Global Child Survival: A Human Rights Priority
VI. Case Study: Uganda

Executive Summary

Uganda, one of the poorest and most indebted countries in the world, has long had one of the worlds highest under-five child mortality rates. With Ugandas 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 countrys 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, Ugandas 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 carewith 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 countrys health concerns as a whole and childrens 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 Ugandas 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 children, the future of Uganda.

Findings of the Uganda case study

Ugandas under-five child mortality rate of 147 deaths per 1000 births is among the worlds 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 worlds 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 Ugandas 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.

Ugandas 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 Childrens 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 Ugandas 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.