Submitted by crinadmin on
Summary: Uganda, one of the poorest and most
indebted countries in the world, has
long had one of the world's highest
under-five child mortality rates.
Executive Summary
Uganda, one of the poorest and most indebted countries in the world,
has long had one of the world's highest under-five child mortality
rates. With Uganda's staggering foreign debt of over $3.5 billion and
a poverty rate exceeding 60 percent, there are simply not enough
resources at either the national or household level to effectively
address the country's basic social needs, including child survival.
One in seven Ugandan children dies before reaching her or his fifth
birthday. These children still die largely from preventable causes.
Uganda is one of the least urbanized countries in Africa; almost 90
percent of Ugandan families live in rural areas where their children
are particularly disadvantaged and most vulnerable to early death and
disability.
Uganda's economic, health, social, and other infrastructures were
left in ruins after nearly 25 years of civil strife. Even the most
basic health and social services were completely lacking in most
parts of the country. By 1986 when the National Resistance Movement
came to power, it inherited a wrecked economy, a populace overwhelmed
by years of civil and political violence, and a deeply corrupt
bureaucracy.
To address these concerns and to gain support from the international
community, the government signed an agreement with the IMF and the
World Bank in 1987 to carry out an economic structural adjustment
program. Uganda's subsequent economic growth has been steady, but the
benefits are unevenly distributed. Today, Uganda's debt burden is
still enormous; its public revenue base remains limited. The
government is still heavily dependent on external aid to meet public
sector deficits. In 1997, Uganda became the first developing country
to qualify for the Heavily-Indebted-Poor-Countries Debt Initiative of
the IMF and World Bank.
The Ugandan government, in partnership with international aid
agencies and multilateral creditors and donors, has developed a
series of national health plans including the 1992 Ugandan National
Plan of Action for Children (UNPAC). These plans focus on primary
health care-with emphasis on children, disease prevention, increasing
community participation, and rebuilding of the physical health
infrastructure. While the objectives of these plans are well-
delineated, their implementation is still largely frustrated by
pervasive deficiencies in resources, both human and financial. Uganda
has yet to fully implement the UNPAC. Current government allocations
are not sufficiently meeting the country's health concerns as a whole
and children's health needs in particular. National defense
expenditures continue to receive far greater priority, primarily in
response to the insurgency problems in the outlying districts of the
country and to the ongoing instability in Uganda's neighboring
countries.
The health care delivery system in Uganda today remains inaccessible
to many Ugandans, especially those residing in the rural areas.
Moreover, the system is severely constrained by inadequate
investment, and it remains unevenly focused on tertiary (curative)
rather than primary health care. These mounting concerns are further
exacerbated by the current decentralization of health services and by
the implementation of cost sharing programs promoted by the World
Bank. Health financing and delivery of services have devolved to
district governments that are, in most cases, ill-prepared to assume
these tasks. Many local governments are still deficient in both
financial resources and trained personnel. The main aim of cost
sharing is to improve quality of care and access to the poor by
deriving more revenues from the non-poor. The cost sharing scheme in
Uganda, far from achieving this aim, has resulted in a reduction in
the use of preventative health care, a shift in utilization toward
private and missionary health
facilities, increased delays in seeking care, and increased resort to
traditional practices. The plight of the health care system severely
burdens the already precarious state of survival and health of
Uganda's impoverished children.
In summary, Uganda has suffered ruinous civil upheavals since the
late 1960s. When the current government took power in 1986, Uganda
had come to symbolize a worst-case scenario in the developing world:
civil war; economic collapse; widespread infringements of human
rights; corruption; blackmarketeering; and a massive breakdown of
government health and social services. Although the current
government has made impressive strides towards national recovery,
major financial and human capacity constraints persist. Nonetheless,
the significant debt relief package from the IMF and World Bank
should enable the Ugandan government to allocate more resources
toward national initiatives addressing the health and social welfare
of all Ugandans. Moreover, social development should accompany the
steady growth of the economy since 1987. Current government social
policies and programs, with increasing investment and aid of the
international community, should be prioritized towards securing
survival and health for all Ugandan c
hildren, the future of Uganda.
Findings of the Uganda case study
Uganda's under-five child mortality rate of 147 deaths per 1000
births is among the world's highest. Ugandan children still die
largely from preventable diseases. Malaria is the leading killer,
responsible for one in five child deaths. More than a quarter of all
under-five deaths are attributable to measles, diarrhoeal diseases
and respiratory infections. AIDS is now the fifth leading cause of
death for children under age five. The AIDS epidemic continues to
have an adverse impact not just on the children directly, but also on
the family and community, as reflected in the rising numbers of AIDS
orphans.
The health and well-being of Ugandan children are harmed by the
ethnic and regional tensions, the ongoing insurgency, and the legacy
of social and economic disruption from decades of armed conflict,
civil strife, and displacement. Uganda remains one of the world's
poorest countries.
Child survival in Uganda remains under-funded, while the debt burden,
defense spending, and an unwritten commitment to low-impact, tertiary
(curative) health care supersede basic child survival strategies.
The low social status and high rate of illiteracy of women in Uganda
undermine the health of children as well as women. Mortality and
morbidity indicators demonstrate dramatically higher risk for rural
children and women.
The health and social service systems that implement Uganda's law are
in transition during the ongoing process of decentralization. The
Local Governments Act of 1997 devolves authority for providing
medical and health services to the local district councils, subject
to minimum, centrally-set health standards. Control of most resources
has not yet devolved to the district level. Poor rural districts in
particular lack the resources to carry out their new
responsibilities. Current cost-sharing programs for the health sector
appear to be ineffective sources of revenue and have made health
services even more inaccessible to the very poor.
Uganda's domestic law places a priority on child welfare. The 1995
Constitution recognizes and protects the right to life, but it
contains no explicit guarantee of the right to health and health
protection in terms of health services, safe water, and the care of
children. The enforcement provisions of the Constitution do not apply
to the right to health. The Children's Statute of 1996 specifies the
rights of children and places shared responsibility for ensuring
those rights on the nation, parents, extended families, and local
authorities.
While Ugandan law generally appears to address Uganda's international
obligations (with the exception of the anachronistic Public Health
Act), in practice the country faces the enormous challenge of
marshaling adequate human and financial resources to implement the
guarantees provided by the law.
Recommendations
Comply with all human rights obligations under treaties and
instruments to which Uganda is a party.
Promote and protect children's rights, in particular those related to
child health and survival, through adequate programs and funding.
Continue legislative efforts as well as target social spending to
promote the rights and status of women. Government funds should
support the implementation of a massive women's literacy campaign.
Repeal or update provisions of the Public Health Law that are
inconsistent with the Local Governments Act. Increase the resources
available to the Ministry of Health, Local Councils and District
Health Offices to guarantee the implementation of reasonable minimum
health standards regardless of the wealth of the various districts.
The cost sharing programs for the health sector should be re-examined
and modified to ensure accessibility to the poor.
Observe the Alma-Ata principles of primary health care by ensuring
equity, universality, community participation, and intersectoral
collaboration in health policies and programs. All segments of the
population must be enabled to define and guide their own well-being.
Adopt a cohesive strategy for child survival that promotes long-term
investments and solutions and de-emphasizes short-term measures.
Provide funds to support high-impact primary health care strategies
as a national priority, including the required human capacity
resources outlined in the Uganda National Plan of Action for Children
reform program. Funds made available from the current IMF and World
Bank debt relief initiative provide an excellent opportunity to
invest in the Uganda National Plan of Action for Children primary
health care package.
Use debt relief funds effectively and sustainably to increase child
survival. After the impact of debt relief on child survival has been
demonstrated, more IMF and World Bank debt should be forgiven.
Accede to the United Nations' 20:20 initiative that calls for a
prioritized resource allocation towards basic health and social
development: a minimum allocation of 20 percent of governmental
budgets and 20 percent of donor countries' official development
assistance.
Target rural communities in the provision of health and social
service funds.