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The Politics of Sexual and Reproductive Health and Rights in Uganda

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The Politics of Sexual and Reproductive Health and Rights in Uganda UNIVERSITY OF CALIFORNIA SANTA CRUZ “TELLING YOUR FATHER THAT HE’S WRONG”: THE POLITICS OF SEXUAL AND REPRODUCTIVE HEALTH AND RIGHTS IN UGANDA A dissertation submitted in partial satisfaction of the requirements for the degree of DOCTOR OF PHILOSOPHY in SOCIOLOGY by Nichole M. Zlatunich June 2012 The Dissertation of Nichole M. Zlatunich is approved: Professor Ben Crow, Chair Professor Paul Lubeck Sarah Clark, Ph.D. Tyrus Miller Vice Provost and Dean of Graduate Studies Copyright © by Nichole M. Zlatunich 2012 Table of Contents List of Figures .............................................................................................................. iv List of Abbreviations .................................................................................................. vii Abstract ....................................................................................................................... xii Acknowledgements .................................................................................................... xiv Preface..........................................................................................................................xx Chapter 1: Introduction: “You Simply Do Not Care About Women”: An Introduction to Uganda’s Political Economy and Reproductive Health ........................1 Chapter 2: A Short Political, Social, and Economic Background on Uganda .............27 Chapter 3: “The Cairo Consensus of Confusion”: Global Influence and Local Frames in the Struggles over Uganda’s Population Policy and Influences on Its Implementation ............................................................................................................59 Chapter 4: “No One Ever Died of Overpopulation”: Comparing Uganda’s “Success” on Combating HIV with Its “Failure” on Population ...............................129 Chapter 5: “What Is Allocated Is Not What Is Delivered”: The Policy- Implementation Gap of Contraceptive Commodities ................................................185 Chapter 6: Conclusion: “Everyone Takes Our Policies and Just Implements, Why Can’t We?”: The Contribution of a Political Analysis of Policy ...............................229 Appendix A: Methodologies ......................................................................................240 Appendix B: HIV Prevalence Maps ..........................................................................262 References ..................................................................................................................266 Endnotes .....................................................................................................................317 iii List of Figures Figure 1: Political Cartoon Captioned: “Uganda’s high fertility rate, if not checked, could affect primary education and health in the next 30 years.” New Vision, 27 September 2010 ............................................................................................1 Figure 2: The Linear Model of Policy Reform ............................................................16 Figure 3: The Interactive Model of Policy Implementation ........................................17 Figure 4: Map of Uganda .............................................................................................28 Figure 5: Total Bilateral Aid (ODA) to Uganda, in Current Prices, USD Millions ....49 Figure 6: Census Population: 1969, 1980, 1991, 2002, and Mid-2011 Projection, in Millions ....................................................................................................................50 Figure 7: Age-Sex Distribution in Uganda, 2010 ........................................................51 Figure 8: Uganda Sub-County Poverty Incidence (% Below the Poverty Line), 2005..............................................................................................................................54 Figure 9: Foreign Assistance to Uganda, General Budget Support and Project Support, and Total Aid as Percentage of GDP, in USD Millions ................................57 Figure 10: Political Cartoon Captioned: “The Population Secretariat has asked the Government to plan for the rapidly increasing population.”New Vision, 15 October 2008 ................................................................................................................59 Figure 11: Uganda's Fertility Rate by District .............................................................65 Figure 12: Comparison of Total Donor Funding for Health vs. Donor Funding for Population and Reproductive Health Activities, in USD Millions ..............................84 Figure 13: Population Policy/Program & Reproductive Health, Total Donor Funding for Uganda, by program area, in Current Prices, USD Millions ...................85 Figure 14: Top Donors for Population and Reproductive Health Activities, 2002- 2009, in USD Millions .................................................................................................86 Figure 15: USAID Funding to Uganda for Global Health, FY 2008-2012, in USD Millions ........................................................................................................................87 Figure 16: DFID Support to UN Joint Programme for Implementation of the National Population Policy, 2011-2014, in USD Millions ..........................................89 Figure 17: DFID Support to Accelerating the Rise in Contraceptive Prevalence in Uganda, 2011-2015, in USD Millions .........................................................................90 iv Figure 18: UNFPA Project Expenditures in Uganda, 2006-2010, in USD Millions ...91 Figure 19: Active Government Policies Addressing Population and/or Sexual and Reproductive Health and Rights ................................................................................105 Figure 20: National Budget by Sectors, 2009/10 and 2010/11, in USD Millions .....121 Figure 21: Percent Contributions to Sectors by the Government of Uganda, 2009/10 and 2010/11..................................................................................................123 Figure 22: Poster in Uganda, “She’s Keeping Herself for Marriage . What About You?” ..............................................................................................................129 Figure 23: Annual Trends in Antenatal HIV Prevalence at Urban Sentinel Sites in Uganda, 1989-2009 ....................................................................................................136 Figure 24: Annual Trends in Antenatal HIV Prevalence at Non-Urban Sentinel Sites in Uganda, 1989-2009 .......................................................................................137 Figure 25: Annual Trends in Antenatal HIV Prevalence at Urban vs. Non-Urban Sentinel Sites in Uganda, 1989-2009 .........................................................................138 Figure 26: HIV Funding in Uganda, 2007/08-2008/09, in USD Millions .................146 Figure 27: Total Donor Funding for Uganda, for HIV, All Other Population/RH, and General and Basic Health, 2002-2009, in Current Prices, USD Millions ...........147 Figure 28: Population Policy/Program and Reproductive Health, Total Donor Funding for Uganda, 2009, by program area .............................................................148 Figure 29: United States President George W. Bush Meets with Ugandan President Yoweri Museveni on Friday, 11 July 2003 in Entebbe, Uganda ...............149 Figure 30: Estimated HIV Incidence Rate, 15-49 Years Old, Percentage (mid- point), 1990-2009 .......................................................................................................154 Figure 31: Stoneburner and Low-Beer Model of HIV Incidence and Prevalence in Kampala for the Population Aged 15-59, 1981-2005 ................................................155 Figure 32: Changes in sexual behavior among men in Uganda, 1988/89-1995 ........159 Figure 33: Billboard in Kololo, Kampala, March 2010, Good Life Campaign by the Uganda Health Marketing Group .........................................................................162 Figure 34: The Full Stock of Drugs at a Health Center in Southwest Uganda, October 2010 ..............................................................................................................185 Figure 35: Overview of the Processes and Gaps for Reproductive Health Commodity Procurement for Public Health Facilities in Uganda .............................190 v Figure 36: Contraceptive Commodity Procurement in Uganda 2000-2011, in USD Millions ......................................................................................................................193 Figure 37: Utilization of National Budget Line for Reproductive Health Commodities, 2005/06- 2010/11, in USD .................................................................195 Figure 38: Percentage of Public Health Facilities Without Consistent Supply of Basic Drugs ................................................................................................................221 vi List of Abbreviations ABC abstinence, be faithful, condom use ACP AIDS Control Programme ACTS advise, consent, test, support AIDS acquired immune deficiency syndrome ARV antiretroviral AU African Union CDC Centers for Disease Control and Prevention CPR contraceptive prevalence rate DANIDA Danish International Development Agency DFID United Kingdom Department for International Development DHS Demographic and Health Survey DRC Democratic Republic of Congo EQUINET
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