of the population. Information provided to US$4 per capita annually on health, but surveys individuals seeking care and service choice and indicate that per capita health spending from both quality are unsatisfactory. public and private sources increased from US$8 in Reproductive health programs—and indeed 1993-94 to US$12 in 1996-97. all development programs—are now implemented The government’s creation and subsequent in a decentralized fashion, with funding and increase of a primary health care grant to local management responsibilities in the hands of local governments is testimony of its commitment to governments. In this context, the coordination community health, which benefits mostly women of donors, NGOs, and the commercial sector and children. Reproductive health programs are is essential to ensure donor funds are distributed primarily donor-financed—donors pay for about equally to different communities and to ensure 90 percent of all investments. This raises serious access to priority services. The study team observed questions about how programs will be sustained weaknesses in coordination at both the national after donor funding ends. and local levels. Nevertheless, health programs currently attract Universal access to reproductive health services about 22 percent of all development assistance to can only become a reality when the entire system’s the country, an increase from 13 percent in 1993-94. capacity is strengthened. Efforts are needed to Family planning, safe motherhood, and prevention develop human resource capacity and infrastruc- of HIV/AIDS and STIs have attracted more funding ture—in particular, roads and communications in the last five years. More funding has also gone systems. In order for these changes to occur, into universal primary education, agriculture, road resources must be made available and coordinated construction, and poverty alleviation programs, well in the health sector and other sectors that which also have an impact on the population’s influence the health system. health status.

ASSESSMENT OF PROGRESS AND OBSTACLES The study reveals a supportive policy environment for reproductive health and rights whose benefits are yet to be felt at the community level. Major challenges to implementation include a lack of skilled manpower, infrastructure, and community awareness. There are few trained professionals at the national

4 UGANDA Background

REPRODUCTIVE HEALTH IN UGANDA quality of health care. There is also a remarkable Uganda faces many serious reproductive health shortage of manpower in health units at all levels, problems, most of which are preventable. The major poorly motivated providers in public health facilities, reproductive health problems in Uganda include and insufficient drugs, supplies, and equipment. high perinatal, infant, and mater- This situation has led to commu- nal morbidity and mortality. The nities being less able to afford 1995 Uganda Demographic and Uganda is a and access health care, including Health Survey estimated that reproductive health services. the maternal mortality rate is 506 patriarchal society. Other factors associated with deaths per 100,000 live births; Men are the poor reproductive health are perinatal mortality is 47 deaths per sociocultural practices, beliefs, 1,000 live births, and infant decisionmakers in the values, and inappropriate atti- mortality is 81 deaths per 1,000 social, economic, tudes. Examples are early age of live births.1 Uganda has one of marriage and high illiteracy rates, the highest adolescent pregnancy and political spheres, especially among women. Most rates in Africa (43 percent). The and especially in ethnic groups in Uganda are majority of these pregnancies are polygamous, a practice that is unwanted. Consequently, there households. This increasingly associated with the is a high rate of unsafe, induced makes women very spread of STIs and HIV infection. abortion and associated complica- Early marriages and polygamy tions. A 1994 study showed that vulnerable. may also be responsible for the unsafe abortion causes between high fertility and population 20 percent and 30 percent of all growth rates in Uganda. maternal deaths.2 Women have, on average, 6.9 Uganda is a patriarchal society. Men are the children, and only 15 percent of married couples use decisionmakers in the social, economic, and political contraception. There is a high prevalence of repro- spheres, and especially in households. This makes ductive tract infections and STIs, including HIV/ women very vulnerable. Among many ethnic AIDS. Between 1.5 million and 2 million Ugandans groups, children are a means of social security for are infected with HIV/AIDS. Although little data women. Having children allows them to secure are available, infertility and female genital cancers are their marriages, gain social status, and gain access to major public health problems. Female genital family property. mutilation (FGM) is less widespread, but exists in Most women marry before age 18, the legal one tribe, the Sabiny in the Kapchorwa District. age at marriage in Uganda. This promotes high There are currently efforts to stop the practice, and fertility, as women start bearing children at a very the rate appears to be declining. early age and continue unabated until a late age. It is Several factors are believed to have led to the estimated that over 70 percent of Ugandan women poor reproductive health profile in the country. have had their first pregnancy by age 19. These include civil strife, which ravaged the country for over 20 years, leading to the breakdown of the national economy, health infrastructure, and the

5 Background

The literacy rate in Uganda The doctor to population is reported to be 61 percent For most women, ratio is 1:30,000, while that of (50 percent among women and midwives is 1:3,000. Use of 73 percent among men). Illiteracy access to quality maternal health services is low: makes it difficult for women to reproductive health Trained providers in health units access services, understand and deliver babies for only about conceptualize issues, and gain care remains elusive. 38 percent of mothers. TBAs economic power and empower- Many rely instead deliver 15 percent, relatives deliver ment—especially regarding 35 percent, and 12 percent of decisionmaking and controlling on self-medication and women give birth by themselves. their reproductive and sexual traditional healers TBAs have received intensive health and rights. training in a bid to provide For most women, access to and birth attendants mothers with safe maternity quality reproductive health care who operate outside services. These efforts, however, remains elusive. Many rely instead have not reduced the national on self-medication and traditional the formal health maternal mortality rate. The lack healers and birth attendants who system. For example, of effect could be partly due to operate outside the formal health poor targeting of the training system. For example, the majority the majority programs. Relatives, for example, of mothers do not benefit from of mothers do not have not been included in training trained health providers at delivery. programs, although they assist benefit from trained about one-third of deliveries. THE HEALTH CARE SYSTEM health providers The national health policy Health care in Uganda is provided promotes primary health care through the Ministry of Health at delivery. (PHC) by improving the quality (MOH), the local government, and and effectiveness of services and the private sector, which includes by improving sources of funding. NGOs, private medical clinics, drug shops and The government is working to encourage collabora- pharmacies, and traditional birth attendants (TBAs) tion and coordination between health services and and healers. Thirty percent of Ugandans are reported to improve guidelines. to use modern health services. Of those using Presently, Uganda is divided into 43 districts modern services, 40 percent use public health facili- created to facilitate administration. The districts are ties and 60 percent use the private sector. subdivided into counties, parishes, and villages as the The public sector has different levels of care, smallest administrative unit. The administrative including hospitals (at the highest level), health centers, structure is aimed at facilitating community-based dispensaries and maternity units, aide posts, and the problem identification and solving for priority areas community. All of these offer curative and preventive like education, health, sanitation, agriculture, and health services. Providers of these services have diverse roads, under the guidance and supervision of the training and specialization, which dictates the levels and government’s line ministries. type of services given. For example, most doctors and specialists serve in the hospitals and in the private sector in urban settings, while nurses and midwives serve in rural health facilities.

6 Background

ICPD PROGRAMME OF ACTION Economic Development, and Gender, as well as The ICPD, held in Cairo in 1994, emphasized the with major donors in the health sector. The team importance of reproductive health to women’s also reviewed current reproductive health literature, overall well-being and called for programs to government policies, strategic plans, and program increase the availability and equity of reproductive evaluation reports. health services. The ICPD defined reproductive At the district level, the team visited major health as a state of complete physical, mental, and public, nongovernmental, and private service delivery social well-being and not merely absence of disease points and conducted interviews with providers or infirmity, in all matters relating to the reproduc- and with client groups wherever possible. Team tive system. The definition implies expanding access members interviewed administrators, medical depart- to quality services—especially family planning, ment officials, service providers, and clients. In all prevention of maternal and newborn deaths, and four districts, the survey covered 14 health centers, six disability and prevention and management of STIs hospitals, 46 providers, and 34 key informants at the and HIV/AIDS—to every individual. The program national and district level. Three focus group discus- also calls for addressing other dimensions of repro- sions (FGDs) were held with clients and two with ductive health such as FGM, rape, domestic violence, providers. The interviews followed a prepared forced prostitution, infertility, malnutrition and questionnaire for different levels of personnel and anemia, and reproductive tract infections and a FGD question guide. cancers. STUDY SITES STUDY OBJECTIVES AND DESIGN The team chose four districts—Kampala, Jinja, This case study examines how central elements of Lira, and Kabarole—to represent the central the ICPD Programme of Action have been trans- (capital), eastern, northern, and western regions of lated into action in Uganda since 1994. The specific the country, respectively. These four regions have study objectives were the following: different ethnic groups, cultures, and behaviors, and therefore different health and service delivery ៑ to identify how family planning and health challenges. The districts selected also have different services have been modified to address individual donors who can affect the level of funding, priority health needs, as defined in the Programme of programs, and services delivered. Action; ៑ to identify the steps that have been taken to improve the environment in which women and couples make reproductive health decisions; ៑ to examine how resources have been mobilized and allocated to support these changes; and ៑ to find out whether programmatic changes have made a difference to individuals seeking services. The research team conducted a qualitative policy survey at the central government and district levels. The study is based on interviews with officials from the ministries of Health, Finance, Planning and

7 UGANDA Reproductive Health Policies and Programs

POST-ICPD ACTIVITIES more attention. The practice of FGM is also The MOH is conversant with the ICPD being addressed in the one area of the country Programme of Action. Even before the ICPD, where it exists. reproductive health services were implemented The health desk within the Ministry of Finance, through the Maternal and Child Health and Family Planning, and Economic Development is overseeing Planning (MCH/FP) Program. However, the and coordinating planning and budgeting for health MCH/FP commissioner observed that the services sector activities within the overall national programs. and programs had limitations: “The MCH/FP Within this ministry, issues related to reproductive program and services before 1994 health are perceived as important were provided in a disjointed and influencing overall develop- manner. Since Cairo, efforts have “The MCH/FP ment strategies. The head of been made to refocus the pro- the National Execution Unit in grams in a more holistic way. program and services the Ministry of Finance, Planning, Under the ministry restructuring, before 1994 were and Economic Development the MCH/FP division is being said: “All issues of reproductive renamed Reproductive Health provided in a health are government priorities Division. I hope it will do more disjointed manner. and are being re-emphasized in a and achieve more.” more focused way. These are Having endorsed the ICPD Since Cairo, efforts deserving sectors and need to be Programme of Action, Uganda is have been made strongly funded.” committed to its recommenda- As part of government tions. Interviews revealed that the to refocus the commitment to integrate the concept of reproductive health has programs in a more issues of population and repro- support at the highest levels. The ductive health, the Population MOH has adopted the ICPD holistic way.” Secretariat has been created definition of reproductive health, to link central government which emphasizes addressing the initiatives with local governments individual in a holistic manner. Recognizing that and other key ministries and players. This unit has ICPD goals are beyond national capacities, however, had a major role in advocacy and promotion of the MOH chose priority areas, including promotion ICPD recommendations that fall within its mandate. of safe motherhood, capacity building, infrastructure Interviews revealed that the concepts of reproductive improvement, family planning and reproductive health were familiar in the ministries of Health, health advocacy through IEC. These are given Finance, Planning, and Economic Development, major emphasis in the five-year national strategic Gender, and among major donors in the health sector. plan for MCH/FP. Although they have not received It is apparent, however, that there has been little much funding, other reproductive health problems dissemination of Cairo recommendations nor such as infertility and genital cancers are receiving discussions with stakeholders to create a common vision on how to address reproductive health activities. Dissemination of ICPD recommendations is especially lacking at the district level. District

8 Reproductive Health Policies and Programs managers are not aware of ICPD recommendations, of Gender is one of the hallmarks of the although the key concepts have been integrated in government’s commitment to integrate gender training programs for providers. concerns in development. The Land Act, enacted in June 1998, has established a platform for land POLICY ENVIRONMENT FOR ownership by the poor and women in particular. REPRODUCTIVE HEALTH This is considered a major development in the Since 1993, the Ugandan government has enacted empowerment of women. several policies that reinforce reproductive health In response to the high level of illiteracy and its efforts. One of these policies is the national popula- impact on national development, the government tion policy, which was in draft form at the time of launched a Universal Primary Education (UPE) the 1994 ICPD and enacted in 1995. The National policy to provide free primary education to four Population Policy addresses the high annual popula- children per family. Half of UPE enrollment is tion growth of 2.9 percent, high fertility, and related reserved for girls. This is expected to raise school maternal morbidity and mortality. The policy enrollment of girls and female literacy rates. It is goals are to improve these indicators through hoped that this will empower women socially, informed choices, service accessibility, and improved economically, and politically and enable them to quality of care. The implementation strategies demand their rights and reproductive health needs. involve all sectors of development, such as education, This program has received top priority in the health, agriculture, economy, and culture. government social sector spending since its incep- This policy benefited from the recommendations tion in 1996. of the ICPD. It incorporated an emphasis on An Adolescent Health Policy has been drafted individual choice, reproductive rights, and the and seeks to address adolescents’ needs in a multifac- removal of family planning targets. Other aspects of eted way. As far as reproductive health is concerned, the ICPD incorporated in the policy include more the policy calls for establishment of friendly, confi- focus on adolescent health programs and the need to dential young peoples’ services. Though sex educa- enhance collaboration with NGOs and the private tion has long been incorporated in the school sector in policy implementation. curricula, its implementation has been questionable. The Uganda constitution guarantees the partici- The policy gives more impetus to implement health pation of women in decisionmaking processes at all education programs in schools and out of school to levels of government by reserving 30 percent of the equip adolescents with life skills before sexual electorate seats for women. This is an effort to activity. Adolescent programs are being piloted in promote the status of women and to promote gender urban areas, with the hope of being adopted eventu- sensitivity at all levels. In addition, women are free to ally at the national level. In addition, the parliament contest for other seats in their own capacity. This has set the minimum age of marriage at 18 years. enhanced women’s decisionmaking at all levels and has helped women’s voices be heard. Women in DECENTRALIZATION leadership have formed associations to train them- The government is pursuing a policy of decentrali- selves and their peers in leadership roles and also to zation with the objective of strengthening local build awareness among women leaders about issues governments and empowering communities to concerning women and development. govern and mobilize their own resources. The In 1997, the government adopted a National process is still in its infancy, however. Constraints Gender Policy whose key aspects are to integrate gender into development efforts at all levels for planning, resource allocation, and implementation of development programs. The creation of a Ministry

9 Reproductive Health Policies and Programs include political conflicts in some communities, PROGRAM PRIORITIES which have occurred because of competition Given resource constraints in Uganda and the breadth for influence. of the ICPD recommendations, the government has In some cases, inconsistent government actions prioritized reproductive health programs to include may have undermined local leadership capabilities. safe motherhood, family planning, STI/HIV preven- More often than not, the central government tion and treatment, child survival, and adolescent releases funds that fall short of health. Other priority areas requirements or are cut to accom- include capacity building, infra- modate certain unplanned activi- In spite of the structure rehabilitation and ties. Technical deficiencies, as well expansion, postabortion care, IEC, as lack of human capacity, are also government’s and reproductive health advocacy. a real challenge. Successful commitment to ICPD These programs are receiving decentralization requires a strong, major emphasis in the Five-Year capable central government to goals, implementation National Strategic Plan for Health mentor, monitor, and regulate is constrained by 1997-2001. The strategy aims at activities without undue adminis- having a phased approach to the trative interference. lack of community comprehensive reproductive In spite of the government’s awareness, skilled health package. This approach commitment to ICPD goals, ensures that progress is made in implementation is constrained by labor, and priority programs before new ones lack of community awareness, infrastructure, as well are added. Peter Savosnick, chief skilled labor, and infrastructure, as of party, Delivery of Improved well as poverty and sociocultural as poverty and Services for Health (DISH) barriers. Many observers have sociocultural barriers. project, said, “We could not t noted that most of the policies ake Cairo wholesale, even if we enacted have not filtered to the Many observers have wanted to … until the systems household/family level. In order noted that most of the are ready and people are in place to bridge the gap between na- to handle the workload.” tional policies and household policies enacted Lack of capacity at the local practices, the government is have not filtered to the level is a major constraint in the attempting to communicate more implementation of reproductive with local leaders. The govern- household/ health services. The MOH and ment is also trying to enhance donors perceive manpower economic empowerment through family level. resources to be an even greater poverty alleviation programs. On constraint than finances. another front, a domestic relations The process of decentralization bill is currently being debated and seeks to address has given the responsibility of planning, decision- family issues such as property rights and polygamy, making, and implementation of all programs to the among others. This bill has been widely debated by districts. Unfortunately, the awareness and capability the public and has met some resistance from certain at the district level was found to be seriously lacking. religious denominations. “Decentralization has given us more responsibility than both human and financial resources to implement programs,” said Betty Rwigare, chief administration officer, Jinja District.

10 Reproductive Health Policies and Programs

SERVICE INTEGRATION The team found family planning services offered The team found that health centers offered in all institutions visited, including public and NGO comprehensive and integrated reproductive health hospitals and clinics of the Family Planning Associa- services. Family planning, prenatal care, delivery and tion of Uganda (FPAU). While family planning postnatal care, STI/HIV care and counseling, nutri- programs have focused on women for a long time, tion education and childhood immunizations are recently some programs have made efforts to involve provided daily by the same provid- men. Most programs provide ers. The move from providing information, education, and separate “vertical” services to The move from counseling to men. Some health integrated services is a new centers are promoting male development in the last three to providing separate contraceptive methods such as five years. Most health centers are “vertical” services surgical contraception (vasec- training and supervising TBAs and tomy). Midwives in FPAU offering community outreach to integrated services clinics and medical attendants in clinics for all services except is a new health centers said they are delivery care. promoting condom use. Some Unlike health centers, both development in the health center staff members NGO and government hospitals last three reported that they encourage still provide reproductive health men to support women to use services in a vertical manner—in to five years. Most family planning. The Association special clinics, by specialized health centers for Voluntary Surgical Contracep- providers, and on specific days. In tion (AVSC) initiated a program some NGO hospitals and health are training and to ensure quality surgical centers, there is little or no specific supervising TBAs contraception. The scope of focus on reproductive health. AVSC has been broadened to The director of a Catholic hospital and offering include HIV/STI counseling and in Kabarole admitted, “I can’t say community outreach testing, postabortion care, infec- that we are doing much about tion prevention, and support reproductive health.” clinics for all supervision. services except Most women use injectables, FAMILY PLANNING such as Depo-Provera®, because of The national goal for family delivery care. the method’s convenience and planning is to increase the contra- privacy. Oral contraceptives and ceptive prevalence rate from intrauterine devices (IUDs) are 15 percent to 30 percent by the year 2001. The less common and more closely associated with strategies include efforts to improve the quality and misconceptions and myths. One client expressed her accessibility of contraceptives and to diversify the fears about using an IUD: “The piece is said to cause range of methods and distribution outlets available. a lump in the tubes leading to cancer, also may get Access has been increased through community-based pushed up by the man and disappear inside during distributors (CBDs), social marketing programs, and sexual intercourse.” use of mobile clinics. Family planning training Oral contraceptives and condoms are second programs have also targeted nontraditional providers to injectables in popularity. Inadequate supplies of such as pharmacists, private practitioners, drugshops, other contraceptives in health centers leave clients bar attendants, and community health workers to increase service access.

11 Reproductive Health Policies and Programs with few choices. Surgical contraception was reproductive health issues. Condom use continues available at all hospitals visited, while Norplant® was to be low; this method is chosen mainly for HIV/ offered in only two. In any case, many clients do STI control rather than for family planning. not want to be referred to hospitals for methods not offered at the health center. They are discouraged THE SAFE MOTHERHOOD PROGRAM by transport costs, the unfamiliar hospital environ- Maternal mortality is unacceptably high in Uganda, ment, and the need to keep their search for a at an estimated rate of 506 deaths per 100,000 live method secret from disapproving husbands. births. Although rates of disability are undocu- The Uganda Demographic and Health Survey mented, there is evidence that this is also exception- estimates current unmet need for family planning at ally high. The safe motherhood program aims to 29 percent. (Unmet need is the percent of women reduce maternal deaths by 20 percent by the year expressing a desire to space or limit childbearing, 2001. The major components of the program are but not using contraception.) Although it is believed provision of quality prenatal care, ensuring availabil- that one of the major reasons for nonuse of family ity and accessibility of emergency obstetric care, safe planning is the desire for large families, about and clean delivery, postnatal care, and family plan- 27 percent of women are not using contraception ning. Activities include training of midwives and because of myths and misconceptions about meth- other health providers, including TBAs, in life-saving ods, indicating a significant need for more education skills to provide quality delivery care. A training about contraception. program for comprehensive reproductive health has Physical access to family planning services is a also been instituted. The program is trying to major barrier to those in need. The median distance standardize training through the development of to the nearest facility with family planning services common curriculum guidelines, supervisory is estimated to be 20 kilometers. This is too far for tools, and a team of trainers. The program is also most women, since the main mode of transport is attempting to develop a functional, sustainable walking or cycling. referral system to prevent maternal deaths. In CBD programs distribute mainly contraceptive Kabarole, the 1997 district health report states that pills and condoms. The success of CBDs, which are about 10 percent of Caesarean sections are due to a staffed by community volunteers, indicates that ruptured uterus, which results from a late referral. availability and accessibility strongly influences the The MOH is working on the safe motherhood choice of method. Their influence as peers was program in collaboration with donors, NGOs, the found to be an important determinant of method private sector (especially private midwives) and choice. Interviews revealed, however, this approach community health providers. The MOH is carrying may not be sustainable. CBDs in one focus group out training programs to build awareness among complained about the lack of incentives, and some district and subcounty administrations and commu- had dropped out due to lack of remuneration. The nities about safe motherhood issues. At the commu- only compensation they receive is the status of their nity level, programs are training health workers such role as CBD. as TBAs, pregnancy monitors, and traditional healers Overall, there is evidence of increasing use of to identify women with potential complications for contraceptives. Nonetheless, there is a need for appropriate referral. Due to the acute shortage of greater male participation in family planning and midwives, TBAs are being trained and equipped to provide safe and clean maternity services in the communities. IEC materials have been developed in the form of pamphlets and videos to address issues faced by fathers and adolescents.

12 Reproductive Health Policies and Programs

Abortion in Uganda is a major public health (5) strengthen national capacity to undertake problem. Although induced abortion is against the research on HIV/AIDS control and prevention. law (except where the life of mother or her unborn The main programs include IEC, research, child is at risk), unsafe abortion is common. Abor- voluntary testing and counseling, safe blood transfu- tion complications lead to between 25 percent and sions, school health programs, and home-based 30 percent of maternal deaths and are linked to care for people living with AIDS (PLWA) and for problems such as hemorrhaging, infections, ectopic orphans. Recognizing that STIs were responsible pregnancies, and infertility. A for the fueling of the spread of postabortion care program has the epidemic, the government been developed that trains and Due to the nature has made available nationwide supervises doctors and midwives of transmission, treatment campaigns through a in both public and private sectors World Bank program. They have in postabortion care and the use HIV cuts across also integrated the AIDS control of manual vacuum aspiration different cultures and and the STI programs. technology. The program is currently economic classes, extending services to underserved THE HIV/STI PROGRAM intermingling groups such as youth, women, The HIV/AIDS epidemic is a and PLWA. In order to target major challenge to social and issues of poverty, youth before they start having economic development in Uganda. inequity, culture, and sex, sex education programs are An estimated 1.5 million Ugandans being instituted in schools. are infected with HIV, and sexuality. The program encourages parents 1 million children are orphaned and community leaders to get due to HIV/AIDS. The age group involved in these efforts. In most affected by AIDS (ages 15 to 50) occupies a addition, UNICEF and UNFPA are piloting several critical position in family support systems, commu- programs in essential life-skills training to provide nity development, the labor force, and leadership in sex negotiation skills. society. HIV therefore touches every aspect of The government formed the Uganda AIDS national life and development. Due to the nature of Commission (UAC) to harmonize policies and plans transmission, HIV cuts across different cultures and for the AIDS response in the country. Members of economic classes, intermingling issues of poverty, the Commission include parliamentarians and inequity, culture, and sexuality. As early as 1986, the representatives of ministries and religious organiza- government recognized the disease’s impact on tions. The Commission’s mandate also includes national development and began fighting its spread. efforts to improve treatment, vaccine development, The government instituted a multisectoral and promotion of behavior change. The deliberate strategy involving all relevant ministries, including government openness to the HIV/STI problem Health, Labor, Gender, Defense, Education Informa- has facilitated collaborative research in HIV/AIDS tion, and Agriculture; as well as private citizens. care and control. The goals of the national program are to (1) stop the spread of HIV infection; (2) mitigate the health and socioeconomic impact of AIDS; (3) strengthen national capacity to respond to the epidemic; (4) establish an effective information base; and

13 Reproductive Health Policies and Programs

The national strategic framework for HIV/AIDS 11 percent of men and 2 percent of women are activities in Uganda estimates that HIV/STI-related reporting the use of condoms for the control of HIV spending from 1994-96 was US$117 million.3 and 53 percent and 55 percent of women and men From 1998 to 2001, estimates indicate that the respectively report having restricted their sexual cost of critical activities is equivalent to the entire activity to one partner.5 annual health budget of US$130 million. This means There is still a need to link the success achieved allocating over 25 percent of the health sector budget at the national level to grassroots and community- to HIV/STI activities in the next four years. The based organizations. Though still weak, community critical areas include HIV testing efforts to cope with the HIV and counseling, STI screening and epidemic have been commend- treatment, home-based care of Despite serious able. The threat of HIV has PLWA, and capacity building at constraints, HIV transformed the communities the district and national levels for into groups to prevent HIV, epidemic response and control. control efforts are support victims, and provide care Resources are not adequate showing a declining for orphans. Youth organizations enough to put even this modest and social groups are taking care package into action. It does not trend in HIV of victims and helping to mobi- include ambitious programs with prevalence. lize against the spread of HIV. prohibitive costs such as the By 1994, over 4,000 NGOs were retroviral therapy now available in Of the 20 sentinel registered and operating in the developed countries at US$15,000 surveillance hospitals area of HIV/AIDS care, preven- per patient per year. John tion, and orphan support. Rwomushana, who works with in the country, The AIDS Information the AIDS Commission, said: five report a Center (AIC) is now offering “More needs to be done to bring counseling, testing, and treatment comfort to the lives of people sick declining trend for STIs, as well as offering family from HIV-related illness. Painkill- from 1991 to 1995. planning. Traditionally, AIC ers, anti-diarrheals, and basic offered anonymous testing and medicines to treat opportunistic counseling as a strategy to curb infection are not affordable to the HIV/AIDS transmission. There majority of people in the poorest communities.” has been a move to integrate AIC services by adding Despite serious constraints, HIV control efforts family planning and STI counseling and treatment are showing a declining trend in HIV prevalence. in order to serve clients better. The benefits of these Of the 20 sentinel surveillance hospitals in the efforts are evident as increasing numbers of youth country, five report a declining trend from 1991 to come for services. Josephine Kalule, the Information 1995. For example, in Nsambya hospital, rates and Evaluation officer of the AIC, said: “This is a among prenatal women have decreased from 28.8 new aspect of integration that we have just adopted. percent to 16.8 percent.4 Public awareness of HIV is A need has been felt to have these additional over 90 percent in the adult population, though services incorporated in the clinical package in behavior change is seriously lagging behind. Only order to service a wider clientele and also reduce the stigma attached to the traditional vertical HIV services. We want to evaluate how service integration reinforces the utilization of each of the services provided.”

14 Reproductive Health Policies and Programs

In order to reach the poor, AIC has set aside behavior. The government now has a draft adoles- one free clinic day each week to provide services to cent policy to provide guidance to all health those who can not afford the user fees of US$3. providers and to integrate adolescent programs The client package includes family planning, HIV into mainstream health services. counseling and testing, and screening and treatment of STIs. The free clinic days are popular with youth INFORMATION AND ADVOCACY ACTIVITIES and poor residents who live near AIC clinics. In Every program component of reproductive health 1997, when the AIC in the capital city relocated to has an IEC component. IEC programs are trying to a highly populated peri-urban involve all afflicted communities, slum, service use by poor and i.e. adolescents, women, men, and young people increased. In general, PLWA in their information networks. Though instituted to ADOLESCENT PROGRAMS [adolescent] outreach combat HIV, IEC programs have Uganda has one of the highest programs are small, now been diversified to promote rates of adolescent pregnancy in broader reproductive health Africa (43 percent). By age 17, community-based issues. This has been done mainly about one-third of girls had given efforts that through the mass media. Popular birth. The majority of adolescents FM radio programs cover topics between ages 15 and 19 are provide reproductive such as sexuality and STI preven- sexually active (68 percent for health information and tion and control. Newspapers, females and 75 percent for males). special youth magazines, pam- The UN-supported Basic Educa- counseling to teens. phlets, awareness-raising work- tion for Childcare and Adolescent They are yet to be shops, and drama shows have Development (BECCAD) and the targeted different levels of society, Program to Enhance Adolescent integrated in including the grassroots level. Reproductive Life (PEARL) mainstream health The STI project is leading in this programs are focusing on improv- effort, due to its nationwide ing reproductive health informa- services. coverage and involvement of as tion for adolescents. BECCAD many stakeholders as possible. covers 29 districts with the focus Advocacy for reproductive on STIs, sexuality, postabortion care, family plan- health is not yet very strong. There is, however, a ning, early pregnancy, rights of children, and the multisectoral reproductive health advocacy commit- prevention of defilement and rape. Their strategies tee, as well as women’s groups and activists who include creating “adolescent-friendly” services advocate for women’s reproductive health. There and recreation activities. They offer training in is a Ministry of Gender, Community Development psychosocial life skills to promote behavior change. and Labor that has the mandate to advocate for In general, these outreach programs are small, women’s health, rights, and empowerment. community-based efforts that provide reproductive health information and counseling to teens. They are yet to be integrated in mainstream health services. Often, adolescents do not seek care or will not use the same services as adults. Or health providers may be too overworked to reach out to young people and may not approve of their

15 Reproductive Health Policies and Programs

INFRASTRUCTURE AND hospitals are directly under the MOH. Hospital CAPACITY BUILDING budgets do not make allowances for provider One of the major constraints in service delivery, training, yet the district budgets reserve a significant expansion, and quality remains the lack of trained amount of funds for this purpose. manpower. The doctor and midwife to population Selective training of providers in health centers ratios are 1:30,000 and 1:3,000, respectively.6 In order without training hospital staff may have serious to improve this dismal situation, much effort has gone implications for the management of referred clients to in-service training and retraining and the supervision roles of the of health providers to enable them hospital. Due to the current to provide up-to-date care and to Strong coordination shortage of trained manpower, address more health needs, espe- TBAs, CBDs of contraceptives, cially in reproductive health. There is also desirable community counseling aides, and are also efforts aimed at improving due to the multitude many other groups have been management information systems trained as a short-term strategy for better health planning, budget- of donors and to improve the quality of care at ing, and accounting. NGOs trying to the community level. There have been obvious Due to the prolonged period efforts to train in comprehensive implement programs of neglect and infrastructure reproductive health services in in a decentralized deterioration, the government most districts. This is particularly has financed major renovations evident among the rural health environment. It is of health facilities with help center providers. Nontraditional necessary to avoid from many sources, especially the reproductive health providers, World Bank and the European such as general nurses and clinical variability in service Union. In some health facilities, officers, have been trained to standards and the World Bank project (District provide reproductive health Health Services Project) has services, which were traditionally messages getting out procured and distributed new provided by midwives. The team to the communities. equipment. The general state of found that between 40 percent equipment at all levels, however, and 50 percent of staff in health is unsatisfactory.7 centers were trained in comprehensive reproductive health service provision. COORDINATION AND COLLABORATION In addition, the trained staff were training their Given the breadth and diversity of ICPD recom- colleagues, a practice not found in hospitals. mendations and the number of stakeholders, success- Though hospitals serve as district referral centers ful implementation of reproductive health objectives and are responsible for supervision of rural health requires strong coordination among donors, minis- networks, they have benefited less from the recent tries, district managers, and services. Strong coordi- training efforts. In the hospitals, only one or two nation is also desirable due to the multitude of people have been trained in comprehensive repro- donors and NGOs trying to implement programs ductive health services. This is largely because the in a decentralized environment. It is necessary to rural health center networks are directly under avoid variability in service standards and messages the decentralized district health systems, while the getting out to the communities. In order to distribute donor funding equitably among districts in the country, the Ministry of Finance, Planning, and Economic Development

16 Reproductive Health Policies and Programs registers and assigns donors to different districts. The maintain standards and quality, which is difficult in assignment of a donor to a particular district depends an uncoordinated environment. Improved coordi- on the district’s needs, resource gaps, and donors’ nation would reduce duplication of efforts, save desired programs. resources, and build on different programs’ strengths. The donors have formed a forum where they meet regularly to share experiences and information. ROLE OF NGOS At such meetings, different donors’ roles have been The NGO health delivery sector is broad, mapped out to avoid duplication of efforts, especially consisting of religious groups who manage health in the procurement of drugs. The United Kingdom’s units, private medical clinics, and other specialized Department for International Development (DFID) reproductive health organizations. Examples is currently procuring most STI drugs and injectable of the latter category are the FPAU, Marie Stopes, contraceptives, while the United States Agency for PEARL, RESCUER (Rural Extended Service International Development (USAID) procures all and Care for Ultimate Emergency Relief) and oral contraceptives, and the Danish International REACH (Reproductive, Educative and Community Development Agency (DANIDA) provides general Health). PEARL is a program for adolescents essential drugs. There have been discussions on the while RESCUER and REACH are programs for “sector-wide approach,” which aims to harmonize maternal referral and communication systems planning and strengthen coordination among the and FGM control respectively. government and donors. Most donors, however, The government has long recognized the need express the desire for stronger leadership and for partnerships with NGOs in health delivery, guidance from the MOH—especially in policy but following the ICPD, collaboration with NGOs formulation, defining standards of care, training has been revitalized and strengthened. The main curricula development, and supervision. Given the objectives of collaboration are to improve quality of decentralized health systems, ongoing reforms, and care, increase cost-effectiveness of services, and make restructuring processes, the MOH has to define its optimal use of the limited manpower available roles and develop the capacity to set and supervise for health programs. Since the ICPD, the private standards, and develop and evaluate policies—in sector has been incorporated in government activi- addition to playing its traditional role of directing ties for reproductive health services. Private mid- health service delivery. wives, TBAs, and traditional healers are being supported and supervised to provide quality services DONOR INFLUENCE in the community. Despite their efforts to honor national priorities, Collaboration between governments and NGOs donors more or less dictate programs. The bargaining has taken place in the development of polices and power of district decisionmakers is minimal because collaborative training, provision of grants, and sharing of the inadequate funds at their disposal. Because of trained staff. The government is moving toward they depend so heavily on donors for funds, they tend contracting service delivery to NGOs. District to accept projects as they arrive. Decentralization administrations are also increasingly supporting means that standardization of programs in different NGOs and the private sector. For example, the districts is difficult. There is, therefore, a strong need MOH is giving FPAU clinics funds for community for appropriate guidelines for all districts. outreach and NGO hospitals block grants for their Lack of coordination at different levels still leads operations. The government has also developed to duplication of efforts. For example, donors rarely share training materials and monitoring tools. Fortunately, central training manuals are being developed. Another important issue is the need to

17 Reproductive Health Policies and Programs formal relationships with the traditional sector. health provision and were unmotivated. Due to Traditional birth attendants have been trained on the the shortage of staff in public hospitals, there job in public health units and are being supervised is a “run through and clear the line” attitude by upon return to their communities. Although all midwives, making the quality of care provided to health providers of government, NGOs, and private clients and patients unsatisfactory. “[Pre]natal care is medical clinics are required to still a problem. Although a report directly to the district significant number of mothers medical officer, this is far from About 40 percent to attend, the quality is low,” said being realized. As such, there are Dr. Kabagambe, the district inadequate statistics on the use of 50 percent of director of Health Services in specific services. Sharing infor- providers in the rural the Kabarole District. mation is paramount for meaning- Hospital providers see integra- ful planning, budgeting, and health centers have tion of services as additional work coordination at the district level. recently been trained and, unlike their counterparts in the health centers, they do not PROVIDERS’ PERSPECTIVES or retrained in appreciate how to link up services The team found that providers’ reproductive health to provide a holistic reproductive attitudes depend on whether they health package. As a consequence, work in public, private, or NGO and STI care. This reproductive health service settings and whether they work improves providers’ components are fragmented, with in hospitals, family planning intra-hospital referral practices association clinics, or health knowledge and skills to creating some missed opportuni- centers. Attitudes also depend on handle reproductive ties for family planning and the providers’ training, skills, and STI treatment. “We are few and understanding of reproductive health problems already overworked,” said health concepts. with confidence. a midwife in the Lira District About 40 percent to 50 percent Hospital. “Imagine attending to of providers in the rural health 100 plus (prenatal) mothers a centers have recently been trained day, then EPI (childhood immuni- or retrained in reproductive health and STI care. zation), family planning and STIs. We need more This improves providers’ knowledge and skills staff to do all this at once.” to handle reproductive health problems with confi- Providers in the health centers, FPAU, and NGO dence. A few trained providers are passing on the hospitals reported that integration had revolutionized skills to their colleagues on the job. A midwife the services they provide and that they worked at Kawempe Health Center said: “The two of us better as a team. They have added new services. For have been trained in comprehensive reproductive example, the FPAU clinic in the Kabarole District, health by DISH. We are treating the mothers with the support of district health department, has better. We counsel and give treatment for HIV, started immunizing children at the clinic and at STI, and family planning. Mothers go away with outreach sites. Missionary facilities provide surgical everything they need at the same visit.” family planning services or invite FPAU to provide However, most providers in public hospitals had family planning services at their facilities. A woman not had training or refresher courses in reproductive in charge of the Mission Health Center in Kabarole District said: “The District medical office supports the FPAU to come and offer family planning from here every Thursday. We counsel the mothers about family

18 Reproductive Health Policies and Programs planning, especially the natural methods. Since we information about family planning and HIV/STI serve everybody in this area, we tell those interested during health education talks and counseling. in other methods to come and see the FPAU people.” Providers feel this has slowly helped their clients A midwife in the Kampala District said: “It was make decisions about child spacing, sexual behavior, evident that the providers saw the process of inte- and family planning method choice. Male interest gration as addressing the client in these issues is generally poor. needs in a holistic manner. Pro- Although rarely, some men do viders were happy with the A midwife in the accompany their wives to the integration since they claim it family planning clinics. Providers saves time for both the provider Kampala District said: think this is due to the wide and the clients. We used to have “It was evident range of services now provided, fully packed clinics every day, but especially STI treatment and the the same mothers were coming that the providers saw system of partner notification. for the different clinics.” the process of Men were also said to accompany Overall, integration of services their wives to give moral has helped to increase the number integration as support, especially when the of clients, especially for family addressing the client family planning method chosen planning. Mothers use health is sterilization. The few men center visits (immunizing their needs in a holistic seeking vasectomies, however, children, in particular) as opportu- manner. Providers are said to come alone and prefer nities to obtain family planning to keep the procedure a secret secretly. This practice is partly due were happy with from their wives. to a lack of cooperation from the integration since Providers noted that few husbands regarding family plan- clients request HIV counseling ning. The method of choice for they claim it saves time and testing. They felt there is still ® these women is Depo Provera for both a lot of denial regarding HIV/ injections because they can AIDS risk and infection by the conceal the method from their the provider and community. One provider in Lira disapproving husbands. In addi- the clients.” said, “Although we see many tion, more people are being patients on the wards, most people treated for STIs due to the in the communities regard HIV/ integration of STI screening in AIDS as witchcraft.” the reproductive health services. Communities need more information about A midwife in the Kampala District said: “Clients HIV/AIDS and STIs. Providers noted that they see are more encouraged to come for STI now than many STIs. People openly talk about them and seek before due to a couple of reasons: The clients need treatment. One provider in the Lira District health not undergo the dehumanizing process of laboratory center said: “Our patients do not know the relation- investigation or the need to tell the story to the ship between HIV and STI. When you try to counsel whole hospital staff. I remember we used to call our and relate the two disease entities, the patients get friends to see a male with gonorrhea at the clinic. annoyed that we think they have AIDS—some go Few of the clients would come for the whole course away without further investigations and treatment.” of treatment due to the stigmatization of STI. Now all this is history.” Providers regarded HIV/STI and fertility-related problems as very important. They routinely provide

19 Reproductive Health Policies and Programs

Providers are very concerned about infection— The discussions also revealed that men are the especially HIV—as they provide reproductive health decisionmakers in many reproductive health matters. services. A midwife in Jinja said: “Because our In most cases, couples do not seem to decide patients are not tested, neither most of us, we need together when to have the next child. Because most to keep absolute barriers between ourselves and the women are not using contraception, they find patients. We have a big problem of gloves and Jik themselves repeatedly pregnant. One 30-year-old (chlorine solution) to ensure absolute sterility, but woman in a maternity ward in Kabarole was suffer- we try our best.” ing from maternal depletion syndrome as she Providers also expressed concerns over other prepared to have her eighth child. She said she had general issues such as lack of training to deliver the not discussed family planning with her husband, but expected services, heavy patient loads for too few she assumed he would be opposed. Continued use providers, lack of consistent supplies and equipment, of family planning is dependent on the approval and and low and erratically paid salaries. The providers support of men. trained in comprehensive reproductive health were The FGDs revealed that most participants want a happy about their new skills, but expected regular minimum of five children. Also, there is a preference supervision from the trainers as well as better salary for boys, indicating that couples will continue benefits and promotions with their new roles. producing in search of male babies. Peer influence affects the method of choice for family planning. CLIENTS’ PERSPECTIVES In one clinic in Kabarole, every woman wanted The researchers interviewed family planning clients, injectables because friends/neighbors had success- mothers in maternity wards, and relatives of patients. fully used the method. The role of information The team found that clients are more satisfied with and counseling was also weak and resigned to the providers’ services and attitudes in lower-level health “pre-determined” choice in the community. In centers than in hospitals. In hospitals, clients feel they an FPAU clinic in Kampala, clients said their choice wait for too long for services. Clients expressed a of method depended not just on counseling desire to have more information on their conditions, but also on peer influence and husbands’ attitudes instructions on care, and follow-up care. toward certain methods. The team also found that women were more In two health centers, clients were happy and positive than men about using contraceptives. Most more satisfied with the way services were provided. women believe that their partners are not supportive. “These days it is much better coming here because However, there was evidence that couples rarely they treat for everything daily. Those days, you discuss family planning and sexuality. would have to come many times, now we come once In interviews and FGDs, men felt that women for ANC, my immunization and also they see those should take responsibility for family planning, since children who are sick. It saves money,” said a preg- they are the ones who endure childbirth, while nant mother with a 2-year-old child. women complained that their husbands prevent them Service clients pay user fees with no reservations. from practicing family planning. Men prefer their One woman in an FGD in a client group in the Jinja wives to have surgical contraception (tubal ligation) District said: “We pay something for treatment, but instead of having vasectomies themselves. Neither not much—Shs. 500 or Shs. 1,000 (US$.50-US$1). men nor women seem to understand how vasectomy Most of us can afford it and we get better treatment. works. Indeed, women prefer undergoing a surgical The nurses care. They are very friendly.” procedure themselves instead of asking their husbands to have a vasectomy.

20 UGANDA Funding for Health Services

he Minister of Finance reported in a DONOR FUNDING OF HEALTH PROGRAMS T 1998 budget speech that Uganda Health programs in Uganda are largely dependent is considered successful in improving its on donor financing. In recent years, the donors’ economy through the structural adjustment contribution to development expenditure has been program. Uganda’s apparent success with structural in excess of 90 percent. Much of this is in the adjustment has attracted donors. Uganda is form of grants and loans. A proportion of what is experiencing economic growth as it undergoes counted as development expenditures actually reforms. Inflation is about 5 percent. contributes to recurrent costs such as drugs and The government commits 7 percent to 9 percent supplies and, in some instances, staff salaries. The of the total budget, or currently about $4 per capita, health sector has attracted about 13 percent of to the health sector. Considering total health expen- the total aid allocation to Uganda, and this share ditures from the government, private sector, and donors, per Table 1 capita spending on health was Recurrent health expenditures, 1994-98, Uganda (in billion shillings) about US$8 in 1993. The Social Dimensions of Adjustment (SDA) 1994-95 1995-96 1996-97 1997-981 survey showed that this increased Private expenditures (SDA survey and projection) 132.75 159.31 183.20 210.68 to US$12 in 1996.8 Public expenditures (health)2 32.13 37.12 54.67 46.50 RECURRENT EXPENDI- TURES ON HEALTH International donors 20.70 23.10 21.28 21.28 The private, government, and Total health expenditures 186.08 219.98 259.89 278.55 donor contribution to recurrent health expenditures is about 75 Per capita (Uganda shilling) 10,489.00 12,350.00 14,641.00 15,265.00 percent, 17 percent, and 3 10 percent respectively.9 Most Per capita (US dollar) 11.22 12.19 13.84 14.27 government spending is on Total public recurrent expenditures 524.00 592.00 675.00 733.00 operational costs like salaries and materials, rather than on particular Notes: programs. However, operational 1. Uganda budget estimates 1997-98. 2. Health planning unit, MOH. costs are still grossly underfunded, 3. Average exchange rate: US$1 = 1,000 Uganda shillings. as illustrated by low salaries and inadequate materials and drugs. Underfunding of health programs is principally increased to 22 percent in 1996-97, from US$60 attributable to a low tax base. Tax revenue in the million to US$110 million.11 Similarly, donor financial year 1996-97 was only 11.5 percent of gross support to the health sector and to reproductive domestic product (GDP). While government revenue health has increased over the years as illustrated by will increase with economic growth, it is not projected to rise above 17 percent of GDP by 2001.10 Table 1 summarizes recurrent expenditures in the health sector between 1994-95 and 1997-98.

21 Funding for Health Services

Figure 1 Figure 2 Total health sector development Reproductive health funding by expenditures, 1994-97, Uganda USAID, 1995-98, Uganda

123

Government 123Maternal health AIDS/STI 1234

1234 Millions US$ Donor 1234 Child survival and nutrition Family planning 140 Millions US$ 18 120 12345

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1234567890123 6 1234567890123 0 1994-95 1995-96 1996-97 4 Source: Government budgets and expenditures, Ministry of Finance, Planning, and Economic Development. 2

0 Figure 1 above. The donor requirement for govern- 1995 1996 1997 1998 ment counter-funding has increased the government’s Source: USAID/Kampala 1998. allocation of funds to the health sector. However, given the dominant contribution by donors to health Some donor funding supports activities in the programs and low counter-funding from the govern- MOH, such as development of policies and training ment, this raises serious questions about sustainability. curricula, research, and technical assistance. Most The major programs funded by donors include donor funding is disbursed at the district level, safe motherhood, family planning, STI/HIV, adoles- where programs are planned and implemented. cent health, IEC, infrastructure development, and In some districts, decentralization appears to have training of providers. The major donors supporting increased the recurrent resources available for reproductive health programs are the World Bank, health services. In a study of 13 districts covered DFID, UNFPA, USAID, DANIDA, UNICEF, and by the World Bank project, government, donor, and the World Health Organization (WHO). Many private spending increased in total from US$7.37 recent donor-funded programs did not start imple- to US$9.41 per capita.12 mentation until 1996-97. This time period marked a big leap in the health expenditure contribution FUNDING AT THE DISTRICT LEVEL from the donors and in government counter- Due to the enormous responsibility given to dis- funding. All programs supported by donors fall tricts as a result of decentralization, the local district within national policies and priorities. Figure 2 administration is the operational level for health provides an illustration of the various programs and planning, delivery, and program evaluation. District levels of funding supported by USAID. administrators receive funds through central government funds, local revenue, and donors. The central government provides funding for salaries and materials. However, the experience of the past five years of spending in the districts made clear that

22 Funding for Health Services some national priority areas were not taken as district priorities. The central government has therefore Figure 3 created conditional, primary health care (PHC) Reproductive health budget allocation, grants to the districts to ensure that government Kabarole District, 1997-98 priorities are served at the district level. Safe Reproductive The PHC grant is about $60,000 per year, per motherhood health program 14% support district, to guarantee funding for services, including 1% reproductive health. This funding mechanism, however, has created tensions between the central Research 14% government and the districts over the extent of Family central control of district-level allocations and planning 18% priorities. In the current financial year, 1998-99, the Adolescent PHC grant has been increased about three times. In programs the districts investigated in this study, the team found 7% that about 50 percent to 60 percent of the PHC grant goes to reproductive health services. In the Kabarole IEC STI/HIV District, where the presence of a comprehensive programs programs 2% 44% health sector budget lent itself to analysis, 55 percent of the financial resources (excluding salaries and the Total district health budget, US$3.83 million costs of essential drug kits*) were allocated to repro- Total reproductive health budget, US$2.08 million ductive health services, as shown in Figure 3. STI/HIV, family planning, and safe motherhood receives 30 percent to 40 percent of the total district programs receive the most funding at the district budget. This indicates that donors have a huge input level. Donor funding contributed substantially to in the health sector at the district level. Districts recurrent costs such as staff salaries, drugs and cannot sustain their health programs without donor supplies, and short-term training workshops. In and government funding. every district the team visited, several donors were Local district managers believe that the health providing funding. In some districts, donors have sector is relatively well funded by donors compared experienced poor program performance by depend- to other priority sectors like primary education, ing on poorly paid staff. The German agency,GTZ, roads, and agriculture extension. With few resources has pioneered an effort in the Kabarole District to available, the district management therefore focuses improve staff performance through substantial on areas other than health. contributions to staff salaries. Donor funding at the district level varies The district-level, recurrent budget allocations to according to each donor. Though in principle the health services are in principle about 10 percent to districts have the mandate to negotiate the programs 12 percent of the projected internal district revenue. to be funded, the experience in practice is that the However, given the low level of tax collections, district administration has little negotiating power, the actual funds released to the health sector was because most decisions about funding, programs, and found to be only 1 percent to 2 percent, which operating conditions are centrally determined. translates to about US$2,000 to US$5,000 annually. Donor funds at the district level are often not fully On the other hand, considering both recurrent and used. In the Lira District, for example, less than development budget allocations, the health sector 50 percent of the funds available for health programs were used, mainly due to lack of personnel to *District budgets did not allow for allocation of staff salaries and drug costs to put the programs into action. various health programs. This is due to nonprogram budgeting of these items and the integrated nature of health service delivery.

23 Funding for Health Services

FUNDING OF SERVICES Due to the small amounts charged and inefficient Staff salaries and other operational costs of public collection systems, very few funds are raised by this health facilities are paid from local district adminis- scheme. User fee collections currently have little trations, which receive them as an earmarked fund impact on recurrent hospital costs or provider atti- from the central government. Delays and salary tudes. In rural health centers, user fees have a greater arrears of up to three months were common among effect in improving running costs and provider the providers interviewed, however. Salary shortfalls incentives. Of the user fees collected in a health result in low morale among health providers in center, 50 percent goes toward operations and public institutions. The director of the Kabarole maintenance, while the rest is shared as staff incentive. Given the small number of providers Table 2 in health centers, the user fee Client charges by service and level of care (in US$) contribution to their benefits is HEALTH MARIE substantial compared to hospital SERVICES HOSPITALS CENTERS FPAU STOPES providers. User fees are also playing a crucial role in supplementing the Prenatal care 2.5 – 5.0 0.5 – 1.5 1.5 n/a essential drug kits, as well as filling Delivery care (Normal) 5.0 – 30.0 2.5 – 30.0 n/a n/a other needs in health centers, like repairs and equipment replacement. Delivery care (C–section) 20.0 – 40.0 n/a n/a n/a A study done in one district found Family planning that heath centers were recovering Pills (3 month) 0.0 – 0.5 0.3 – 1.0 0.3 1.0 10 percent to 23 percent of their recurrent costs.13 ® Depo-Provera 0.5 – 5.0 0.3 – 1.0 0.3 0.5 – 1.0 Most NGO hospitals that the Sterilization 5.0 – 30.0 n/a n/a 25.0* team visited were charging user fees to recover their costs and were Norplant® Limited n/a n/a 25.0 self-sustaining, except Kakira Condoms (for 3) 0.0 – 0.03 0.01 0.01 0.02 Hospital, where services were “free” to the factory workers. Two IUD 0.5 – 20.0 n/a 0.5 1.0 – 5.0 NGO facilities visited in Kabarole and Lira were recovering about Jelly/foam 0.0 – 0.5 n/a 0.5 0.5 95 percent or more from user fees. Notes: Kakira Hospital operated through * Subsidized at no cost to the client a direct insurance scheme for its n/a = not available industrial workers. Having realized the role played Hospital described his dilemma: “I have not been by NGOs in health care provision and the obvious able to pay salaries of my staff for three months decline in donor support to hospitals, the government now. I cannot have the moral authority to ensure is providing support through grants and salaries of their diligent service.” doctors and midwives. NGO facilities use fewer and District hospitals are funded by the central better paid staff. Most public hospital workers, government. Because this funding is insufficient, the though full-time, spend part of their working time hospitals have introduced alternative sources of in private practice to supplement the low salaries. funding, such as user fees. Health facilities charge clients a nominal amount for most services, including reproductive health (see Table 2).

24 UGANDA Policy Implications

here has been tremendous change in DONOR DEPENDENCY T Uganda in the last 10 years, in particular The government has worked with donors to following the ICPD. Major reforms are identify the priority reproductive health problems. underway in all sectors—social, economic, develop- Despite the government’s efforts, however, health ment, and health. The govern- services are still strongly ment has developed a Population dependent on donor financing. Policy, a Universal Primary Despite the Therefore, donors are playing Education Policy, Gender Policy, an influential role in deter- Adolescent Health Policy, and government’s efforts ... mining Uganda’s reproductive others that create a positive health services health agenda. environment for reproductive The major donors in the health services. are still strongly reproductive health field are dependent on donor UNFPA, World Bank, DFID, COMMUNICATING HEALTH International Planned Parenthood POLICIES financing. Therefore, Federation (IPPF), USAID, The policies are well articulated at donors are playing UNICEF, and WHO. These higher and central levels of donors are funding STI/HIV, safe government; however, the benefits an influential role motherhood, family planning, of these policies have not filtered in determining IEC, and others such as post- through to the grassroots level. abortion care, adolescent health, This is mainly due to lack of Uganda’s reproductive and child survival. While infertil- awareness and capacity to imple- health agenda. ity, female genital cancers, and ment policies. In addition, there menopause are being addressed, are major reforms in all sectors, they are not yet well-funded. which means that the frameworks within which the policies are to be implemented CHARGING USER FEES are not yet in place or are in their pilot stages. While not a national policy, most local govern- Decentralization at the district level, for example, is ments have required public health facilities to a new process in Uganda. As the districts are trying charge user fees in an effort to improve service to cope with the responsibilities of decentralization, quality and sustain services. The fees are very small, there is even a push for further decentralization and the majority of patients and clients can afford at lower levels. them. Although the collections are small, they Women’s rights are also receiving increased contribute substantially to operational costs, which attention. The Ministry of Gender, Labour and include drugs, supplies, and infrastructure mainte- Development, the Uganda Women Lawyers Asso- nance, particularly in rural health centers. The ciation (FIDA), and other women NGOs and additional income also has a positive effect on activists are strong advocates. These groups are providers’ attitudes. championing the causes of economic rights, education of girls, abolition of FGM, and the prevention of rape, defilement, and domestic violence.

25 Policy Implications

NGO AND PRIVATE-SECTOR ACCESS TO QUALITY COLLABORATION REPRODUCTIVE HEALTH CARE NGOs play an increasingly important role in health The team found the quality of services to be unsatis- services provision. The government and donors factory in many units. In particular, the districts lack are beginning to support them to provide services skilled and trained manpower. There is an overall to underserved and underprivileged groups and shortage of midwives in all districts, with an apparent communities. Private-sector providers, however, concentration working in the district hospitals. This seem to operate in a parallel universe. Most private- is a major constraint in the provision of reproductive sector providers are unaware of ICPD goals or of health services in the PHC network. Staff deploy- their potentially collaborative role in the health ment is not yet in line with the government’s policy care system. The private sector is growing fast and of reorienting the health services delivery to primary has better prospects for recovering a high propor- health care. Whereas 70 percent of the district- tion of operational costs through user fees. As the trained midwives are in the hospitals, only 5 percent quality of services improves, the private sector will of the population has access to these facilities. increasingly provide more reproductive health services with better prospects for sustainability. CLIENT INFORMATION Though not systematically assessed, the team found TRAINING FOR REPRODUCTIVE that the information provided to clients and spouses HEALTH CARE was still weak. Discussions with some family The training of nontraditional reproductive health planning providers during the survey revealed that providers such as nurses and clinical officers, and they did not give information routinely about the the retraining of midwives and doctors in specific range of services available. Instead, all clients were reproductive health skills has increased the number given Depo Provera®, including a client who had of providers and consequently increased access to had recurrent abortions who should have been services. The comprehensiveness of the reproduc- referred, and another with 12 children who had a tive health training has greatly improved providers’ strong desire for permanent surgical methods. skills, confidence, and attitudes toward clients seeking services. There is evidence that these CONTRACEPTIVE METHOD MIX changes have led to greater use of reproductive There is a limited method mix in both public and health services as well as increased client satisfac- NGO facilities, which means that clients have to tion. Clients perceive providing integrated services take what is available or be referred. Intrauterine as cost-effective. devices, tubal ligation, and Norplant® are not Many providers are still untrained, meaning that commonly available, except at the district hospital, many clients are offered inadequate reproductive because of staff skills, equipment, and space. Doctors health care services. The lack of trained manpower in hospitals are trained in surgical contraception is the most significant obstacle to implementing methods, but physical distance and the US$25 fee reproductive health programs. Training institutions has limited use of this service. are responding to this challenge by strengthening Pilot efforts with community-based providers of their curricula. reproductive health services are contributing substantially to the distribution of contraceptives, but are limited to providing pills and condoms. Access to a full range of reproductive health services remains a major constraint in all districts visited.

26 Policy Implications

DELIVERY CARE SUSTAINABILITY OF PROGRAMS While most mothers receive some form of prenatal The government faces a strong challenge in crafting care, most deliver without the benefit of a skilled policies that address Uganda’s diverse population. provider. Over 80 percent of mothers make at Certain programs—especially family planning, HIV/ least one prenatal visit during AIDS control, and adolescent pregnancy to a health facility. The pregnancy—do not easily attract majority of mothers start pre- The government is community support. It is diffi- natal care in the second and third cult, for example, to advocate for trimester, although only 32 percent attempting to smaller families in an environ- make three or more visits. Very create sustainable ment of high infant mortality, or few of these women receive to advocate for HIV/AIDS trained care at delivery, however. programs by involving prevention in a polygamous Nationally, trained health communities in community. providers with midwifery skills The government is attempting attend only 38 percent of programs and to create sustainable programs the deliveries. Instead, women by using community by involving communities in deliver with untrained assistants— programs and by using community often relatives. volunteers to provide volunteers to provide reproductive Late referral of women with reproductive health services (community-based complications to the hospital is still distribution of contraceptives and a major issue. Poverty and poor health services home-based care for AIDS road networks discourage hospital (community-based patients and orphans). deliveries. Most peripheral areas Programs that are predomi- visited had only a few transport distribution of nantly donor-supported face the vehicles that were over-loaded contraceptives and issue of sustainability. When with people and goods making one donor support ceases, programs route per day to the town, where home-based care collapse. In an effort to alleviate the hospital is located. The for AIDS patients this situation, government situation is worse during the counter-funding has been built rainy seasons, when most roads and orphans). into most donor-supported become impassable. programs. There are efforts to raise internal revenue to support MALE INVOLVEMENT priority programs. For instance, there is an ear- There have been some efforts to involve men in marked fund for PHC, 60 percent of which is family planning decisions. In the Kabarole tea estates devoted to reproductive health. Since this fund was and in a Jinja sugar factory, male work groups have introduced, it has been progressively increased. been used to raise awareness of children’s rights to education and quality of life in the home, and the rationale for a smaller and manageable family size. The workers reported seeing more men accompany- ing their wives to the family planning clinics than before. Most women feel, however, that men are not supportive of family planning. More male youth are using the private sector to obtain condoms and STI treatment.

UGANDA Recommendations

៑ DISSEMINATE POLICIES comprehensive manpower development. Aggressive The supportive policies for reproductive health training at all levels of services, and in particular need to be translated and disseminated at the for family planning services, is necessary. The community level in order to create awareness for MOH needs to develop guidelines and protocols, informed decisionmaking and for overall commu- especially regarding the information given to clients nity and women’s empowerment. The reproductive and standards of care, to ensure appropriate client heath status of the country stands to benefit as decisionmaking and care. individuals make informed decisions and demand their reproductive rights. ៑ STRENGTHEN COORDINATION Planning, coordination, and overall use of health ៑ PROMOTE COLLABORATION management information systems need to be Reproductive health service coverage is still a big strengthened. The MOH needs to strengthen its challenge. Program managers with new innovations coordination role with the different national and will have to identify and work with competent district-level stakeholders. Information sharing NGOs and the private sector to improve service at the national and district level is important for coverage to rural women and men with unmet meaningful planning and management. needs for contraception. The private sector capacity to expand, especially given incentives to ៑ IMPROVE HOSPITAL CARE extend services to rural areas, offers a more sustain- Hospital activities need to be seen in the light of a able alternative. Initial financial incentives to NGOs comprehensive PHC system. Hospital services need to provide a comprehensive reproductive health not lag behind in quality or coverage. Though the services package is strongly recommended. referral system for maternal care is a major problem Collaboration between the MOH and training in Uganda, hospital services should remain attractive institutions is essential in developing sound repro- and contemporary to those that use them. ductive health programs. ៑ STUDY SERVICE INTEGRATION ៑ INCREASE TRAINING FOR There is need to study the process of service inte- BETTER SERVICES gration. It seems to have preliminary success, but Staffing levels in both the public and private sectors there is not complete understanding of the issues of are very low. More rational staff deployment and services costs, quality, and use of individual services. better pay will enhance staff morale to provide friendly services. Midwifery training needs to be given long-term priority as a strategy to improve service coverage. This needs to be integrated in all existing paramedical training programs for

C. HUGHES/PANOS PICTURES C. HUGHES/PANOS 29 Endnotes

1. Statistics Department, Ministry of Finance, Planning, and Economic Development and Macro International, Uganda Demographic and Health Survey, (UDHS) 1995 (1996). 2. F. Mirembe F and P. Okong, Situation analysis of Induced Abortion in Uganda, Makerere University, Department of Obstetrics and Gynecology (1994). 3. J. Kayita and J. Kyakulaga J., AIDS status Report, AIDS Commission (1997). 4. Ministry of Health AIDS Control Program (ACP), Sentinel surveillance report (1995). 5. Statistics Department, Ministry of Finance, Planning, and Economic Development and Macro International, Uganda Demographic and Health Survey, (UDHS) 1995 (1996). 6. Health Planning Department., Ministry of Health, 1997 Inventory of Health Services in Uganda. 7. Department of Planning, Ministry of Health, Health Care Inventory (1997b). 8. World Bank and Uganda Government, Social Dimensions of Adjustment (SDA) Survey (1996). 9. Ibid. 10. Ministry of Finance, Planning, and Economic Development, National Budgets and Expenditures, 1997/98. 11. District Health Service Project, Ministry of Health, (1997a) Health Expenditure Review (1997). 12. Ibid. 13. Z. Karyabakabo, Cost Recovery of Rural Health Centres in Mukono District, BMPH, dissertation, Institute of Public Health (1996).

Design and Production: ALPHAWAVE DESIGNS

Printing: THE OFFSET HOUSE Cover Photo: T. BELSTAD/PANOS PICTURES

30 UGANDA Appendix

People Contacted

PEOPLE INTERVIEWED AT THE CENTRAL LEVEL (ministries and donors) Mr. Peter Savosnick Dr. Kambugu Mrs. Nyabongo chief of party, DISH Project STI Project, MOH director of National Execution Unit, Ministry of Planning and Economic Development Ms. Tembi Matatu Dr. Abongomera reproductive health advisor, DISH Project MOH Planning Unit Dr. Ekema A. deputy director, National Execution Unit, Mr. Jay Anderson Mr. Mukundi Ministry of Planning and Economic director, Population and Development, senior planner, MOH Development USAID Mr. Ndazimana Mr. Ken Mugambe Dr. Lim Lim MOH Planning Unit Health Desk, Ministry of Planning and UNICEF Dr. S. Okwonzi Economic Development Dr. O. Sentumbwe Mugisa director, District Health Service Pilot Project Mr. Ndoroleire WHO/MOH Dr. E. Madraa Health Desk, Ministry of Planning and Dr. Maggie Bangser director, AIDS Control Program Economic Development reproductive health consultant Dr. J. Musinguzi Ms. Eva Mulema Mr. F. Byomuhangi Population Secretariat legal officer, FIDA associate representative, UNFPA Mr. J. Atiku Ms. Harriet Nanyonjo Prof. E.M. Kaijuka executive director, FPAU Adolescent The World Bank commissioner health service, MOH Health Prof. Rwomushana J. Dr. Peter Nsubuga Ms. Nakato Lydia coordinator, AIDS Information Centre STI Project, MOH coordinator, FPAU

PEOPLE INTERVIEWED IN THE LIRA DISTRICT Mr. Mos Oswerp Ms. Hariet Otolo Sr. Anna Maria Gugole deputy RDC senior nursing officer, Lira Hospital senior nursing officer in-charge, Ngetta Dispensary Mr. Onen-Orach Mrs. Beth Okello chief administration officer, Lira nursing officer, FPAU, Lira Dr. Aceng-Ochero Jane medical officer, Lira Hospital Dr. Quinto Okello Mrs. Margaret Acen district medical officer (DMO), Lira nursing officer, FPAU, Lira Ms. Elizabeth Nabukwaso enrolled nurse, FP Clinic Dr. Felix Asuua Mr. John Bosco medical officer, DMO’s Office Okao medical assistant, Dorkoro Ms. Magdalen Okello Health Centre enrolled midwife, FP Clinic Mrs. Otim nursing officer, DMO’s Office Mrs. Margaret Vvella Ms. Ruth Obuko assistant health visitor, Dokoro nursing officer in-charge FP Dr. Felix Ochon Health Centre medical superintendent, Lira Hospital Dr. Rebecca Namusubo Ms. Edina Achao district medical officer medical assistant, Ngetta Dispensary

31 Appendix: People Contacted

PEOPLE INTERVIEWED IN THE JINJA DISTRICT Dr. Kitimbo Ms. Monica Ngobi Ms. Ejongu district medical officer regional coordinator, FPAU, Jinja nursing officer, Kakira Health Centre Mrs. Joyce Isiko Ms. Beatrice Isoba Mr. Semugabi S. district health visitor registered midwife, FPAU, Jinja medical assistant, Kakira Health Centre Ms. Betty Rwigare Dr. Samina Mr. Waiswa chief administrative officer medical officers, Vithi Medical Centre laboratory technician, Kakira Health Centre. Dr. Agel Akii Dr. Rafique Dr. Andrew Baryeku ag. med. superintendent, Jinja Hospital Vithi Medical Centre medical officer health, Jinja Mrs. Florence Ameso Dr. Parkashi Mr. Boniface Ntalo principal nursing officer, Jinja Hospital Kakira Hospital district health educator Ms. Irene Kanobe Ms. Katherine Amuge Ms. Matild Babuuza Busoga Diocese registered midwife, Kakira Hospital ag. in-charge, Bugembe Health Centre Mr. Loy Naugosa Ms. Alice Obiru Mr. Mufumba Busoga Diocese registered Midwife, Kakira Hospital nurse, Bugembe Health Centre

PEOPLE INTERVIEWED IN THE IGANGA DISTRICT Dr. Rebecca Namusubo Ms. Margaret Musenge district medical officer, Iganga district health visitor, Iganga

PEOPLE INTERVIEWED IN KAMPALA CITY COUNCIL (KCC) Dr. Mubiru Ms. Irene Gwambe Dr. Senyonga-Kyanda medical officer health, KCC counselor, Naguru Teenage Information obstetrician, Mengo Hospital Dr. Waira Centre Dr. Bukenya assistant district officer (Health) Mr. B. Kigozi medical superintendent Dr. Habomugisha male counselor Ms. Mukasa medical officer Dr. Mutattira principal nursing officer Ms. Magdalene Nyeringoni Marie Stopes Nurse Naguru Health Centre Ms. Kasule Mengo Hospital Ms. Scolastic Okello AIDS Information Centre

PEOPLE INTERVIEWED IN THE KABAROLE DISTRICT Dr. Kabagambe Ms. Nyinakamunyu Sr. Efuransie Katuku district medical officer reproduction health coordinator clinical officer, Kyakatara Health Centre Dr. Ndyanabangi Ms. Sarah Kabatebe consultant, Reproductive Health-GTZ nursing officer, FPAU, Fort Portal Mrs. Sempebwa nursing officer, District Medical Ms. Naomi Kalyebara Administrative Officer Officer’s Office assistant health visitor, Kijura Kabarole Health Centre Ms. Kyomuhendo M. nursing aide, Rukungiri Health Centre