country briefing: Uganda – health

Kyetume Team- Yuko Amizaki, Terry Hu, Shirley Li, Jeongyeon Shim
for Global Health Delivery Lab, February 2011

Health Indicators, prevalence of diseases, other measures

Major Infectious Diseases:

Degree of risk: very high

Food or waterborne diseases:

• bacterial diarrhea
• hepatitis A
• typhoid fever

Vectorborne diseases:

• malaria
• plague
• African trypanosomiasis (sleeping sickness)

Water contact disease: schistosomiasis (bilharzia)

Animal contact disease: rabies (2009)

(CIA World Factbook)

Sample health statistics:

Refer to attached charts.

Health Systems Overview

Uganda’s healthcare expenditure amounted to $25 per capita as of 2006. This is slightly higher than other countries in Sub-Saharan Africa ($24), though lower than the average for all low income countries ($27). At the same time, it should be noted that Uganda spends a higher share of its GNI to healthcare, 7.2%, compared to 4.8% and 4.6% for sub-Saharan Africa and low income countries respectively (WDI & WHO data).

The sources of healthcare expenditures are composed of three primary sources. Out-of-pocket expenses accounted for the largest share, with 37.9%, followed by the government with 33.6%, and external sources with 28.5% (World Bank, 2010).

The Ugandan healthcare delivery system is composed of seven levels. Health Centers, categorized into levels I to IV, cover geographic areas ranging from villages to counties, with varying level of population coverage (1,000 for level I to 100,000 for level IV). Their roles also differ, from Heath Center I focusing on prevention and health education to Health Center IV, which cover prevention, cure, rehabilitation, and emergency surgeries. The next level is District Health Services, which typically cover population of 500,000. Regional Referral Hospitals typically cover 2M people, providing select specialty care and outreach services, in addition to the functions provided by the institutions previously mentioned. National Referral Hospitals, which cover 27M people, provides comprehensive specialty care, research and training, in addition to other roles (Markle, 2007).

Current Health Issues in the Country

HIV/AIDS

The HIV prevalence in Uganda has stabilized at between 6.5% and 7.0% since 2001. It has dramatically decreased since the peak in late 1980s. However, there were 110,694 new HIV infections occurred countrywide, and approximately 61,306 people died from AIDS during 2008 alone.

The first AIDS case in Uganda was diagnosed in 1982. In 1986, when the Ugandan civil war ended and President Museveni was firmly in power, the country started a major HIV prevention program. By this time, HIV prevalence rates were as high as 29% in urban areas. Uganda’s first AIDS control program promoted the ABC approach (abstain, be faithful, use condoms), ensured the safety of the blood supply and started HIV surveillance. Strong political leadership and commitment to tackling the rampaging AIDS epidemic were key features of the early response to AIDS in Uganda. Prevention work at grass-roots level also began in this era.

The second phase of the Ugandan HIV epidemic ran from 1992 to 2000. During this period the HIV prevalence fell dramatically, from a peak in 1991 of around 15% among all adults, and over 30% among pregnant women in the cities, to around 5% in 2001. The government’s prevention campaign partly contributed to the decline in prevalence. However, as treatment was not widely available in Uganda, the large numbers of AIDS-related deaths also contributed to the reduction in the number of people living with HIV.

The third phase of Ugandan HIV is the stabilization phase. Free antiretroviral drugs have been available in Uganda since 2004. While this has contributed to stop the increase of HIV in Uganda, some experts critique that it may have lead to the increase in risky behavior.

Currently, it is estimated that 10% of HIV in Uganda is linked to sex work. Also, men older than 25 years are increasingly reporting multiple sex partners in a year. In addition, sexual violence contributes to the increased HIV burden among women, as one in five adolescent females (ages 15 to 19)reported their first sexual experience involved force or coercion, according to a 2007 study by Biddlecom, et al. cited in UNAIDS’ 2008 Epidemic Update.

Mother-to-child transmission remains to be a large issue. In Uganda mother-to-child transmission is estimated to have contributed to 20,500 new HIV infections, according to the 2009 Uganda AIDS Commission report. Without treatment, around 15 to 30 percent of babies born to HIV-positive women will become infected with HIV during pregnancy and delivery. A further five to 20 percent will become infected through breastfeeding, says the 2009 UNAIDS Epidemic Update. While antenatal visits are vital for prevention of mother-to-child transmission, 58 percent of births in Uganda still take place at home, according to the Uganda Demographic Health Survey (UDHS) 2006. There are also rural-urban disparities with the proportion of births occurring in a health facility being higher in urban areas (79 percent) than rural areas (36 percent).   Access to health care is also a challenge with 86 percent of women saying they encounter at least one serious problem in accessing it. Sixty five percent of women say they have financial constraints while 55 percent find the distance to their nearest health facility is very far.

During the 2010 HIV Conference in Vienna in July, the WHO passed new recommendations saying mothers may safely breastfeed provided they or their infants receive ARVs during the breastfeeding period of up to one year. This has been shown to give infants the best chance of protection against HIV transmission. It is difficult to communicate to the mothers living in rural areas and convincing them of the new guidelines. HIV-positive mothers are sensitive about not transmitting the disease through breast feeding and some people are not ready for the new guidelines.

Maternal Health

Uganda s maternal health was among the worst in Africa. The maternal mortality rate stands at 435 deaths per 100,000 live births.  It has been pointed out that Uganda has low contraceptive prevalence rate and the high fertility.

Yellow Fever

In October 2010, there was an outbreak of Yellow Fever, which killed around 50 people in two months. A decision was made to conduct a reactive mass vaccination campaign0020 over 905,000 people.

However, the Health Ministry has postponed the mass vaccination exercise against yellow fever due to the scarcity of the vaccine. Currently, further supplies are awaited.

The yellow fever vaccine works by exposing the recipient to a small dose of the virus, which causes the body to develop immunity to the disease. Symptoms of yellow fever include diarrhea, headache, fever and abdominal pain. Others are flu-like symptoms, jaundice (yellowing of the eyes and skin), liver, kidney and respiratory failure, dizziness and vomiting of blood.

Access to Care

Despite record investment over the past five years—the government expenditure on health has steadily increased from $3.46 per capita in 1995 to almost $9 per capita in 2006 (Keane, Kennan, Massimiliano, Massa, & Dirk, 2010), Uganda’s healthcare performance is still ranked as one of the worst in the world. In 2009, Uganda ranked 186^th out of 191 nations by the WHO in terms of health care performance(Sisay, 2009).

In terms of health facilities, the Uganda Ministry of Health reported 3,237 health facilities in 2006, with 71% public, 21% private-not-for-profit, and 9% private-for-profit (Okwero, Tandon, Sparkes, McLaughlin, & Hoogeveen, March 2010).  Within these health facilities, there are 1.1 hospital beds per 1,000 people in 2006, 5.5 nurses per 10,000 people in 2004, and 1.17 physicians per 10,000 people in 2005 (World Development Indicators (WDI) & Global Development Finance (GDF)).  In terms of physical access to these health facilities, 75.4% of respondents to a World Bank survey reported living within 5 km of a health facility or hospital in 1999, compared to 82.5% in 2006 (Okwero, Tandon, Sparkes, McLaughlin, & Hoogeveen, March 2010).

In terms of services availability, as of 2007, over two thirds of health facilities provide a basic package of health services, 88% provide immunization, 71% provide antenatal care, 80% provide family planning, 98% provide STI services and curative care for children(Kaijuka, et al., 2007).  Among the general population, in 2008 48% has access to improved sanitation – 38% of urban population vs. 49% of rural population.  67% of the population has access to improved water source – 91% of urban population vs. 64% of rural population(World Development Indicators (WDI) & Global Development Finance (GDF)).

In terms of utilization, Uganda eliminated user fees at state health facilities in 2001, resulting in an 80% increase in the number of visits(The Elimination of User Fees in Uganda: Impact on Utilization and Catastrophic Health Expenditures, 2005).  Today, 42% of the births in Uganda are attended by skilled health personnel vs. regional average of 47%, its antenatal care coverage is 94% vs. regional average of 73%, and 68% of Ugandan 1-year-olds receive measles immunization vs. regional average of 73%.   Uganda’s contraceptive prevalence is 24% vs. regional average of the same, its antiretroviral therapy coverage among people with advanced HIV infection is 33% vs. regional average of 44% (Department of Health Statistics and Informatics of the Information, 2010).

On the HIV/AIDS front, given Uganda’s high prevalence rate of 6.4%, available services for prevention and treatment remain limited.  Overall, 3 out of 10 health facilities report having a testing facility.   Among hospitals and Health Centre IVs, the rate is much higher at 98% and 97%, respectively, compared to 46% of Health Centre IIIs and only 10% of Health Centre IIs.  Beyond the initial testing availability, approximately 6 in 10 health facilities have HIV/AIDS care and support services (Okwero, Tandon, Sparkes, McLaughlin, & Hoogeveen, March 2010).

Health Equity

In Uganda, there exists considerable inequity in health outcomes across regions and socio-economic classes.   Whereas some districts such as Kapchorwa and Bukwa have life expectancy rates exceeding 60 years, the national average is about 51 years and there are some districts such as Kitgum where the figure is less than 30 (Okwero, Tandon, Sparkes, McLaughlin, & Hoogeveen, March 2010).  There are similar variations in infant and child mortality rates; in 2010, the under-5 mortality rate for the rural population is 147 deaths per 1,000 live births, as compared to 115 among urban population, 172 among the poorest 20%, and 108 among the wealthiest 20% (Uganda: Health Profile, 2010).

An explaining factor behind the inequitable health outcome is the distribution of healthcare infrastructure.  Whereas in the capital city Kampala, there is 1 facility per 5,295 people, the national average is 1 per 8,785 people and in some rural districts the ratio is much worse at 1 to more than 20,000 people(Health Facilities Inventory, 2006).  Out of 80 districts within Uganda, 16 have no hospitals as compared to 8 in Kampala.  Among facilities of different levels, functionality of available equipment also varies widely; it is 52% at the Health Centre IV level as compared to 44% at the regional referral level and 33% at the general hospital level (Ministry of Health; Report of the Mid-term review of the Health Sector Strategic Plan 2005/05 – 2009/10;, 2008).

In access to health care, the degree of inequity is also notable.   In 2010, the percentage of birth attended by skilled health personnel is 38% for Uganda’s rural population, compared to urban at 80%, the poorest 20% of the population at 28%, and the wealthiest 20% of the population at 77% (Uganda: Health Profile, 2010).  In 2006, about 37.7% in the poorest 20% reported health problems and 15.8% did not seek care.  Among the wealthiest 20%, about 36.8% reported health problems but only 7.9% did not seek care.  With regard to regional breakdowns, people in the eastern region were most likely to report a health problem (47.6% vs. national average of 39.5%), and those in the central and eastern regions were more likely not to seek healthcare, and more likely to cite expense as a reason (Okwero, Tandon, Sparkes, McLaughlin, & Hoogeveen, March 2010).

Overall, however, the government of Uganda has adopted a pro-poor attitude towards health spending.  According to estimates by the World Bank, through utilization of various public health facilities, the poorest 20% of the population captures 24% of government spending while the wealthiest 20% receives about 16.6% (Okwero, Tandon, Sparkes, McLaughlin, & Hoogeveen, March 2010).  And as already discussed in the previous section, Uganda’s elimination of user fees at state health facilities in 2001 has resulted in an 80% increase in visits; over half of the increase came from the poorest 20% of the population (Department of Health Statistics and Informatics of the Information, 2010).  While the non-poor’s utilization of public facilities did not change significantly, utilization among the poor increased substantially after the abolition of fees, but catastrophic expenditure did not fall.   One possible explanation is that “frequent unavailability of drugs at government facilities after 2001 forced patients to purchase from private pharmacies, with the extra payments for pharmaceuticals offsetting the reduction in payments for consultations” (The Elimination of User Fees in Uganda: Impact on Utilization and Catastrophic Health Expenditures, 2005).

What is the impact of public health and health system issues on enterprises’ roles in delivering health care?

Healthcare service facilities are predominantly operated by the government (71%), followed by private not-for profit (21%) and private for-profit institutions (9%), though the number of private for-profit facilities is thought to be underestimated (~2,000 vs. ~300). The number of public and private not-for-profit facilities has grown dramatically in the recent past, at a rate of 10.5% compound annual growth rate during 2000-2006. The growth is thought to be attributable to the effort to increase access to healthcare by building new facilities, especially in the face of HIV/AIDS epidemic (World Bank, 2010).

Private not-for-profit facilities are predominantly run by faith-based organizations (78%), and are coordinated through the diocesan boards and respective bureaus. There is recent growth in non-facility-based providers with HIV/AIDS. Private for-profit facilities include outpatient clinics (90%), as well as drugstores and informal vendors.  The majority of them are concentrated in Kampala (45%) and the Central region (23%) (World Bank, 2010).

While the healthcare system is dominated by public facilities, the actual usage shows a different picture. According to the 2006 household survey, only 29% of Ugandans who needed and sought healthcare did so at a public facility; 46% received care at a private clinic, 13% from drugstores, followed by 6% for NGO facilities. This highlights the importance of private sector players in the Ugandan healthcare system (World Bank, 2010).

HIV/AIDS

Uganda is widely considered to be one of the few success stories in Africa in developing an effective response to HIV/AIDS.  This is largely due to the political leadership’s timely decision to speak out about the epidemic at an early stage, setting the foundation for open discussion, which allowed more players to address the epidemic (Tumushabe, 2006). In 1986, the NRM government admitted the existence and deaths caused by HIV and set up the national AIDS Control Programme (ACP).  The ACP led a mass education campaign, which included the ABC program to reduce HIV prevalence.  Free antiviral drugs have been available since 1994. Today, the bulk of donor funds are channeled through government programs.  Sources of HIV/AIDS funding include the World Bank Multi-Country HIV/AIDS Program for Africa, the Global Fund to Fight AIDS, Tuberculosis, and Malaria, PEPFAR, and other bilateral agreements (Tumushabe, 2006). However, a number of nongovernmental agencies receive donor funding as well, notably The AIDS Support Organization (TASO), which started as a grass-roots organization and evolved to become the largest indigenous AIDS service organization in Africa, providing emotional and medical support to people who are HIV positive (Avert).

In 1992, the Uganda AIDS Commission (UAC) was established to coordinate development and implementation of HIV/AIDS policies and guidelines, integrate and harmonize efforts to combat HIV/AIDS, and monitor HIV/AIDS activities in the country.  The purpose of UAC’s National HIV/AIDS Strategic Plan 2007/8 (NSP) is to coordinate the national response, recognizing the need for systems strengthening and participation of stakeholders including civil society and local governments.  The goal of the NSP is to reduce new infections by 40% in five years through a coordinated multisectoral response.

Sources:

World Bank. Fiscal Space for Health in Uganda. 2010.

William Markle, Melanie Fisher, and Jr., Ray Smego, Understanding Global Health (LANGE Clinical Medicine), McGraw-Hill, 2007.

Department of Health Statistics and Informatics of the Information, E. a. (2010). World Health Statistics. Geneva, Switzerland: World Health Organization.

(2006). Health Facilities Inventory. Kampala, Uganda: Ministry of Health.

Kaijuka, E. M., Ametepi, D. P., Kato, D. F., Katumba, D. F., Mutabazi, D. M., Nsungwa, D. J., et al. (2007). Uganda Service Provision Assessment Survey. Kampala, Uganda: Ministry of Health, Uganda, Macro International Inc.

Keane, J., Kennan, J., Massimiliano, C., Massa, I., & Dirk, W. t. (2010). Uganda – Case Study for the MDG Gap Task Force Report. London: Overseas Development Institute.

(2008). Ministry of Health; Report of the Mid-term review of the Health Sector Strategic Plan 2005/05 – 2009/10;. Kampala, Uganda: Ministry of Health.

Okwero, P., Tandon, A., Sparkes, S., McLaughlin, J., & Hoogeveen, J. G. (March 2010). Fiscal Space for Health in Uganda – World Bank Working Paper No. 186. Washington, D.C.: The International Bank for Reconstruction and Development / The World Bank.

Sisay, A. (2009, April 3). Uganda: Economic Crisis Threatens Healthcare. Retrieved February 9, 2011, from Africa News.com: http://www.africanews.com/site/list_message/19398

(2005). The Elimination of User Fees in Uganda: Impact on Utilization and Catastrophic Health Expenditures. Geneva, Switzerland: World Health Organization.

(2010). Uganda: Health Profile. Geneva, Switzerland: World Health Organization.

World Development Indicators (WDI) & Global Development Finance (GDF). (n.d.). (The World Bank) Retrieved February 9, 2011, from World dataBank: http://databank.worldbank.org/ddp/home.do

AVERT website.  http://www.avert.org/aids-uganda.htm

U.S. Agency for International Development. What Happened in Uganda? Declining HIV Prevalence, Behavior Change, and the National Response.

UNAIDS, Report on the Global AIDS Epidemic. 2010.

USAID, Uganda, HIV/AIDS Health Profile. October 2010.

Bawaba, Al. Uganda : Health sector to get 260b. World Bank, Tenders Info. 18 August 2010.

Kiapi, Evelyn Matsamura. “Uganda: Breastfeeding Dilemma for HIV-positive Mothers,” Terraviva Online News, Inter Press News Service. 21 August 2010.

WHO Global Alert and Response. Yellow fever in Uganda. 19 January 2011.

Bawaba, Al. Yellow Fever Vaccination Postponed, allAfrica. 3 January 2011.

Tumushabe, Joseph. The Politics of HIV/AIDS in Uganda. Social Policy and Development Programme Paper No. 28. UN Research Institute for Social Development. August 2006.

UAC, Moving Toward Universal Access: National HIV & AIDS Strategic Plan 2007/8 – 2011/12. Uganda AIDS Commission, Republic of Uganda. 2007.