Health care in Uganda - selected issues

WORLD BANK DISCUSSION PAPER NO. 404 WDP404 Work in proSIress for public discussion August 1999 Health Care in Uganda Selecte( Issues Patul Hf/t(h/llSo l /I1 co//dabol-/) i/o/ ari//h I)einssi Habt5e (1/zd Alary ll fu/11/1(  Recent World Bank Discussion Papers No. 336 Targeted Credit Programs and Rural Poverty in Bangladesh. Shahidur Khandker and Osman H. Chowdhury No. 337 The Role of Family Planning and Targeted Credit Programs in Demographic Change in Bangladesh. Shahidur R. Khandker and M. Abdul Latif No. 338 Cost Sharing in the Social Sectors of Sub-Saharan Africa: Impact on the Poor. Arvil Van Adams and Teresa Hartnett No. 339 Public and Private Roles in Health: Theory and Financing Patterns. Philip Musgrove No. 340 Developing the Nonfarm Sector in Bangladesh: Lessonsfrom Other Asian Countries. Shahid Yusuf and Praveen Kumar No. 341 Beyond Privatization: The Second Wave of Telecommunications Reforms in Mexico. 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Lister (Continued on the inside back cover)  WORLD BANK DISCUSSION PAPER NO. 404 Health Care in Uganda Selected Issues Paul Hutchinson in collaboration with Demissie Habte and Mary Mulusa The World Bank Washington, D.C.  Copyright C 1999 The International Bank for Reconstruction and Development/THE WORLD BANK 1818 H Street, N.W Washington, D.C. 20433, U.S.A. All rights reserved Manufactured in the United States of America First printing August 1999 Discussion Papers present results of country analysis or research that are circulated to encourage discussion and comment within the development community. The typescript of this paper therefore has not been prepared in accordance with the procedures appropriate to formal printed texts, and the World Bank accepts no responsibility for errors. Some sources cited in this paper may be informal documents that are not readily available. 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ISBN: 0-8213-4531-1 ISSN: 0259-210X Paul Hutchinson is a consultant, Demissie Habte is a health specialist, and Mary Mulusa is operations officer and team leader of Uganda Health Projects, all for the Human Development I division of the World Bank's Africa Technical Family. Library of Congress Cataloging-in-Publication Data Hutchinson, Paul, 1966- Health care in Uganda: selected issues / Paul Hutchinson. p. cm. - (World Bank discussion paper ; 404) Includes bibliographical references and index. ISBN 0-82134531-1 1. Medical care-Uganda. 2. Public health-Uganda. 3. Malaria- Uganda. 4. Primary health care-Uganda. I. Title. II. Series. RA552.U4H88 1999 362.1'096761-dc2l 99-32550 CIP  CONTENTS xi Foreword I Part. 1. Equity of Access to Health Services in Uganda: The Effects of Income, Gender, Proximity to Services, and Quality of Care 3 Abstract 5 Introduction 7 Chapter l.The Health Sector in Uganda 7 Health Care and Geographic Factors 11 Income, Price, and Quality 12 Women and Health I 5 Chapter 2. Geographic Factors and Access 15 Distance to Health Care Providers 17 Quality of Care, Transportation Costs, and Distance t7 Future Studies of Geographic Access 19 Chapter 3. Income and Access 19 Income and Reporting Illness 21 Income and Choice of Curative Care 22 Factors Affecting Use of Modern Curative Care by the Poor 25 Household Medical Expenditure 27 Income and Primary Health Care 30 The Effects of Income on Health 31 Chapter 4. Gender and Access 31 Gender and Reporting Illness 32 Gender and Choice of Treatment 32 Gender and Expenditure on Illness 33 Gender, Work Patterns, and Income Earning 36 Factors Affecting Use of Curative and Preventive Services for Males and Females 37 Access to Care for Children under Five 38 Gender and Use of Health Services 41 Chapter 5. Conclusion 43 Annex A. Analytical Framework and Earlier Studies 43 Model 43 Time Price 44 Price and Income 45 Quality of Services 45 Gender and Access iii  HEALTH CARE IN UGANDA: SELECTED ISSUES 47 Annex B. Data 47 Data 48 Health Unit Infrastructure 48 Econometric Analysis 51 Annex C. Logit Estimations 51 Reporting Illness 52 Use of Modern Curative Care by the Poor: Logit Estimations 55 Logit Estimation Results to Use of Modern Care by Lowest and Highest Income Quartiles 56 Four Types of Preventive Care 57 Use of Modern Curative Care by Men and Women 59 Logit Estimation Results for Simulations of Effects of Work Patterns on Use of Curative Services by Men and Women, 1992-93 61 Annex D. Summary of Findings 63 References 67 Endnotes List of Tables, Part I 8 Table 1. Number of Health Units and Staff Countrywide, 1970 and 1996 8 Table 2. Percentage of Population Living Within 5 Kilometers of a Health Unit, by Region 9 Table 3. Percentage of Health Units Offering Services, by Region 10 Table 4. Percentage of Counties and Subcounties with Health Units Offering Specific Services, 1997 10 Table 5. Choice of Service for Curative Treatment, 1990 16 Table 6. Population Within Specified Distance of Modern Provider, By Urban and Rural Residence, 1993-94 and 1995-96 16 Table 7. Percentage of Surveyed Areas Within Specified Distance of Various Types of Health Care Providers, 1992-93 18 Table 8. Community Leaders' Perceptions of Reasons That People Would Not Use Health Units, 1992-93 (Percent) 22 Table 9. Choice of Curative Care for Lowest and Highest Income Quartiles (Percent) 23 Table 10. Choice of Available Modern Provider Based on Facility Ownership and Residence (Percentage of Ill Individuals) 24 Table 11. Simulations Using Logit Estimation Results for Use of Modern Curative Care, Lowest and Highest Income Quartiles, Rural Areas Only, 1995-96 25 Table 12. Annual Per Capita Household Medical Expenditure by Income Quartile (Constant Dollars) 27 Table 13. Location of Vaccination for Lowest and Highest Income Quartiles, 1992-93 27 Table 14. Percentage of Children Aged 12-48 Months Receiving Immuni- zations, 1995-96 28 Table 15. Reason for Not Vaccinating, Lowest and Highest Income Quartiles, 1992-93 (Percent) iv  CONTENTS 29 Table 16. Percentage of Women Using Prenatal and Postnatal Care for Most Recent Pregnancy, Lowest and Highest Income Quartiles, 1995-96 29 Table 17. Number of Tetanus Toxoid Injections for Most Recent Pregnancy for Lowest and Highest Income Quartiles, 1995-96 30 Table 18. Use and Nonuse of Prenatal and/or Postnatal Care By Lowest and Highest Income Quartiles, 1992-93 (Percentage of Respondents) 32 Table 19. Reporting of Illness in the 30 Days Prior to the Survey, by Gender and Age Group (Percentage of Respondents) 32 Table 20. Reporting of Illness and Likelihood of Using Modern Curative Care, Males and Females for Selected Countries 33 Table 21. Choice of Treatment by Men and Women Aged 15-60 34 Table 22. Household Expenditure on Illness for Men and Women (US Dollars) 34 Table 23. Primary Activity for Men and Women Aged 15-49, 1995-96 35 Table 24. Weekly Allocation of Time to Primary and Secondary Work Activities, 1992-93 (Mean Hours for Those Engaged in the Specified Activity) 35 Table 25. Men and Women's Earnings and Household Status - 1992-93 36 Table 26. Simulated Effects of Changes in Work Pattern Variables on Use of Modern Curative Care, for Men and Women, 1992-93 37 Table 27. Type of Care Sought for Children under Five by Gender, 1993-94 and 1995-96 (Percentage of Respondents) 37 Table 28. Percentage of Children Age 12 to 24 Months with Vaccinations, 1995-96 47 Table B-1. Number of Households and Individuals in Survey Samples 48 Table B-2. Number of Health Facilities in Survey Enumeration Areas (Percentage of Enumeration Areas) 49 Table B-3. Services Offered at Government Health Units Below Hospital Level 49 Table B-4. Women's Allocation of Time to Primary and Secondary Activities, 1995-96 50 Table B-5. Men's Allocation of Time to Primary and Secondary Activities, 1995-96 51 Table C-1. Logit Estimation of Reporting Illness in the Previous 30 Days 53 Table C-2. Logit Estimations of Factors Determining Use of Modern Curative Care, 1993-94 and 1995-96 55 Table C-3. Logit Estimation for Simulations of Changes in Facility Characteristics on Use of Modern Curative Care for Lowest and Highest Income Quartiles, 1995-96 56 Table C-4. Logit Estimations of Use of Preventive Services, 1995-96 57 Table C-5. Logit Estimations of Use of Modern Provider with Female- Interacted Variables 59 Table C-6. Logit Estimations of Use of Curative Care for Males and Females, 1992-93 List of Figures, Part I 9 Figure 1. Distribution of Health Facilities in Uganda, 1995-96 17 Figure 2. Percentage of Ill Individuals Using a Modern Provider by Distance from Residence, 1993-94 and 1995-96 20 Figure 3. Percentage of Lowest and Highest Income Quartiles Using Curative and Preventive Care, 1995-96 v  HEALTH CARE IN UGANDA: SELECTED ISSUES 20 Figure 4. Percentage of Income Quartile Reporting Illness in the Past 30 Days 26 Figure 5. Percentage of Monthly Expenditure on Medical Care By Income Quartile, 1993-94 26 Figure 6. Percentage of Monthly Expenditure on Health for Lowest and Highest Income Quartiles, 1993-94 38 Figure 7. Percentage of Age Group of Males and Females Having Completed Primary Education, 1995-96 69 Part. II. Decentralization of Health Services in Uganda: Moving toward Improved Delivery of Services 71 Abstract 73 Introduction 73 Decentralization 74 Decentralization in the Health Sector 77 Chapter l.The Conceptual Framework 77 The Role of Government in the Health Sector 78 The Case for Decentralization 80 Potential Negative Effects of Decentralization 81 Country Experiences with Decentralization 87 Chapter 2. Decentralization of the Health Sector in Uganda 87 Uganda's Program of Decentralization 88 The Structure of the Health Sector under Decentralization 93 Chapter 3. The Financing of Decentralization 93 The Recurrent Budget 98 The Development Budget 100 Initiating a Sector-Wide Approach (SWAP) 103 Chapter 4. Community Participation 104 Health Unit Management Committees 107 Village Health Committees 107 Subcounty Health Committees 109 Chapter 5.Allocative Efficiency and Control of Resources 109 District Flexibility in Resource Allocation under Decentralization 111 District Allocation Patterns 115 District Allocations to Priority Areas 1 17 Chapter 6. Other Issues in Decentralization 117 Technical Efficiency 119 District Personnel 120 Skewed Distribution of Resources 121 Dedining Support Supervision vi  CONTENTS 123 Chapter 7. Conclusion 125 Statistical Annex 141 Annex A. Summary of Country Experiences with Decentralization 145 Annex B. Development Budget, 1996-97-1998-99 146 Ten Largest Projects in the Development Budget, 1996-97 - 1998-99 (Ush Billion) 147 References 151 Endnotes List of Tables, Part If 89 Table 1. Health Units by Type and Ownership, 1996 (Number/Percent in Parentheses) 95 Table 2. Total Health Sector Allocations to the Recurrent and Development Budgets, 1997-98 97 Table 3. Total District Public Expenditures by Category, All Districts, 1996-97-1997-98 ('000 Ush) 110 Table 4. Types of Funding for Annual Work Plan Activities, 1997-98 (Ush '000) 111 Table 5. Allocation to Program Areas, Fiscal Year 1996-97 and 1997-98 (Percent) 112 Table 6. Average District Allocations to Types of Interventions, 1995-96 and 1997-98 (Ush) 114 Table 7. Average District Allocations to Diseases/Health Problems, 1995-96 and 1997-98 (Ush) 115 Table 8. Funding for Primary Health Care, 1995-96 and 1997-98 (Ush '000) 118 Table 9. Average Costs at Government and Nongovernmental Organization Hospitals, 1997 (Ush) 125 Table Al. Decentralization-Rationales, Positive and Negative Impacts of Decentralization, and Country Experiences 126 Table A2. Extent of the Decentralization of Key Functions within the Health Sector 127 Table A3. Recurrent Expenditures on Health, 1994-95-1996-97 (Current Year Prices in Ush Billions) 127 Table A4a. Sources of District Revenue, 1995-96 (25 Districts Reporting) (Ush Millions) 127 Table A4b. Ministry of Finance Allocations to Districts for Health,1997-98 (Ush Millions) 128 Table A5. Recurrent Health Expenditures by Source, 1992-93-1996-97 (Millions of Ush at 1996-97 Prices) 128 Table A6. Allocation of Cost-Sharing Revenue in 45 Government Hospitals, 1996-97 and 1997-98 (Percent) 128 Table A7. Average Allocations of Cost-Sharing Revenue in Health Units, Mukono (1995-96) and Kabale Districts (1996) (Percent) vii  HEALTH CARE IN UGANDA: SELECTED ISSUES 129 Table A8. Types of District Annual Work Plan Interventions 130 Table A9. Development Budget, 1992-93-1998-99 (Current Year Prices in Ush Billions; Percent in Parentheses) 131 Table A10. Shadow Expenditure Estimates for Primary Health Care for 1995-96 and 1996-97, and Conditional Grant for Primary Health Care for 1997-98 (Ush) 132 Table All. Characteristics of Selected Government, Nonprofit, and Private Health Units, 1993-94 133 Table A12. Estimated Total Health Expenditure Per Capita - 1997-98 (US$) 141 Summary of Country Experiences with Decentralization (Annex A) 145 Development Budget, 1996-97-1998-99 (Annex B) 146 Ten Largest Projects in the Development Budget, 1996-97-1998-99 (Ush Billion) (Annex B) List of Figures, Part 11 91 Figure 1. Current Structure of the District Health Sector 92 Figure 2. Proposed Macro-Structure of the District Health Department 94 Figure 3. Annual Budgets 95 Figure 4. Government Recurrent Expenditure on Health (Current Year Prices) 99 Figure 5. Development Budget by Project Area, 1992/93-1999 134 Figure Al. Donor and Government Development Expenditures, 1995-96-1998-99 135 Figure A2. District Directors of Health Services: Responses on the Positive Impacts of Decentralization (n=15) 136 Figure A3. District Directors of Health Services: Responses on the Negative Impacts of Decentralization (n=15) 137 Figure A4. District Directors of Health Services: Reported Impediments to Implementation of Work Plan Activities (n=15) 138 Figure A5. District Directors of Health Services: Suggestions for Improving Coordination of Districts, Donors, and the Ministry of Health (n=15) 139 Figure A6. District Directors of Health Services: Responses to Personnel Changes Under Decentralization (n=15) 140 Figure A7. District Disease-Specific per Capita Expenditures versus Percent of Disease in District Burden of Disease, 1995/96-1997/98 153 Part. IIl. Malaria: A Priority Health Problem 155 Abstract 157 Abbreviations 159 Introduction 161 Overview 161 The Epidemiology of Malaria in Uganda 162 Morbidity and Mortality 165 Knowledge of Malaria viii  CONTENTS 171 Treatment of Malaria 174 The Economic Costs of Malaria 175 Epidemics 176 A Pilot Community Intervention 176 Spraying 177 Malaria Control in Kampala 179 Chapter 2. Bed Net Studies in Africa and Uganda 179 Recent Studies 180 Bed Net Availability in Selected Districts of Uganda 183 Chapter 3. Malaria Control and Decentralization in Uganda 183 District-Level Malaria Control 186 Types of Intervention 186 Major Sources of Funding 186 Limitations of Analysis 189 Chapter 4. Malaria Control in Uganda:The Way Forward 189 Case Management 190 Preventive Measures 190 Epidemic Preparedness 190 Research 191 Annex A. Malaria Endemicity 193 Annex B. Burden of Disease versus Malaria Expenditure 195 Annex C. District Work Plan Malaria Interventions, 1996-97 and 1997-98(US$) 197 References 201 Endnotes List of Tables, Part Ill 162 Table 1. Parasite and Spleen Rates in Children Aged Two to Nine 165 Table 2. Prevalence of Malaria Fever in Selected Districts and Populations 167 Table 3. Perceived Modes of Malaria Transmission in Selected Districts (Percentage of Surveyed Population) 167 Table 4. Percentage of Households Citing Correct Cause of Malaria 169 Table 5. Use of Personal Protection Mechanisms 171 Table 6. Sensitivity of ParaSightTm- F Dipstick Test 172 Table 7. Choice of Treatment for Malaria in Soroti for Children under Two Years of Age 172 Table 8. Provider of Treatment for Fever in Selected Districts (Percentage of Households) 173 Table 9. Drug Treatment for Malaria in Selected Districts (Percentage of Cases) 173 Table 10. Drug Resistance in Selected Districts (Percentage of Patients) ix  HEALTH CARE IN UGANDA: SELECTED ISSUES 174 Table 11. Outcome of Chloroquine Treatment After 14-Day Follow-Up (Percentage of Patients) 174 Table 12. Development of In-Vivo Resistance to Chloroquine in Uganda in the Last Three Years in Various Strata 176 Table 13. Distribution of Number of Days of Work Lost Due to a Malaria Episode (Percent of Working Individuals Who Report a Malaria Episode) 180 Table 14. Effect on Malaria Outcome from Use of Permethrin-Treated Bed Nets 185 Table 15. Expenditure on Malaria Control in 13 Districts, 1995-98 (US$) 186 Table 16. Sources of Funding for Malaria Control, 1996-97 191 Classification of Endemicity (Annex A) 193 Ordinary Least Squares Estimation of Total Per Capita Malaria Expenditure on the Percentage of Malaria in Total District Burden of Disease (Annex B) 195 District Work Plan Malaria Interventions, 1996-97 and 1997-98 (US$) (Annex C) List of Figures, Part III 163 Figure 1. Discounted Life Years Lost Due to Malaria in Selected Districts, 1996 (Percent of Total District Discounted Life Years) 163 Figure 2. Deaths Among Children Under Five (Per 1,000) 164 Figure 3. Cause of Death Among Children Aged I to 12 Months as Revealed by Verbal Autopsy 164 Figure 4. Cause of Death Among Children Aged One to Five Years, as Revealed by Verbal Autopsy 165 Figure 5. Percentage of Boys and Girls Under Five Years Old Reporting Fever in the Preceding Two Weeks 165 Figure 6. Percentage of Urban and Rural Children Reporting Fever in Preceding Two Weeks 166 Figure 7. Percentage of Children Reporting Fever, by Mother's Education 166 Figure 8. Percentage of Children Reporting Fever, by Region 167 Figure 9. Percentage of Age Group Reporting Fever in Past Two Weeks 168 Figure 10. Percentage of Mothers Aware of Malaria-Prevention Measures 168 Figure 11. Percentage of Households Using Protective Measures in Selected Districts 169 Figure 12. Percentage of Households with Specific Antimalarial Products 170 Figure 13. Percentage of Population Clinically Diagnosed with Malaria that Actually has Malaria Parasites 175 Figure 14. Percentage of Monthly Income Spent on Medical Goods and Services by Income Quartile 177 Figure 15. Changes in Malaria Control Practices as a Result of Community Intervention Project, Rubaga 181 Figure 16. Distribution of Bed Net Vendors in Selected Districts 184 Figure 17. Uganda's Malaria Control Infrastructure 202 Index x  Foreword T nhe government of Uganda faces a multitude of challenges in the health care arena, from ensuring that health care services are delivered in the most equitable manner, to structuring the health care delivery system to be most effective and waging campaigns against the leading causes of mortality and morbidity. The government needs the best information available on existing conditions, in order to devise strategies to successfully meet these challenges. This technical paper, Health Care in Uganda: Se- of roles of government agencies. This is being carried out lected Issues, summarizes the results of three research through a number of policy changes that include: the Civil efforts concerning current health care issues in Uganda. Service Reform, revision of the government constitution In "Part I, Equity of Access to Health Services in Uganda: (1995), and enactment of new legislation, such as the Lo- The Effects of Income, Gender, Proximity to Services, cal Government Statute of 1997. As a result of the policy and Quality of Care," the author examines a number of changes, the role of ministries will be reduced to policy factors that affect access to health services. Using em- guidance, technical support, and supervision, while man- pirical evidence from Uganda's Integrated Household agement and delivery of services will be the responsibil- Surveys and Social Dimensions of Adjustment Monitor- ity of districts. Change of management from a centralized ing Surveys from 1992-93 to 1995-96, the paper ana- to a decentralized system is a difficult undertaking that lyzes the impact of access, quality of services, and income presents many challenges. on the use of health services, especially on vulnerable The purpose of this paper is to summarize the key groups in society, such as the poor, women, and chil- actions that have been undertaken and to identify chal- dren. The impetus for this analysis is one of the goals of lenges that are emerging during this process. It is hoped the Ugandan government, recently articulated in a health that this information will be useful to those working in policy paper-to create a health care system in which Uganda, and in other countries facing similar policy all citizens have easy and equal access to appropriate and changes, to anticipate the challenges as they seek to im- high quality health care. prove the quality of health and other public services. Part II of this technical paper, "Decentralization of Finally, this report examines the progress being Health Services in Uganda: Moving toward Improved made against one of the deadliest threats to health in Delivery of Services," documents the process of decen- Uganda: malaria. Part III of this technical paper, "Ma- tralization in Uganda's health sector. laria: A Priority Health Problem," summarizes the sta- The government of Uganda has adopted a policy of tus of malaria control in Uganda and highlights some decentralization aimed at increasing local democratic con- of the key issues that need to be addressed to further trol and participation in decisionmaking, which should strengthen malaria control efforts. lead to development that is responsive to local needs. De- Malaria accounts for the largest share of morbid- centralization has necessitated a review and redefinition ity and mortality in Uganda. Despite being the xi  HEALTH CARE IN UGANDA: SELECTED ISSUES country's greatest disease burden, however, malaria technical guidance in the preparation of the paper. The control in Uganda has received declining amounts of following people reviewed and provided comments on the attention and resources over the past three decades. paper: Health Specialist for the Africa Region, Mr. John This is partly due to the breakdown in internal health Akin (Professor of Economics, University of North Caro- systems in the 1970s and early 1980s but also largely lina and former consultant in AFTHl), Mr. Charles Grif- due to a shift of focus at both national and interna- fin (Sector Manager, LCHSD), Ms. Ritva Reinnika tional levels. This situation will now be addressed by (Economist, AFTM2), Ms. Anne Martin (Health Econom- the renewed international focus on malaria through ics Lecturer, Princeton University), and Mr. James Adams the Roll Back Malaria Initiative and ongoing national (Uganda Country Director, AFC04). Preparation, review, efforts. The government of Uganda is already taking and production of the paper was coordinated by Ms. Mary steps to revitalize malaria control. A new Malaria Con- Mulusa (Operations Officer and Team Leader of Uganda trol Policy has just been prepared and both the na- Health Projects, AFTH1). tional and Malaria Control Program and districts are being strengthened. Mrs. Ruth Kagia This technical paper was written by Paul Hutchinson, Sector Manager Consultant to the Human Development Unit 1, who was Human Development Unit 1 based in Uganda for a period of two years. Mr. Demissie Africa Region Habte (Health Specialist, Africa Region) provided overall April 1999 xii  PART I Equity of Access to Health Services in Uganda: The Effects of Income, Gender, Proximity to Services, and Quality of Care   Abstract This study examines equity of access to health services waves of national household surveys conducted in in Uganda in relation to several important factors: prox- Uganda: the 1992-93 Integrated Household Survey and imity to health care providers, quality of care, income, the 1993-94, 1994-95, and 1995-96 Social Dimensions and gender. The research is based on data from four of Adjustment Monitoring Surveys. 3   Introduction A priority of health care policymakers in developing countries is ensuring that vulnerable groups, particularly the poor, women of child-bearing age, and young children, have access to high quality health services. Policymakers often take great care to ensure that the time and money prices of care are not so burdensome as to deter these groups from using essential health services. As a result, a high proportion of public resources may go to the building of additional health facilities in order to decrease the distance that individuals must travel to use services and to increase the likelihood that health services will be used. However, the mere presence of services within a rea- waves of national household surveys conducted in sonable distance is not sufficient to ensure that those Uganda: the 1992-93 Integrated Household Survey and services will be used. Nor are monetary costs always the the 1993-94, 1994-95, and 1995-96 Social Dimensions major deterrents to use of health services. Evidence in- of Adjustment Monitoring Surveys. With a few excep- dicates that many individuals in developing countries tions, data were collected from each district based on will not use available services - particularly government population (Annex A). health services -even when they are free or nearly free This analysis should be of interest to health planners because of perceptions of low quality and low efficacy. in Uganda and countries at similar levels of development. Individuals, including the poor, have shown a willing- Planners in low-income countries face severe budget con- ness to pay often substantial sums for nonfree provid- straints within which they must address a myriad of health ers in order to obtain health services that they feel will problems. Uganda, no exception, has in recent years ini- meet their health needs. As a result, an apparent para- tiated a Poverty Eradication Action Plan designed to cope dox often results in developing countries: the govern- not just with major health issues but also the proximate ment focuses on building additional facilities at the same determinants of poor health. As part of that plan, the gov- time that existing facilities are vastly underused by poor ernment is striving to increase access to an essential pack- and nonpoor alike. Much of this paradox can be ex- age of health services. This paper attempts to evaluate the plained by the nature of the available services. Often the success in achieving these objectives to date. services are of such low quality that even the poor do The results of the analysis suggest that, in Uganda, liv- not find that the services warrant the time and money ing close to essential health services, while certainly an in- costs involved in accessing them. centive to use care, does not necessarily ensure that modern This study examines equity of access-defined health care will be used. Despite considerable expansion here as "equal access to available care for equal need" in health infrastructure over the past decade, which has (Whitehead 1990)-for several important factors: prox- brought health services considerably closer to the popula- imity to health care providers, quality of care, income, tion, rates of use of modern health care providers, particu- and gender. The research is based on data from four larly government providers, has remained fairly constant. 5  HEALTH CARE IN UGANDA: SELECTED ISSUES Quality considerations appear to be the principal reason. curative care, and household expenditure on women's For curative care, even the poor tend to use nongovern- health is equal to that of men. Further, in Uganda there ment providers - believed to offer higher quality care al- seems to be no significant differences between (today's) though at a higher price - more than government boys and girls in the rates of immunization and use of providers. Even so, there is some concern that the poor are curative services. The overall effect of women's work, not fully participating in the available health systems. They both income-generating and nonpaid work, on use of are less likely than the nonpoor to use both curative care health services is unclear. Women's work does place and basic primary health cares services-prenatal and post- time constraints on their ability to use services, but natal care, tetanus vaccinations, and childhood immuni- paid work also increases both the overall well-being of zations-even when such services are free and accessible. the household and women's access to financial re- At the same time, they appear to be experiencing a dispro- sources for paying for health services. The interactions portionate increase in reporting of illness. between women's work, autonomy, and the household With respect to gender equality, men and women decisionmaking processes regarding use of health ser- are equally likely to use modern health services for vices will require further study. 6  1 The Health Sector in Uganda ecent government policy documents in Uganda highlight the importance of ensur- ing equity of access to social services for both women and the poor. The corner- tone of the Poverty Eradication Action Plan, initiated in 1996, is providing basic services to the poor: primary health care, primary education, and water and environmen- tal management (Ministry of Planning and Economic Development 1997). The Ministry of Health's draft policy paper lists as one of its objectives the creation of "a just health care system in which all citizens have easy and equal access to appropriate and high quality health care according to their need and without discrimination" (Ministry of Health 1997a and 1998). The considerable emphasis on equity of access requires careful analysis of the current degree of access for the groups of interest to policymakers. The health sector, like most sectors in Uganda, is still although the role of the private and nongovernmental recovering from the years of internal turmoil of the 1970s sector is significant (Figure 1). Roughly two-thirds of all and 1980s, during which time the government health in- modern health facilities are government-owned. As will frastructure virtually collapsed. Efforts since the late 1980s be shown, however, the government sector provides less have focused on renovating and rebuilding previously ex- than two-thirds of all health care.' isting services and extending basic health services to keep pace with population growth. In many respects, these ef- Health Care and Geographic Factors forts have been successful. Even before the troubles, the number of health facilities was increasing rapidly, particu- The expansion of the health unit infrastructure in larly at the lowest levels. Since 1972, the number of pub- Uganda has had a substantial impact on the geographi- lic, nongovernmental, and private facilities has increased cal access of the population to health services. However, by almost 400 percent and population has more than it has been asserted that still a minority of households doubled. However, the number of trained medical per- live in close proximity to modern health care facilities. sonnel has increased by far less, approximately 14 percent. A 1993 inventory of health units found that 49 percent The number of doctors has actually declined by 18 per- of the population live within 5 kilometers, about one cent. As a result, currently a far greater number of people hour's walking distance, of a health facility providing are being served by roughly the same number of trained both curative and preventive health services (Ministry medical personnel as in 1972. There is now one trained of Health 1993). Earlier documents claimed the figure medical person for every 2,346 people; in 1972, there was to be only 27 percent, with an additional 43 percent be- one medical person for half that many people (Table 1). yond 10 kilometers from a health facility (MPED 1997). Government health facilities make up the majority Significant regional differences exist. Far fewer house- of the health infrastructure, particularly at lower levels, holds in northern districts live within 5 kilometers of a 7  HEALTH CARE IN UGANDA: SELECTED ISSUES Table 1. Number of Health Units and Staff Table 2. Percentage of Population Living Countrywide, 1970 and 1996 Within 5 Kilometers of a Health Unit, by 1970 1996 Region Population 9,535,100 19,500,000 1980 1992 Health units Central 32.0 56.3 Hospitals 62 98 East 28.0 59.6 Health centers 46 223 North 18.0 27.4 Dispensaries/maternity units 65 124 West 27.0 46.5 Maternity units 20 367 Total 27.0 49.0 Dispensaries 103 603 Source: Ministry of Health 1993. Subdispensaries 110 57 Aid posts 0 33 Total 406 1505 Another measure of access is the percentage of Population/health unit 23,485 12,957 counties or subcounties with at least one facility offer- Staffing ing specific services. Uganda consists of 45 administra- Doctors 1,171 964 tive districts, subdivided into a total of 163 counties Nurses 3,877 4,059 and 878 subcounties. Counties, on average, have ap- Midwives 1,793 2,624 proximately 100,000 people; subcounties have ap- Medical assistants 435 664 proximately 20,000 people. Ministry of Health Staffing Ratios standards call for the availability of services roughly Overall population/staff 7, 276 8,3 11 equivalent to at least one health center per county and Population/doctor 8,143 20,228 at least one dispensary per subcounty. The current ful- Population/nurse 2,459 4,804 fillment of these standards is shown below, based on Population/midwife 5,318 7,431 the availability of antenatal care, maternity services, Population/medical assistant 21,920 29,367 family planning, inpatient services, and immuniza- Population/ health staff 1,310 2,346 tions (Table 4). The Health Planning Department of Source: Ministry of Health 1996. the Ministry of Health found that at the county level access to most of these services was nearly 100 per- cent, though access to family planning was slightly less health unit relative to the more densely populated re- at 88 percent. At the subcounty level, figures were con- gions of the center and east (Table 2). siderably lower; only 66 percent of subcounties had Even though there are numerous health units in antenatal services, 54 percent had maternity services, the country, many do not offer basic primary health and 56 percent had family planning. care services. Only 69 percent of all health facilities, Admittedly, standards based on geographic area are both government and nongovernment, provide im- not necessarily reliable measures of access. Not only munizations. Even fewer offer family planning and an- do counties and subcounties vary considerably in geo- tenatal care. Delivery care is generally available in graphic size and population, but they are also not is- hospitals, maternity units, dispensary/maternity units lands. This measure fails to account for proximity to (DMUs), and most health centers. The dispensaries, services in contiguous areas. Moreover, populations are subdispensaries, and aid posts, making up about half not equally dispersed, availability and ease of transport of all health units, do not generally offer such services. differs from region to region, and quality and staffing Availability of specific services is greatest in central vary considerably even in health units considered to Uganda (Table 3). be of the same size. 8  PART I: EQUITY OF ACCESS TO HEALTH SERVICES IN UGANDA Figure 1. Distribution of Health Facilities in Uganda, 1995-96 Government NGO/Private Hospitals 55 (4) (3%) 158 6 Health Centers (I 0%) Dispensaries 872 (21 Total 1,085 420 / ~~~~~(72%) (28%)\ Nonetheless, geographic access heavily influences and traditional healers. The poor do not often the extent to which Ugandans avail themselves of mod- buy sufficient or correct doses, leading to the de- ern medical services: velopment of resistance against the drugs, par- ticularly anti-malarial drugs. A large number of The great majority of individuals must walk to rural women deliver at home, many without a a health unit, since public transportation in ru- trained birth attendant. (MPED 1997, p. 35) ral areas is still limited. Faced with absence of health units within reasonable walking distance Geographic access also affects the type of care avail- many poor families rely on self treatment with able to individuals. For many rural inhabitants "there is drugs purchased from nearby kiosks and shops only one health center within reasonable distance. Only Table 3. Percentage of Health Units Offering Services, by Region Immunizations Family planning Antenatal care Deliveries Central 71 48 61 49 East 67 40 48 41 North 58 18 38 33 West 70 46 48 34 Total 69 40 49 40 Source: Ministry of Health 1 993. 9  HEALTH CARE IN UGANDA: SELECTED ISSUES Table 4. Percentage of Counties and A 1990 national household survey, for example, found Subcounties with Health Units Offering that the largest proportion of the ill, 47.3 percent, chose Specific Services, 1997 some form of self-treatment or informal care (Table Service County Subcounty 5). Individuals chose government facilities only 20.9 Antenatal care 99 66 percent of the time for curative care. A larger propor- Maternity services 96 54 tion, 31.6 percent, chose private and NGO (nongov- Family planning 88 56 ernmental organization) facilities. Inpatient services 97 60 While much has been said about long waiting times Immunization 99 85 once patients reach facilities, it is worth noting that travel Average population (1991) 102,907 18,987 time in the 1990 study tended to exceed time spent wait- Source: Ministry of Health 1 997d. ing for services. Distance, travel time, and waiting time were all generally shorter for informal care, while expen- ditures for formal and informal care were comparable. in some instances of referral can patients opt to go to This suggests that time costs, less than the money costs, an NGO hospital instead of the Government hospital" may be important in the decision to choose informal care. (Envirotech 1997 p. 36). Lack of access to health facilities is often used to A few studies have attempted to examine the rela- support the argument for devoting a greater proportion tionship between access and use of facilities in Uganda. of public resources to adding more health facilities. This, Table 5. Choice of Service for Curative Treatment, 1990 Distance Waiting Travel time Expenditure Percentage median Time median median (for those who pay) Choice of care (n = 1,107) (miles) (hrs) (hrs) Median (Ush) Max (Ush) Family 8.9% 0.0 0.0. 0.0 500 4,100 Neighbor 3.9% 0.1 0.0 0.1 1,000 12,000 Herbalist 12.0% 0.1 0.0 0.3 250 8,300 Spiritual 1.7% 0.4 0.0 0.8 550 2,000 Market 18.5% 1.0 0.0 0.3 200 6,000 Pharmacy 1.3% 0.0 0.0 0.3 700 1,000 CHWs/TBAsa 1.0% 1.3 0.0 0.8 800 800 INFORMAL 47.3% Gov't. health center 11.2% 2.0 0.5 1.0 500 7,000 Gov't. hospital 9.7% 1.4 0.3 0.5 600 40,000 GOVERNMENT 20.9% Private clinic 18.4% 1.5 0.0 0.5 600 7,500 NGO health 8.0% 4.0 0.6 1.5 600 20,000 center 5.2% 6.0 0.3 2.0 2,600 8,000 NGO hospital 31.6% PRIVATE/NGO Source: Barton and Bagenda 1993. aCommunity Health Workers/Traditional Birth Attendants. 10  PART I: EQUITY OF ACCESS TO HEALTH SERVICES IN UGANDA it is said, would ensure access for a greater part of the with subsequent fee increases. Exemptions were given population. The central government has committed it- to the very poor and to staff and their families. Revenue self to providing poorer rural areas with additional went to health worker incentives, supplementary drugs, health units, thereby cutting the average distance needed fuel and vehicle maintenance, and stationery. The addi- to travel to use health services (MPED 1997). tional drugs, especially antibiotics and injections, ap- peared to improve patient care, but overuse of the facility Income, Price, and Quality by staff and their families was perceived to have had a significant negative impact on the income of the health The effect of income and user fees on demand for center (Barton and Bagenda 1993). medical care in Uganda has been examined in only a In a more qualitative study, Asiimwe and others few, mostly qualitative, studies. User fees at government (1996) reported that use of 10 out of 12 health units de- health units were not implemented until 1989. Al- clined following imposition of fees. Focus groups ex- though still not part of official central government pressed concern not so much about the fees as the lack policy, such fees are currently charged at most govern- of improvement in quality of care. Fee revenue generally ment health units based on rates set by Local Coun- went to supplementing staff salaries. This finding reflects cils and Health Unit Management Committees. The the conclusion of a recent report examining the effect of rationale for user fees in Uganda, as in most countries user fees in Uganda: the "most outstanding reason for the where they are charged, is to provide additional fund- decline of the rate of utilization of government health fa- ing to improve quality of care and to direct scarce cilities is not the introduction of user charges but rather health resources to those most in need. Exemptions and the poor quality of services rendered by those facilities as waiver guidelines have been established. Certain cat- compared to NGO facilities" (Jitta and others 1996, p.42). egories of patients are supposed to be exempted from Repeated complaints about poor care at government fees, for instance, children under five, patients with health facilities are substantiated by several studies chronic diseases, and accident victims. The very poor (Asiimwe and others 1996, Mwesigye 1996, Olsen and receive waivers, generally as decided by local officials. others 1997). It is widely reported that while the physi- However, the system of enforcing and using fees is not cal infrastructure for curative services exists, quality of uniform, and training of health unit personnel to fa- care varies considerably. Two common problems are staff miliarize them with the guidelines has been accom- absenteeism and sporadic availability of supplies. Some plished in only a small percentage of health units. studies indicated that staff were present at health facili- Further, the effects of fees on use and quality of ser- ties only 30 percent of the time they were scheduled to vices are also not well documented. It is generally be- work (Olsen and others 1997, Mwesigye 1996). As for lieved that the revenue generated from user fees is small the problem of short supplies, Asiimwe and others and has not been channeled into improving quality. (1996) found that approximately 80 percent of drugs dis- A study of 36 health units in Tororo District in 1993 appeared from health units before being dispensed to indicated a drop in the use of health facilities after user patients. Cockcroft (1996) tells of a widespread belief fees were introduced. However, systems for reallocating that drugs "are taken by the health workers to sell in or- the additional resources were not well developed, and der to supplement their meager incomes. Some groups fee increases were not accompanied by improvements reported that even when drugs are present in the health in the quality of services (Hansen 1995). facility, patients can only get them if they pay the health A carefully monitored two-year study at one health worker" (Cockcroft 1996, p. 15). center examined the effect that charging for curative care Some studies report a more favorable impression had on use of services. The study found no significant of the quality of government services. According to one decrease in use following the institution of user fees or report, of individuals visiting government facilities, 96 11  HEALTH CARE IN UGANDA: SELECTED ISSUES percent were helped by a health worker, only 8 percent However, many health indicators have shown had to wait more than three hours, and 80 percent marked improvement in recent years, due largely to po- found drugs available. However, the availability of staff litical stability and economic growth. From 1988-89 to was likely to be overstated by respondents. Individuals 1995, the Total Fertility Rate decreased from 7.3 to 6.8 tended to go to health units "when they knew from ex- births per woman.2 The Contraceptive Prevalence Rate perience the worker was likely to be there. Most wait- increased three-fold during the same period, from 5 to ing was associated with late arrival of health workers" 15 percent, and has most likely continued to rise since. (Cockcroft 1996, p. 15). Almost half of all contraceptives come from public sec- Most studies have assumed that decreased use of tor facilities, indicating the significant contribution that facilities is a negative consequence of user fees. How- the public sector plays in this area. Most women do re- ever, such fees could serve to screen patients, discour- ceive antenatal care, 10 percent from a doctor and 82 aging unnecessary visitations and thereby allotting percent from a nurse or trained midwife (Macro Inter- scarce resources to the neediest cases. It is worth not- national 1995). ing that in a recent study of nine districts, approxi- HIV/AIDS is a tremendous health problem for mately two-thirds of households expressed a both men and women, but awareness is high and willingness to pay for improved health services at gov- roughly comparable for the two sexes. Over 90 percent ernment facilities (Cockcroft 1996). of both men and women are aware of HIV/AIDS, and The available studies in Uganda indicate that the similar percentages of both men and women know how variance in quality of government health services leads to avoid getting HIV/AIDS. On the other hand, the abil- to a situation in which consumers are uncertain about ity of women to avoid becoming infected is likely to the quality of the care they will receive once they get to be less than that of men. For women who perceived a facility. This adds another disincentive to the time, themselves as being of moderate or great risk of be- travel, and monetary costs they expect to face when de- coming infected, over half said it was because their ciding whether to use government services. However, spouse had multiple partners. For men who reported none of the studies of price and user charges in Uganda similar concern, over one-third said it was because they have been able to examine the effects of user charges on had multiple sex partners and another third said it was different income groups or differences in treatment be- because they did not use condoms. Only 10 percent of havior by income level. men said that their concern was because their spouse had multiple partners (Macro International 1995). Women and Health In Uganda, women and children make up the ma- jority of users of health services. At the primary level in The health situation of women in Uganda has been Uganda, children under five constitute approximately one of the worst in the world. The maternal mortality one-third of all outpatient attendees. Curative care for rate is currently estimated at 506 deaths per 100,000 reproductive health problems, prenatal and safe deliv- live births, accounting for roughly 17 percent of all ery care, and family planning make up a significant pro- deaths that occur among women aged 15 to 49 years. portion of health unit visits (MOH 1997c). Only 13.7 percent of pregnant women receive prenatal Few studies of use of curative care by males and fe- care in the first trimester, and only 35.4 percent of males have been conducted in Uganda. A 1990 study births occur in a medical facility. Of all births, 65.9 per- found that women were slightly more likely to self-treat cent are considered high risk. The Total Fertility Rate and less likely to use modern formal care (Barton and remains high, at almost seven births per woman. Fur- Bagenda 1993). In 1995, women who reported a sexu- ther, no change has been noted in the age at first birth, ally transmitted infection were more likely to seek treat- and in fact fertility rates among teenagers may be in- ment, and more likely to inform partners, than men creasing (Macro International 1995) (Macro International 1995). 12  PART I: EQUITY OF ACCESS TO HEALTH SERVICES IN UGANDA Use of both curative and preventive services by for women. Women plan the incomes and men plan the women is significantly affected by proximity. "Roughly expenditure" (Jitta and others 1996, p. 17). half of women in Uganda live within 5 km of a facility Some studies argue that women simply do not providing antenatal care, delivery care, and have time to avail themselves of health services. One immunisation services. However, the data show that chil- study cited different allocations of time to various ac- dren whose mothers receive both antenatal and deliv- tivities for men and women as evidence that women ery care are more likely to live within 5 kilometers of a do not have sufficient time to use health services. It is facility providing maternal and child health services (70 estimated that rural women work from 12-18 hours per percent) than either those whose mothers received only day and are largely responsible for farm labor and ob- one of these services (46 percent) or those whose moth- taining water and firewood (UNICEF 1989). In rural ers received neither antenatal nor delivery care (39 per- areas, self-employed women working in agriculture cent)" (Macro International 1995, p. xviii). A 1989 study spend on average 14 percent of their time on farming, concluded that many maternal deaths could be pre- whereas their male equivalents spend only 7.7 percent vented with better access to pre- and postnatal care and of their time on farming. Women spend 4.4 percent of more hygienic delivery, either at home with trained birth their time fetching water, men 1.5 percent. Women also attendants or in health facilities (UNICEF 1989). spend three times as much time collecting firewood as Ithas been argued, mostlyfrom qualitative interviews men (Jitta and othersl996). A study of women in and focus group discussions, that women are discouraged Kampala theorized that their health was likely to suf- from using health services by lack of access to household fer because time spent on income earning activities did finances. In many households in Uganda, decisionmaking not allow them time to seek medical attention when is "is characterized by male dominance and lack of voice necessary (Kyomuhendo 1997). 13   Geographic Factors and Access T he distance that individuals must travel in order to reach modern health care providers is an important determinant of access to health services and is at the center of debates on access to an Essential Package of Health Services. This section provides some initial evidence that access to a modern provider in Uganda may be greater than has been thought and that the effects of distance on use of services may be overstated. Distance to Health Care Providers 66 percent of the population lived in villages 5 kilo- meters or fewer from a modern provider, although the Distance is a proxy for the time price of health care; official government figure was 49 percent. In 1995-96, greater distance generally means more travel time and approximately 71 percent of the population lived in more time away from productive labor. In both 1993- villages 5 kilometers or fewer from a modern provider. 94 and 1995-96, community surveys collected data on More importantly, in 1995-96,90 percent of the popu- one or two health facilities serving each survey area. lation lived in villages 10 kilometers or less from a It was then possible to link data on the health facili- modern provider, and 99 percent in villages within 20 ties with the individuals living in most survey areas3 kilometers. (Annex B). The health facilities were located anywhere In 1992-93, one male and one female commu- from 0 to 48 kilometers from the village center or enu- nity leader for each surveyed area were asked about meration area. In 1993-94, on average, the modern the availability of different types of health care pro- provider was located 4.99 kilometers from the village viders for that community. Overall, 62 percent of sur- center or enumeration area. This does not mean that veyed areas had a modern provider-a hospital, health on average the nearest modern provider is 5 kilome- center, maternity clinic, doctor or qualified nurse/ ters from the population, because the survey popula- midwife-within 5 kilometers and 84 percent had one tion is generally not located directly in the village within 10 kilometers. This is similar to the 66 percent center or center of the enumeration area. Rather, and 71 percent of the survey population within 5 ki- populations are dispersed around the survey area. Be- lometers and 88 percent and 90 percent within 10 ki- cause this method of determining distance may lometers for 1993-94 and 1995-96 respectively slightly overstate access, additional analysis using a described above. On average, enumeration areas were more accurate measure is recommended. Regardless, closest to traditional practitioners-3.4 kilometers to it is felt that this measure achieves a suitable ranking a traditional midwife and 5.6 kilometers to a tradi- of areas by distance to health care providers. tional doctor. They were 7.7 kilometers on average The numbers for the 1993-94 and 1995-96 surveys from a health center, and 11.4 kilometers from a quali- are revealing (Table 6). In 1993-94, approximately fied nurse/midwife (Table 7). 15  HEALTH CARE IN UGANDA: SELECTED ISSUES Table 6. Population Within Specified Distance of Modern Provider, by Urban and Rural Residence, 1993-94 and 1995-96 Distance 1993-94 (percentage of population) 1995-96 (percentage of population) (km) Rural Urban Survey population Rural Urban Survey population 0.5 II 13 11 21 20 21 1.0 19 40 22 3 1 58 35 2.5 29 73 35 44 84 49 5.0 62 94 66 67 99 71 10.0 86 99 88 88 100 90 15.0 97 100 97 95 96 20.0 99 99 98 98 25.0 99 99 99 99 64.0 100 100 Source: Social Dimensions of Adjustment Monitoring Surveys 1993-94 and 1995-96. In large part, distance determines whether people was slightly higher in 1995-96. However, the likelihood will seek out a modern provider. A more direct method of using a modern provider depended on how close of evaluating the importance of proximity is to look at that provider was. For instance, in 1993-94 just over the proportion of ill individuals who visit a modern pro- 65 percent of sick people went to a provider that was vider, defined here as a government or private health unit within 1 kilometer. That percentage dropped to 46 per- or a nongovernmental organization, for given distances cent if the nearest provider was more than 15 kilome- between their residence and the modern provider ters away. In general, for every additional kilometer in (Figure 2). Overall, approximately 58 percent of the sick distance, the likelihood of use dropped by just under used a modern provider in 1993-94, a percentage that 1 percent. Table 7. Percentage of Surveyed Areas Within Specified Distance of Various Types of Health Care Providers, 1992-93 Percentage of survey areas within specified distance to a Type of health health care provider (distance measured in kilometers) Distance care provider <I <3 <5 -<10 -<20 <50 <100 Mean S.D. Max. Hospital 3% 8% 13% 24% 45% 83% 99% 29.9 26.3 432 Health center 18% 37% 55% 82% 94% 99% 100% 7.7 10.9 200 Maternity clinic 11% 22% 35% 61% 79% 96% 100% 14.9 23.5 700 Doctor 7% 13% 19% 31% 52% 85% 98% 26.8 25.3 221 Traditional doctor 65% 76% 83% 88% 93% 98% 100% 5.6 30.5 800 Pharmacy 6% 13% 18% 28% 41% 62% 78% 100.3 154.0 900 Qualified nurse/midwife 18% 33% 47% 68% 84% 97% 100% 11.4 15.0 130 Traditional midwife 70% 81% 90% 95% 97% 99% 100% 3.4 18.6 500 Any hosp/hc/dr/ qualified nurse 26% 46% 62% 84% 95% 100% 100% 1.0 4.5 67 Source: Integrated Household Survey 1992-93. 16  PART I: EQuITY OF ACCESS To HEALTH SERVICES IN UGANDA Figure 2. Percentage of IlI Individuals Using a Modern Provider by Distance from Residence, 1993-94 and 1995-96 70%- 70 6 0 % - - - - - - - - - - - - - - - - - 0 oo \ 1 99~~~~~~~~~~3-94 v50% -\ 45% 40% - I <I 1-2 km. 2-5 km. 5-10 km. 10-15 km. 15+ km. Distance to Nearest Modern Health Care Provider Source: Social Dimensions of Adjustment Monitoring Surveys 1993-94 and 1995-96. For 1995-96, the effects of distance on utilization important; either drugs were not available or were too were less striking; 64 percent of individuals used a mod- costly. Distance was the third most important reason ern provider when ill if they lived within 1 kilometer of for not using a health unit. a modern provider, as opposed to 56 percent of those The same 1992-93 survey looked at the extent to who lived 10-15 kilometers from a modern provider. which transportation costs associated with greater dis- tance deterred use of health services. As would be ex- Quality of Care,Transportation Costs, and pected, transportation costs increased the longer the Distance distance traveled. On average, however, the monetary costs of transportation accounted for only a fraction of An assessment of how individuals value distance to total expenditure on illness, 3 percent. Thus it appears health care providers relative to other factors affect- that the cost of transportation is unlikely to impede ac- ing utilization is available using the 1992-93 commu- cess to modern care. nity survey (Table 8). In 1992-93, the male and female community leaders were presented with a list of rea- Future Studies of Geographic Access sons why individuals might not use an available health unit and then were asked to rate these reasons as "very Providing a more accurate estimate of the physical important," "important," or "not important." While distance from households to health facilities could be distance was considered to be an important reason for easily and inexpensively obtained in household surveys not using a health unit, drug issues were rated as more by using Global Positioning Systems to pinpoint more 17  HEALTH CARE IN UGANDA: SELECTED ISSUES Table 8. Community Leaders' Perceptions of Reasons That People Would Not Use Health Units, 1992-93 (Percent) Reason for not using a health clinic Very important Important Not important Lack of necessary drugs 42 27 31 Drugs very costly 35 19 46 Clinic too far away 23 16 60 Consultation fees too high 10 1 1 78 Staff normally not present 7 14 79 Lack sterile needles/syringes 7 11 82 Staff rude 7 9 84 Other 70 6 25 Source: Integrated Household Survey 1992-93. precisely the locations of specific households and health increasing access to alternative providers such as commu- units. This will be done in upcoming household surveys. nity health workers and outreach programs. There are no A more elaborate exercise would examine the pub- available data on the use of outreach services. It would lic and private costs of increasing the percentage of also be useful to compare access to modern care in coun- population within a specified distance of a modern pro- tries that have an income level similar to Uganda's. Both vider. These would need to be compared to the costs of exercises are beyond the scope of this analysis. 18  Income and Access n general, differences in income appear to be significantly related to utilization both of preventive services (e.g., immunization, reproductive care, etc.), which tend to be free, and of curative care, as well as to factors affecting health such as sanitation and hy- giene conditions in which households live (Figure 3). The differences between the poor and nonpoor in likelihood of use and use of specific types of modern health care are fairly significant for curative care, full immunization, and postnatal care. For prenatal care, the difference between the two groups is considerably smaller, and, in fact, 80 to 90 percent of women of all income groups receive some prenatal care. The analysis that follows is based on total annual groups. For most of the outcomes of interest, a continu- income from several sources: salaries and wages; enter- ous positive relationship is exhibited -higher income prises, property, dividends; and transfers from family, levels lead to higher utilization levels. Outcomes for the government, and others. A separate variable stratified two middle income groups generally fall between the val- households by detailed weekly, monthly, and annual ex- ues observed for the lowest and highest income groups. penditure, including information such as purchases of It is also recognized that there are difficulties in ex- food, beverages, and tobacco and of nondurable and du- amining causal relationships between income and health rable goods. It also included the value of income from status in cross-sectional studies. While it may be obvious home production of (generally agricultural) goods and that there is a high degree of correlation between health services. Because the value of home-produced goods was status and income, the exact nature of this relationship is calculated only in 1993-94, comparisons using the ex- not always clear. On the one hand, low income could lead penditure data across years were not considered reliable. to increased risk factors leading to poor health. On the As a result, the income variable was used instead. In gen- other hand, ill health could propel households into lower eral, however, the results that follow did not change sig- income groups due to inability to work or significant nificantly regardless of whether the income or medical expenditures. Distinguishing between the two expenditure variables were used. situations is difficult unless adequate measures of perma- For most of the analysis, the population is catego- nent wealth can be identified. Longitudinal surveys com- rized into income quartiles for ease of comparison. Cat- paring changes in health status and income would be egorization was based on population rather than number more appropriate for such an analysis but, again, are not of households. Since higher income households tended possible using the existing data. to have fewer members, there were more households over- all in the lower quartiles than in the upper quartiles, even Income and Reporting Illness though total population was nearly the same in each. Also, to minimize the number of comparisons, results are gen- In 1992-93, 1993-94, and 1995-96, individuals reported erally presented only for the lowest and highest income whether they had experienced an illness in the 30 days 19  HEALTH CARE IN UGANDA: SELECTED ISSUES Figure 3. Percentage of Lowest and Highest Income Quartiles Using Curative and Preventive Care, 1995-964 Modern Curative I: Fully Immunized I I 1 1 _ BCG _I _ I I I _ DPT3 _ _ _____ _____ ___- __=_ Measles f I( - <.., ;f - ..; _ r'i 13~~~~I Highest U | 1 1 1 l . *0 Highest Polio3 :: ::::: ::SvS ;< :! 1 :-: : <: a t P ____ i r i res Prenatal Care : i;__ _ Postntlar_____ Tetanus To I I I I 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Source: Social Dimensions of Adjustment Monitoring Survey 1995-96. Figure 4. Percentage of Income Quartile Reporting Illness in the Past 30 Days 35% - 31% 1 _ 1992-93 __ 1993-94 * 1995-96 30%- 28% 26% 25% - _24% 20% - ** 3 _ 3 _ ~~~~ ~~~23% _22%. _ 15% - 19% 22% I 0% - 5% 0% I Lowest 2nd Lowest 2nd Highest Highest Source: Integrated Household Survey 1992-93; Social Dimensions of Adjustment Surveys 1993-94 and 1995-96. 20  PART I: EQUITY OF ACCESS TO HEALTH SERVICES IN UGANDA prior to the survey. The results on self-reporting of ill- reflect differing ideas of what constitutes illness on the ness by income quartile are mixed. While higher income part of urban and rural inhabitants. Several factors were quartiles were slightly more likely to report illness in associated with greater likelihood of reporting illness in 1992-93 than lower income quartiles, the opposite was 1995-96 than in 1993-94. These included being female, a true in 1993-94 and 1995-96 (Figure 4). Overall, there rural resident, older (46 to 99 years), a resident of the appeared to be a significant increase in reporting of ill- north or west, and a member of a larger household. ness from 1993-94 to 1995-96, although this increase was Better sanitation also plays a significant role in re- most dramatic in the lowest income quartile. A logit es- porting illness, indicating that both continued economic timation based on pooled data for the 1993-94 and 1995- development and public health campaigns can make a 96 waves showed that this increase did not appear to be difference in improving health outcomes. Residents of associated with any particular household, individual, or households with flush toilets or pit latrines are less likely regional characteristic (Annex C Table C-1). to report illness than other residents. Those with access The reasons for the increase in reporting are not im- to taps, whether public or private, boreholes, or pro- mediately clear, particularly whether the increase is a re- tected springs are less likely to report illness than those flection of the current state of the AIDS epidemic. These depending on natural or unprotected water sources. data alone cannot answer that question, though they could be linked with other sources to examine that issue. Income and Choice of Curative Care It was hypothesized that a higher proportion of household interviews in the 1995-96 survey occurred For individuals reporting illness, income is closely related during or soon after the rainy season, when certain vec- to the choice of curative care (Table 9). This result is more tor-borne illnesses are more widespread. However, an pronounced in 1993-94 and 1995-96 than in 1992-93. examination of results from the different surveys found In general, the wealthiest are more likely to choose pri- no significant relationship between season and report- vate and nongovernmental providers, while the poorest ing of illness. are more likely to self-treat. Estimation results show that It is likely that perceptions of illness have changed this pattern holds for both urban and rural areas and for over time as a result of health education and increased different regions of Uganda. media exposure. It may be that the population now as- Individuals in the lowest income quartile are more sociates certain symptoms or conditions with illness that likely to choose some form of self-care than those in the they previously accepted as normal. This argument is highest income quartile. The surveys reported two types supported by the data that found a growing percentage of self-care: no medical attention and no medicine used, of the population choosing either self-treatment or no and home treatment. In 1992-93, 44.9 percent of those treatment. Self-treatment would reflect action taken in in the lowest income quartile chose self-care compared minor cases of illness. Alternatively, people coping with with 33.4 percent of those in the highest income quartile. HIV- or AIDS-related illnesses may have found that little In 1993-94, nearly 50 percent of those in the lowest in- is to be gained from visiting a modern provider. come group chose self-care compared with only 21.8 A logit estimation using a pooled sample of 1993-94 percent in the highest income quartile. In 1995-96, the and 1995-96 data indicates that several factors are associ- figures were 43 percent and 25 percent, respectively. ated with greater likelihood of reporting illness: younger A significant finding is that the proportion of ill in- and older individuals; individuals in the lowest income dividuals in the lowest income quartile who choose to do quartile; and residence in central Uganda. Other factors, nothing has been increasing over the three waves. For such as being a rural resident and higher levels of educa- 1993-94, individuals in the lowest income quartile are 10 tion, were correlated with a lower likelihood of reporting times as likely to report "no medical attention and no (Annex C Table C-i). The rural-resident factor may medicine used" than individuals in the highest income 21  HEALTH CARE IN UGANDA: SELECTED ISSUES Table 9. Choice of Curative Care for Lowest and Highest Income Quartiles (Percent) 1992-93 1993-94 1995-96 Treatment sought Highest Lowest Highest Lowest Lowest Highest No medical attention and no medicine used 7 4 16 2 25 5 Home treatment 38 29 34 20 18 20 OP government facility 17 19 17 14 25 19 OP private facility 28 37 25 52 25 48 Private doctor 3 5 2 5 2 2 Pharmacy 2 1 1 3 3 1 Traditional doctor 2 1 4 0 2 1 IP government facility I I I I I I IP private facility 2 2 0 2 0 0 Other 0 0 0 1 0 1 Total 100 100 100 100 100 100 N 2,405 1,426 1,041 2,664 2,2259 1,174 Source: Integrated Household Survey 1992-93, Social Dimensions of Adjustment Monitoring Surveys 1993-94 and 1995-96. Note: OP = outpatient; IP = inpatient. quartile (15.7 percent versus 1.5 percent). For 1992-93, curative care has remained mostly unchanged. Choice they were only slightly more likely to report "no medical of curative care data from the 1992-96 surveys can be attention and no medicine used:' compared with data from the 1990 analysis of the Fam- That such a high proportion of the lowest income ily Household Health and Budget Survey. In that sur- group self-treat might be reason to strengthen commu- vey, government health units delivered 20.9 percent of nity education on how to treat common illnesses and all curative care. The more recent data show no signifi- improve quality of care. More information is needed cant increase in the use of government curative services. about whether the care received by the poor adequately Nor, despite efforts to build and reconstruct health units addresses their needs. It would be useful to examine between 1988 and 1996, does there appear to have been whether quality of care, for example, drugs and time an increase in the likelihood of people seeking out a spent with health workers, is significantly different for modern provider for curative care. During those years the poor than for the nonpoor. the number of government, nongovernment, and pri- Overall, outpatient private and nongovernmental vate health units rose by about 40 percent. WVhile these facilities were the most common choice for ill individu- units certainly provide services beyond curative care, als (34.7 percent) in 1993-94, followed by home treat- their negligible impact on curative behavior may be im- ment (29.0 percent). Outpatient government hospitals portant to policymakers trying to allocate health re- and health centers were chosen half as often as outpa- sources in the most cost-effective manner. tient private hospitals and health centers. Perhaps most important, even in the lowest income quartile, private Factors Affecting Use of Modern Curative and nongovernmental providers were generally preferred Care by the Poor over government providers. Despite a substantial increase in the number of To examine the factors affecting whether or not the health units countrywide since 1986, use of government poor seek curative care from a modern provider, logit 22  PART I: EQUITY OF ACCESS TO HEALTH SERVICES IN UGANDA estimations were performed for urban and rural resi- 1995-96 chose a modern provider when ill. However, dents in the 1993-94 and 1995-96 samples (Annex C at least in 1993-94, facilities were more likely to be cho- Table C-2).5 Characteristics of the available health sen if they were private or owned by nongovernmen- unit are also included in the estimations, as well as tal organizations. variables interacting "being in the lowest income Indeed, the logit estimation indicates that quality quartile" with specific facility characteristics. The lat- of care was an important consideration for the poor. ter interacted variables serve to test whether certain For simplicity, only the results for rural areas, where factors are more important for the poor relative to the the majority of the population of Uganda lives, are con- nonpoor in affecting use of curative care. sidered here. For example, the presence of a doctor at For this analysis, the dependent variable is a di- a health unit and greater numbers of support staff ap- chotomous variable for whether or not an ill indi- peared to have a positive impact on whether poor vidual uses a modern provider for curative care. This people decided to use the nearest modern health facil- was chosen over a more explicit categorical variable ity. Both results may reflect the possibility that the looking at ownership (government, nonprofit, or pri- available facility is a hospital or other large-scale facil- vate) or size (hospital, health center, or clinic) because ity. The latter result on number of support staff may most individuals do not have such an explicit choice also reflect the informal nature that is often used by set when ill and because the community surveys col- individuals in order to obtain services; as pointed out lected information on only one health care provider by Cockcroft (1996), individuals often rely on know- per enumeration area. It is believed that this choice ing someone at a facility in order to expedite delivery set is more likely to be a realistic scenario in rural ar- of services. Greater numbers of support staff increase eas than in urban areas, and for this reason separate the likelihood that an individual can employ this in- estimations are performed for urban and rural indi- formal means of receiving services. Other factors im- viduals. Future analyses will explore different variables portant to the poor included the availability of for choice of curative care. antibiotics and general upkeep of a facility. The issue of quality is apparent in the type of fa- The most important result of the logit estimation, cilities that individuals choose for curative care (Table already discussed, is that individuals in lower income 10). It is generally believed that higher level NGO and households appeared less likely to use modern services, private facilities offer higher quality health services than even when such factors as distance were taken into ac- similarly sized government facilities. Small, private count. All individuals are less likely to use services the clinics are unregulated and vary considerably in qual- farther they are from a health unit, but the effects are ity. Overall, 58 percent in 1993-94 and 61 percent in no greater for the poor than the nonpoor, and in fact in Table 10. Choice of Available Modern Provider Based on Facility Ownership and Residence (Percentage of Ill Individuals) 1993-94 1995-96 Ownership of health facility Urban Rural All Uganda Urban Rural All Uganda Government 65 53 55 70 59 60 Nongovernmental org. 65 66 66 56 60 59 Private health unit 78 61 62 74 65 67 Average 67 57 58 70 60 61 Source: Social Dimensions of Adjustment Monitoring Surveys 1993-94 and 1995-96. 23  HEALTH CARE IN UGANDA: SELECTED ISSUES 1993-94 the poor are actually more likely than the the simulations, equivalent-sized changes in different in- nonpoor to use services if they live farther away. Such a dependent variables are represented by altering their val- finding is consistent with other studies that find the time ues by approximately one standard deviation from their price of medical care to be less important to the poor mean. than the nonpoor. The simulations show that changes in quality vari- The monetary price of care does not appear to be a ables-availability of antibiotics and doctors, the pres- significant deterrent to use of curative care for the poor ence of a functioning cold chain, and whether a facility or the nonpoor. In model specifications both with and is nonprofit, nongovernment owned-have equal or without income variables, the estimated coefficients for larger impacts than other factors such as price and dis- price of care (consultation fee, price of antibiotics), while tance, on whether or not the poor use curative care. occasionally statistically significant, are generally quite For example, if everyone in the lowest income quartile small. This would tend to support arguments that user were within 5 kilometers of a modern health unit-a fees are not the principal deterrents of care. decrease in the mean distance from 5 kilometers to 2.8 A final important result is the impact of education kilometers-use of curative care would increase by on use of services, particularly for women. In both ur- only 2.3 percent. This has the same impact for the poor ban and rural areas in 1995, individuals in households as reducing the consultation fee for services to zero. with women of higher levels of education were much However, increasing the proportion of health units with more likely to use curative care than those in households antibiotics by 20 percent leads to twice the effect, an with less educated women. increase from 54 to 57 percent in the proportion of the To further illustrate the impacts of important vari- poor using curative services. If all facilities had doc- ables relative to one another on use of services, simula- tors, the effect would be twice as large - an increase tions were undertaken using logit estimation results for of 9.3 percent from 54 percent to 59 percent. individuals in the lowest and highest income quartiles Many of the effects of changes in quality variables (Table 11 and Annex C Table C-3). Simulations are used are similar for the poor and nonpoor alike. Increasing to model how similar-sized changes in independent vari- the availability of doctors increases the likelihood that ables, such as availability of drugs or distance to a facil- both the poor and nonpoor will use modern curative ity, impact on the use of curative services. For most of services by approximately 10 percent. If all facilities had Table I 1. Simulations Using Logit Estimation Results for Use of Modern Curative Care, Lowest and Highest Income Quartiles, Rural Areas Only, 1995-96 Lowest Highest Simulation Use Pct. change Use Pct. change Baseline 54.1% 71.7% If consultation fees increased by Ush 500 51.6% -4.6% 80.3% 12.1% If number of support staff increased by 20% 54.4% 0.7% 70.9% - 1.0% If everyone was within 5 kilometers 55.3% 2.3% 71.0% -0.9% If consultation fees were 0 55.3% 2.3% 66.0% -7.9% If antibiotic availability increased by 20% 56.5% 4.6% 62.2% - 13.2% If all facilities had at least I doctor 59.1% 9.3% 79.4% 10.8% If all facilities had functioning cold chain 60.8% 12.5% 80.8% 12.8% If all facilities were a nonprofit 62.7% 16.0% 68.9% -3.9% 24  PART I: EQUITY OF ACCESS TO HEALTH SERVICES IN UGANDA a functioning cold chain, utilization would increase by poor chose the same provider, the gap in expenditure approximately 12 percent for both groups. In short, widened. these results would tend to indicate that the quality of Several explanations for the expenditure gap are services is at least as important as distance and price possible. One reason may be the questionnaire's struc- in determining use of curative care for both the poor ture. Space was provided for only one type of cura- and nonpoor alike. tive treatment, though considerable evidence suggests that ill individuals are likely to use multiple sources Household Medical Expenditure of curative care. Wealthier households may in fact use more sources of care that could not be distinguished Another way of viewing equity of health service utili- given the questionnaire format. Alternatively some zation is to examine the financial burden that health lower income households might have fees waived or care places on households of different income levels. pay a smaller proportion of medical bills, which In general, illness leads households to incur two types would indicate that the fee system was functioning. of costs: direct costs, that is, money spent on such On the negative side, lower expenditure by poor things as drugs and transportation; and indirect costs, households might reflect different, perhaps inad- or lost labor time. The available data are insufficient equate, health care treatment. More data are required for examining the value of lost labor time. As a result, to pinpoint the reason for the expenditure gap be- this analysis looks only at direct costs. tween rich and poor. Wealthier households spent more for all types of The percentage of total monthly expenditure on medical care than did poorer households (Table 12). health care suggests the extent to which illness affects Overall, in 1992-93 upper income households spent households of different income levels. In 1993-94, for almost twice as much as households in the lower example, the poorest households devoted a slightly bracket. In 1993-94 richer households spent four higher percentage of monthly expenditure to health care times as much treating illness as poor households and than did the richest households (Figure 5). in 1995-96 they spent over three times as much. The While lower income households were more likely increase in the expenditure gap between rich and poor to devote a higher percentage of total monthly expen- from 1992-93 to 1995-96 is probably related to an diture on medical care, they were also more likely to increase in the proportion of the poor choosing to spend nothing on such care (Figure 6). This would in- self-treat or do nothing. However, even when rich and dicate that they were either exempted from payment Table 12. Annual Per Capita Household Medical Expenditure by Income Quartile (Constant Dollars) Income quartile 1992/3 1993/4 199415 199516 Lowest $ 5.77 $ 3.92 $ 5.55 $ 4.85 Second Lowest $ 5.54 $ 7.55 $ 7.20 $ 7.48 Second Highest $ 7.27 $ 10.18 $ 12.89 $ 9.30 Highest $ 11.02 $ 12.07 $ 19.04 $ 15.37 Average $ 6.98 $ 6.81 $ 8.71 $ 7.70 Inflation 6.50% 6.10% 7.50% (Consumer Price Index, September 1997, Statistics Department) ($I = ],100 Ush) 25  HEALTH CARE IN UGANDA: SELECTED ISSUES Figure S. Percentage of Monthly Expenditure on Medical Care By Income Quartile, 1993-94 5.0% 4.0% 3.0% 4.0% 3.5% 2.0% 3.5% 2.7% 1.0% 0.0% 2 - Hig-est Lowest 2nd 2nd Highest Lowest Highest Source: Social Dimensions of Adjustment Survey 1993-94. Figure 6. Percentage of Monthly Expenditure on Health for Lowest and Highest Income Quartiles, 1993-94 60%/ no 50% 52% r Lst z 40% - z | | Cl H~~~~~~~EBFiighe~st| 50 ; 40% 0 C= 30% 26~~~~~~~~~6 gU 20% 0 a- 3/ 0% 0 <=5 5-15 > 15 Source: Social Dimensions of Adjustment Survey 1993-94. 26  PART I: EQUITY OF ACCESS TO HEALTH SERVICES IN UGANDA when they sought medical care, did not seek medical Table 13. Location of Vaccination for Lowest care when ill, or were simply not ill and therefore did and Highest Income Quartiles, 1992-93 not need medical care. Location Lowest Highest Govt hospital or health center 64.8% 61.1% Income and Primary Health Care Field worker 15.8% 15.0% School 0.3% 1.3% In general, the poor were less likely to use preventive Special camp 4.1% 5.9% and primary health care services, that is, immuniza- Total public 85.0% 83.3% tion for children, prenatal and postnatal care, and Private hospital or health center 14.8% 16.2% tetanus toxoid vaccination during pregnancy. This re- Private doctor 0.3% 0.3% sult is perhaps surprising, given that these services are Pharmacy 0.0% 0.1% supposed to be provided free and therefore financial Total private 15.1% 16.6% constraints should not be a problem. The question is Total 100% 100% then whether these services are either not accessible Source: Integrated Household Survey 1992-93. because of physical or time constraints, are of low quality, or are simply not valued by the poor as much as the nonpoor. It is appears that some combination Ministry of Health, children are supposed to receive the of these factors is at work. following schedule of immunizations: polio and BCG (for tuberculosis) at birth; polio and DPT (diptheria, pertus- Immunizations sis, and tetanus) at 6, 10, and 14 weeks; and measles at 9 The government is the principal provider of immuni- months. To be fully vaccinated, a child should receive a zations. Almost two-thirds of vaccinations occur at gov- BCG vaccination, three doses of DPT vaccine, three doses ernment facilities (Table 13). The private sector accounts of polio vaccine, and one dose of measles vaccine (Macro for only about 15 percent of vaccinations. As a result, International 1995). Using these criteria,6 approximately the government has a strong role to play in promoting 64 percent of children aged 12-48 months have been fully vaccination coverage, particularly among the poor. vaccinated (Table 14). The differences across income According to the protocol of the Uganda National Ex- groups are significant. Children in the highest income panded Programme on Immunisation (UNEPI) of the quartile are approximately 50 percent more likely to be Table 14. Percentage of Children Aged 12-48 Months Receiving Immunizations, 1995-96 Vaccination Lowest 2nd lowest 2nd highest Highest Total BCG 82% 86% 90% 95% 87% DPTI 82% 88% 91% 95% 88% DPT2 77% 84% 88% 92% 84% DPT3 70% 77% 84% 91% 79% PolioO 45% 54% 57% 74% 55% Polio 1 83% 86% 90% 94% 87% Polio2 76% 83% 88% 92% 84% Polio3 70% 77% 84% 90% 79% Measles 69% 77% 81% 89% 78% Full coverage 53% 64% 68% 79% 64% Source: Social Dimensions of Adjustment Monitoring Survey 1995-96. 27  HEALTH CARE IN UGANDA: SELECTED ISSUES Table 15. Reason for NotVaccinating, likely to be immunized than children in urban areas Lowest and Highest Income Quartiles, when all other factors are controlled for. The 1995 De- 1992-93 (Percent) mographic and Health Survey data find that children Reason Lowest Highest in rural areas are actually more likely to be immunized Lack of knowledge 17% 16% than children in urban areas. Too young 27% 30% Another perhaps unexpected result is the value of Opposed to vacc. 8% 8% education in determining whether a child is fully im- Facilities too far 21% 23% munized. Children in households with more educated Too costly 1% 2% adult females are much more likely to be fully immu- Other 27% 21% nized. Many other results probably reflect the fact that Total 100% 100% the government is the principal provider of vaccinations Source: Integrated Household Survey 1992-93. and many vaccinations occur at larger facilities. Indi- I viduals living near a nonprofit, nongovernmental orga- nization facility were less likely to be fully vaccinated. fully immunized than children in the lowest income Quality factors were also important, particularly avail- quartile. ability of vaccines themselves. While the poorest were less likely to have their children immunized, the two income levels did not Prenatal and Postnatal Care differ with respect to why vaccinations were skipped In Uganda, most pregnant mothers receive trained or where they were obtained (Table 15). The reason prenatal care during their pregnancies, although only most commonly offered for not vaccinating children a small number receive such care during the first tri- was that they were too young; 27 percent of mothers mester. According to the 1995 Demographic and in the lowest income quartile gave this response, and Health Survey (Macro International), approximately 30 percent of those in the highest quartile. Cost was 82 percent of women receive prenatal care from a not a consideration. nurse or trained midwife; doctors account for an ad- Logit estimations of factors affecting whether or ditional 10 percent. The principal components of pre- not a child aged 12-48 months is fully immunized sup- natal care are pregnancy monitoring and detection of port the available evidence that there are significant dif- complications. It is recommended that women make ferences in immunization coverage across income monthly prenatal visits for the first seven months of groups (Annex C Table C-4). Controlling for all other a pregnancy, every two weeks during the eighth factors, children in households in upper income month, and weekly until birth. These data do not list quartiles were much more likely to be fully immunized the number of prenatal visits that a woman makes. than children in households of the lowest income Despite high prenatal care rates, only one-third of quartile. Distance to the nearest modern provider, sur- births occur in health facilities. prisingly, was not a statistically significant constraint These data also show high prenatal care rates, though for immunization coverage. Individuals at greater dis- not quite as high as those found in the DHS (Table 16). tances from health units were not statistically signifi- Approximately 81 percent of women overall receive pre- cantly less likely to be immunized than individuals natal care from trained staff. An additional 6 percent re- living closer. This may simply reflect the fact that, un- ceive prenatal care from a traditional birth attendant. Only like curative care, whose need is unpredictable, the de- a small proportion, 4 percent, do not receive prenatal care mand for immunizations can be planned sufficiently because there are no facilities within a reasonable distance. so that distance constraints are minimized. The lack of No data are available here on location of delivery. significance of physical accessibility is also supported For prenatal care, the differences in utilization across by the fact that children in rural areas appear no less income groups are not large - nearly 80 percent of 28  PART I: EQUITY OF ACCESS TO HEALTH SERVICES IN UGANDA Table 16. Percentage ofWomen Using Prenatal and Postnatal Care for Most Recent Pregnancy, Lowest and Highest Income Quartiles, 1995-96 Prenatal care Postnatal care Type of care Lowest Highest Total Lowest Highest Total Trained staff 78% 89% 81% 41% 66% 51% Traditional birth attendant 7% 3% 6% 20% 7% 13% No care - absence of facility 6% 3% 4% 9% 3% 8% No care - other reason 8% 5% 8% 30% 24% 28% Total 100% 100% 100% 100% 100% 100% Source: Social Dimensions of Adjustmenc Monitoring Survey 1995-96. women in the lowest income quartile and nearly 90 per- individuals in the lowest income group were statistically cent of women in the highest income quartile receive less likely to use all preventive services. This relation- prenatal care from trained medical staff. ship was least pronounced for prenatal care. Distance, Most women in Uganda also receive tetanus tox- hence time price, was not a significant indicator of use, oid vaccinations in the course of their prenatal care to nor was monetary price. Households with an educated prevent infant deaths from neonatal tetanus (Table 17). female member were more likely to use all forms of pre- It is recommended that at least two doses of tetanus ventive care, while households in rural areas were less toxoid injections be given per pregnancy, though only likely to do so. Quality indicators - availability of drugs one may be necessary if injections were given for a pre- and supplies, staffing, etc. - also affected use. That ac- vious pregnancy. Information on the number of teta- cessibility and cost do not seem to be the principal de- nus toxoid vaccinations during the most recent terminants of nonuse for the poor would tend to indicate pregnancy are available in these data. On average, 70 that such services are not valued as highly by the poor percent of women in higher income quartiles receive as by the nonpoor or that other factors such as work two or more injections as compared with 60 percent patterns affect use. The former explanation might pro- of women in the lowest income quartile. vide a basis for expanding health education programs In 1992-93, those mothers who did not seek pre- targeted toward the poor. or postnatal care were asked the reason for not doing so. The most common response was that no care was needed (Table 18). This was a particularly common re- sponse for older and higher parity women. It was also Table 17. Number ofTetanusToxoid slightly more common for women in the lowest income Injections for Most Recent Pregnancy for As with vaccinations, the costs of pre- and p Lowest and Highest Income Quartiles, group. A thvcmhn,tecssopr-adot- 1995-96 natal care were not cited as restrictions to use, as would be expected since these services are supposed to be free. Number As with curative care and immunizations, logit es- of injections Lowest Highest Total timations were conducted to examine the factors that 0 18% 13% 15% I 22% 1 7% 20% affect utilization of the three primary health care activi- 2 22% 7% 20% 2 or more 60% 70% 64% ties examined here-use of prenatal care, use of postna- Total 100% 100% 100% tal care, and receipt of tetanus toxoid vaccinations during pregnancy (Annex C Table C-4). Again, even when con- Source: Social Dimensions of Adjustment Monitoring Survey 1995-96. trolling for factors such as greater distances to facilities, 29  HEALTH CARE IN UGANDA: SELECTED ISSUES Table 18. Use and Nonuse of Prenatal and/or Postnatal Care By Lowest and Highest Income Quartiles, 1992-93 (Percentage of Respondents) Prenatal care Postnatal care Reason Lowest Highest Lowest Highest No care -not necessary unless complications 19 16 55 52 No care - too early or vulnerable period over 6 8 3 5 No care - cost considerations 3 1 2 2 No care - Facilities too far 3 1 4 1 Care by traditional birth attendant 2 2 5 4 Care by doctor/trained nurse/midwife 67 73 32 36 Total 100 100 100 100 Source: Integrated Household Survey 1992-93. The Effects of Income on Health across income groups. Other services - full immuni- zation coverage and postnatal care - show significant In general, the analysis of the effects of income on differences between the poor and nonpoor. In general, health and health care seeking behavior produces use of preventive services appears to be lower for lower some cause for concern. It appears that reporting of income households, even when other factors such as ru- illness is increasing, and that the likelihood of using ral residence, level of education, and distance to the near- a modern provider is decreasing, more so for the poor. est available health unit are controlled for. In terms of The expansion in access to modern health units does accessing an essential package of health services, it ap- not appear to have increased the likelihood of use of pears that lower income households are somewhat less curative care. likely to participate, even if the essential services are rea- On some fronts, it appears that the benefits of pro- sonably available and without charge. This places lower vision of certain preventive services are likely to be more income households at greater risk for certain diseases evenly distributed across income groups than for cura- and pregnancy complications, as well as for additional tive services. Use of prenatal care is roughly equivalent medical expenditures. 30  4 Gender and Access M any of the factors affecting whether health services are used by the poor - proximity, quality, and income - apply to whether services are used by women. However, many other issues also arise when discussing access to ser- vices for women. On the supply side, the quality and availability of health services for women depends in large part on the extent to which government planners consider women's health to be a priority. This will be reflected in government allocations of re- sources to promoting essential services for women-safe deliveries and pregnancy related care, health education, family planning, and prevention and treatment of sexually trans- mitted infections. If such issues are not considered to be priorities by planners then this will be reflected in fewer available services or lower quality services for women. At the household level, additional concerns emerge. evaluate whether certain factors are more important for Is the health of the mother considered to be a priority, men or women in determining whether or not they use reflected in allocations of financial resources to ensuring health services. In particular, it is possible to examine the proper use of preventive services and curative care and relationship between work patterns, education, and facil- to ensuring adequate nutrition? To what extent do women ity characteristics and differences in use of health services have autonomy over decisions regarding their own health? between men and women. Do they have their own financial resources or can they access household financial resources when necessary for Gender and Reporting Illness using health services? Even if they do have access to funds for services, do they have the time to use health services Overall, women are only slightly more likely to report re- or do their work responsibilities, both within and out- cent illness in the past 30 days than men (Table 19). As side of the household, preclude use of services? Finally, would be expected, the difference is mostly for women to what extent are they aware of their own health needs? of reproductive ages. In 1992-93 and 1993-94, approxi- Are traditionally lower levels of education for women mately 22 percent of women reported being ill in the pre- translated into worse health outcomes? vious 30 days as compared with 20 percent of men. While Household surveys are useful for examining some of overall reporting of illness increased in 1995-96, the gen- these issues. Determining whether a woman's health is der difference in reporting remained about the same. considered to be a household priority can be surmised The results in Uganda are similar to patterns observed by whether women are more or less likely than men to in household surveys from other countries (Table 20). In use health services, to use services of at least equal qual- the three additional countries shown below, women are ity as men, and to spend at least as much money on health slightly more likely to report illness in the past 30 days as male members. Econometric analyses can be used to and, with the exception of Tanzania, slightly more likely 31  HEALTH CARE IN UGANDA: SELECTED ISSUES Table 19. Reporting of Illness in the 30 Days Prior to the Survey, by Gender and Age Group (Percentage of Respondents) Age 1992-93 1993-94 1995-96 Group Men Women Total Men Women Total Men Women Total 0-1 34 36 35 37 38 38 44 42 43 2-5 21 21 21 26 21 24 34 31 33 6-15 14 15 15 12 14 14 20 19 19 16-30 17 21 19 14 20 17 22 27 25 31-45 22 27 25 21 25 23 24 36 30 46+ 29 32 31 33 34 33 43 50 47 Total 20 22 21 20 22 21 27 30 29 Source: Integrated Household Survey 1992-93, Social Dimensions of Adjustment Monitoring Surveys 1993-94 and 1995-96. to seek care at a modem facility (Tanzania Living Stan- In all years between 1992 and 1996, females dards Measurement Survey 1993, Chinese Academy of showed only a slightly greater tendency to choose Preventive Medicine 1993, Sri Lanka Department of Cen- modern treatment and a slightly lesser tendency to sus and Statistics 1992). self-treat (Table 21). Again, this is not proof that women are any more or less likely than males to re- Gender and Choice of Treatment ceive care that is sufficient to meet their health needs. They may face more severe health problems, particu- A central question regarding household resource allo- larly regarding reproductive health, that more often cations to males and females is whether or not they use require modern care. A more detailed analysis is nec- different types of services when they become ill. Is it the essary to distinguish between curative-care-seeking case that males are more likely to use higher quality and for reproductive and nonreproductive health reasons. generally more expensive services when they are ill while females use lower quality services, no services, or self- Gender and Expenditure on Illness treatment? The answer appears to be no. With regard to specific household allocations to men's and women's health, expenditure on women's Table 20. Reporting of Illness and Likelihood health tends to exceed expenditure on men's health, of Using Modern Curative Care, Males and US$1.91 compared with US$1.58 (Table 22), though Females for Selected Countries the differences are not statistically significant. For Reporting illness Seeking care boys and girls, whose health needs are perhaps more Country Males Females Males Females likely to be equivalent, expenditure is also fairly Uganda (I 992/3) 20% 22% 56% 58% equivalent. For reproductive-age adults, expenditure Uganda (1993/4) 20% 22% 59% 62% on females exceeds that of males. Whether this dif- Uganda (1995/6) 27% 30% 58% 63% ference is sufficient to address women's greater Tanzania (1993) 15% 18% 68% 66% health needs is difficult to conclude from these data. Sri Lanka (1991) 22% 26% 59% 60% In both 1992-93 and 1993-94, expenditure on China (1993) 48% 51% 77% 78% treatment was slightly higher for women than for men. Average expenditure on treatment declined from 32  PART I: EQUITY OF ACCESS TO HEALTH SERVICES IN UGANDA Table 21. Choice of Treatment by Men and Women Aged 15-60 1992-93 1993-94 1995-96 Treatment Men Women Men Women Men Women No medical attention 6 5 7 8 17 15 Home treatment 33 33 29 26 21 19 Outpatient government 19 19 17 17 23 23 Outpatient private 32 33 38 41 3 1 34 Private doctor 5 3 2 2 2 2 Pharmacy 2 2 3 3 3 2 Traditional doctor 2 2 2 1 1 1 Inpatient government 1 2 1 2 1 1 Inpatient private 1 2 1 2 0 1 Other 0 0 0 0 1 1 Total 100 100 100 100 100 100 N 4,571 5,312 2,240 2,583 1,368 2,008 Source: Integrated Household Survey 1992-93, Social Dimensions of Adiustment Monitoring Surveys 1993-94 and 1995-96. 1992-93 to 1993-94. This change can probably be at- To further complicate the picture, individuals with tributed to differences in the way questions were higher incomes also tend to be more educated and to posed in the two surveys. The 1992-93 questionnaire have different perceptions of what constitutes illness. asked for total monthly health expenditure on each They are therefore often found to report more episodes person; the 1993-94 questionnaire asked for total ex- of illness than poorer individuals, not necessarily be- penditure per person on the most recent illness. cause they are less healthy, but because they have differ- ent standards for what is adequate health status. Gender,Work Patterns, and Income The majority of women age 15 to 49 in Uganda Earning are engaged in both agricultural activities and domes- tic work (Table 23 and Annex B Table B4); 74 percent Men's and women's work patterns can significantly im- of women report being involved in agriculture, with pact on whether they will use health services. However, 58 percent of women saying that this is their primary the relationship between seeking care and work is not activity and an additional 16 percent saying that this straightforward and is a reflection of several compli- is a secondary activity. Most women engage in agri- cated income and substitution effects. Healthier indi- culture as household workers and are not paid directly viduals are more likely to work and to work more for this work. A smaller proportion, 43.1 percent, of hours. As a result, healthier individuals are more likely men aged 15 to 49 are engaged in agriculture as their to have higher incomes. When ill, individuals with primary activity. This is principally because a higher higher incomes are better able to afford to use services, proportion of men are enrolled in secondary educa- but the cost of time away from work for such individu- tion and above and a higher proportion are engaged als may also be higher. The likelihood of using health in other income-earning activities (Table 23 and An- services will be a reflection of how an individual or nex B Table B5). At the same time, a considerably household values, both in time and money, health rela- higher proportion of men are paid for their agricul- tive to other goods and services. tural work. In addition, approximately 84 percent of 33  HEALTH CARE IN UGANDA: SELECTED ISSUES Table 22. Household Expenditure on Illness for Men and Women (US Dollars) 1992-93 1993-94 Age Group Statistic Men Women Men Women 0-1 Mean 1.88 1.56 1.62 1.43 Std. Dev. 3.52 3.24 2.01 2.48 2-5 Mean 1.38 1.59 1.9 1.4 Std. Dev. 2.71 3.83 5.83 2.16 6-15 Mean 1.39 1.42 1.06 1.22 Std. Dev. 4.62 5.39 2.37 1.6 16-30 Mean 1.95 2.55 2.2 2.95 Std. Dev. 3.92 5.96 5.07 7 31-45 Mean 2.23 2.35 1.57 2.25 Std.Dev. 4.94 5.1 2.68 4.21 46+ Mean 3.11 1.99 1.12 1.63 Std. Dev. 15.93 5.42 2.47 2.83 Total Mean 1.94 1.97 1.58 1.91 Std. Dev. 7.31 5.12 3.94 4.28 Note: US$= 1,100 Ush; No controls for inflation. Source: Integrated Household Survey 1992-93, Social Dimensions of Adjustment Monitoring Surveys 1993-94. women are involved in domestic work, either as a pri- tions to domestic activities (Table 24). Both men and mary or secondary activity. women spend approximately 40 hours per week in their The time burdens of work for women generally ex- primary occupation. However, only half of men report ceed those of men, mainly due to greater time alloca- a secondary occupation as compared with 80 percent of Table 23. Primary Activity for Men and Women Aged 15-49, 1995-96 Males Females Main activity Subtotal Total SubTotal Total Student 21.8% 11.7% Own account worker (self-employed) 43.0% 26.1% Agriculture 31.6% 20.6% Retail trade 5.1% 3.0% Other 6.3% 2.5% Helper in household enterprise 12.6% 38.2% Agriculture 11.5% 37.3% Other 1.1% 1.0% Domestic duties 0.7% 17.2% Other 22.0% 6.8% Total 100.0% 100.0% Source: Social Dimensions of Adjustment Monitoring Survey 1995-96. 34  PART I: EQUITY OF ACCESS TO HEALTH SERVICES IN UGANDA Table 24.Weekly Allocation of Time to Primary and Secondary Work Activities, 1992-93 (Mean Hours for Those Engaged in the Specified Activity) Primary Secondary Total Activity Males Females Males Females Males Females Student 49.6 52.2 18.2 23.6 67.7 70.1 Own Account Agriculture 34.8 33.5 17.9 19.2 47.4 63.5 Retail 58.6 52.1 22.2 26.6 65.8 71.5 Other 32.9 40.7 62.8 68.7 Household Enterprise Agriculture 52.9 31.9 19.9 21.2 48.4 60.3 Other 39.3 40.1 18.6 19.3 64.7 65.6 Domestic Duties 39.3 45.5 20.2 27.7 46.8 56.1 Other 48.5 40.6 21.3 59.0 60.0 Total/Average 42.5 38.2 11.1 21.5 55.7 61.7 Source: Integrated Household Survey 1992-93. women. Men, on average, spend approximately 11 hours of men. However, women earned considerably less than per week in their secondary activity; women, on the men. The average annual cash earnings for men aged 15 other hand, spend approximately 21 hours per week on to 49 were $238, while women earned only $91 annually. their secondary activity, usually domestic work. On av- Women's earnings, even for older women who are more erage, therefore, women spend 62 hours per week work- likely to be involved in income-earning activities, consti- ing, as compared with 56 hours per week for men. tute a minority of a household's monetary earnings. In spite of their greater time spent on work, women The 1995 Demographic and Health Survey found are much less likely to earn money and earn less money that approximately 65 percent of women with cash earn- overall than men (Table 25). Of women aged 15 to 49 ings were the sole determiners of how that money was years old, 42 percent report earning income in 1992-937. used, with an additional 19 percent jointly deciding with This compares with approximately 64 percent of men. a husband or partner or other individual. Applying those Older men and women aged 25-54 are much more likely figures to these data imply that approximately 27 to 35 to report earnings-56 percent of women and 89 percent percent of women aged 15-49 and 36 to 47 percent of Table 25. Men and Women's Earnings and Household Status - 1992-93l Pct. with Ave. cash Pct. of household Pct. who are cash earnings earnings cash earnings household head Aged 15-49 Men 64% 238 49% 55% Women 42% 91 23% 15% Aged 25-54 Men 89% 368 72% 83% Women 56% 137 35% 25% Source: Integrated Household Survey 1992-93. 35  HEALTH CARE IN UGANDA: SELECTED ISSUES women aged 25 to 54 have earnings over which they have relative to males'. Having more nurses, although not some degree of autonomy. support staff, tended to increase the likelihood of uti- lization by females in 1993-94, as did having inpatient Factors Affecting Use of Curative and services. Preventive Services for Males and Females Women's work patterns do appear to have an im- pact on use of curative services (Annex C Table C-6). For 1992-93, 1993-94, and 1995-96, it was possible Data, from 1992-93 were used to examine the effects to examine the factors affecting use of curative ser- of work patterns on use of a modern health care pro- vices by males and females. However, for 1992-93, it vider.'