Ugandan Global Health Profile_MackenzieWright_2015
Uganda Health Profile Mackenzie Wright MIDTERM A health profile of Uganda, including the biosocial factors contributing to its health situation. Wright 1 Uganda is a landlocked country in Eastern Africa, home to a population of nearly 37,000,000 people and an abundant wildlife; its capitol is located in Kampala, the countrys largest city. Uganda is bordered to the east by Kenya, to the north by South Sudan, to the west by the Democratic Republic of the Congo, to the southwest by Rwanda, and to the south by Tanzania. The official languages of Uganda are English and Swahili, accompanied by dozens of indigenous languages scattered across the country such as Bantu in southern Uganda and Acholi in parts of northern Uganda. The most prominent ethnic groups are the Baganda (16.2%), Bagisu (5.1%), Iteso (8.1%), Acholi (4.4%), Basoga (7.7%), Lugbara (3.6%), Banyankore (8.0%), Banyoro (2.9%), Banyaruanda (5.8%), Batoro (3.2%), Bakiga (7.1%), Karamojong (2.0%), Lango (5.6%) and others (20.3%) 1. None of these ethnic groups constitutes a majority, thus limiting the ability of one group to control the others. Apart from socio-economic cleavages, the ethnic groups differ in how they have participated in the political rule of the country after independence in 1962. The political rulers of the country have traditionally been from Baganda and are therefore often perceived as the dominating elite. Uganda is thus struggling with fragmentation over ethnic lines and lacks a sense of nationalism. This segmentation of the populace has also impacted Ugandas health care system by providing unequal care across regions, incomes and ages. Uganda is divided into districts, spread across four administrative regions: Northern, Eastern, Central (Kingdom of Buganda) and Western 1. There are now over 100 districts that are responsible for providing and supplying services, such as healthcare, based on resources provided by the government. In the past, Northern districts have accused the central government of favoritism and corruption, claiming the President takes better care of his home districts than the rest of the country. Ugandas current president, Wright 2 Museveni has been in power since 1986 after a military coup by his National Resistance Army (NRA). Transparency International has rated Uganda's public sector as one of the most corrupt in the world. In 2014, Uganda ranked 142nd worst out of 175 and had a score of 26 on a scale from 0 (perceived as most corrupt) to 100 (perceived as clean) 2. Since 1987 Joseph Kony and the Lords Resistance Army have terrorized Northern Uganda, kidnapping children and forcing them to become child soldiers, decimating communities, killing without question and displacing hundreds of thousands of Ugandans. In recent years President Museveni has claimed that the LRA is close to defeat, however the terrorist group then stepped up its attacks on the civilian population, specifically the Acholi ethnic group in the North where many internally displaced peoples have been forced into camps over the last decade where health and sanitation facilities are very poor 3. While Southern Uganda is relatively stable with signs of growth and progress in health, the North is plagued by conflict and receives little aid from the government to help those affected by violence and poor health conditions. In spite of all of this, Uganda is seeing progress in improving the health of its populace. While Ugandas population steadily grows the country has begun the second stage of the demographic transition by reducing its exceptionally high death rate. However, a stable and high birth rate has in effect produced an imbalance in the Ugandan population. Since its first data collection in the 1970s, Ugandas high mortality rates have been surpassed by even higher fertility rates (Table 1). This imbalance signifies an unevenly distributed population (Figure 1). In other words, there is a growing number of Ugandan children; however, they do not have a promising chance to reach adulthood because high mortality rates continue to reduce the adult population. This is especially true in rural Wright 3 communities. Rural regions of Uganda lack consistent and quality access to health care these areas and have higher rates of fertility than urban regions. The higher fertility rates are also partly due to the lack of contraception for women and children in rural areas. Women in the poorest quintile have eight children on average during their lives, while women in the wealthiest quintile have just over four children. Similarly, 41 percent of young women ages 15 to 19 in the poorest quintile have begun childbearing, while only 16 percent in the wealthiest quintile have 4. Access to and prevalent use of contraceptives varies in Uganda based on economic status. In the poorest quintile, which affects 19.6% of the population, only 14.7% of this group uses modern or traditional methods of contraception. For the poorest quintile in Uganda, only 27.4% who wanted family planning actually received these resources 4. Within the perimeters of Omrans Stages of Epidemiologic Transition Uganda is currently in Stage Two, the Age of Receding Pandemics, where mortality progressively declines as increased technologies and improvements to health mitigate Stage One nutritional deficiencies or infectious diseases and emerging Stage Two chronic diseases. Even though Uganda is in Stage Two of its Epidemiologic Transition, the country still suffers from many Stage One causes of death. Communicable diseases, maternal and perinatal conditions and nutritional deficiencies are cause for 63.7% of Ugandas Disability-Adjusted Life Years (DALY) (Table 2). Prevalent Stage Two chronic or non-communicable diseases such as mental and behavioral disorders or cardiovascular disease also make up only 24.3% of total DALYs, illustrating that Uganda has not moved out of Stage Two, the last stage in which cause of death is not dominated by chronic disease (Table 2). In terms of the number of years of life lost due to premature death in Wright 4 Uganda, HIV/AIDS, malaria, and lower respiratory infections were the highest-ranking causes. The HIV/AIDS epidemic is a prominent reason for the failure of the process of epidemiologic transition as mortality rates soared and fertility rates remained at their already high level. Additionally, with one of the highest rates of alcohol consumption in the world the leading risk factor in Uganda is alcohol use, directly affecting Ugandans DALY and ability to progress in terms of health. Another factor that describes the failure of the process of epidemiologic transition is the high prevalence of violence and conflict that has plagued Uganda for decades. From the Lords Resistance Army in Northern Uganda to strife between President Museveni, neighboring countries and Northern districts, Uganda has lost many lives to violence and conflict. Uganda has taken great strides and made incredible progress improving maternal and child health in the last three decades. Pregnant women receiving more than one antenatal clinic visit are currently at 95%, which is highest rate ever recorded (Table 3). This high proportion of pregnant mothers acting on their ability to have an antenatal check-up in a clinic at least once is astounding progress in Uganda and has no doubt been a leading factor in improved maternal health overall. Unlike in fertility rates, there is very little difference within economic classes regarding access to and use of antenatal care in Uganda. In the poorest quintile, 94% received at least one antenatal visit and in the richest quintile 97% received the same care. However, as we move to an increased number of visits (more than four) these numbers drop and a familiar trend can be seen between the poorest and richest quintiles 4. Unfortunately, all Ugandan women are less likely to visit an antenatal clinic four or more times during pregnancy (Table 3). Poor mothers are the least likely to receive this care at only 41.6% with 58% of wealthier Wright 5 mothers receiving more than four antenatal check-ups 4. Clearly, there are still improvements to be made in Ugandas healthcare delivery system to mothers and their children of all economic means. Another key Ugandan maternal health improvement is the growing use of a skilled health attendant at birth. In 1990 health personnel attended only 37% of births for the general population, but in 2013 this number has reached 58% (Table 3). There are stark differences in healthcare again between economic classes in which only 44.5% of mothers in the poorest quintile have a personnel attendant at birth yet 89.2% of the richest quintile receives this care 4. Between the fourth and fifth quintile is the largest and most notable gap where in the fourth richest quintile only 61.3% of births are attended by health personnel compared to nearly 90% in the very next economic class; it is clear Ugandans with higher economic status receive far better maternal and child health care. According to the World Health Report the maternal mortality ratio of Uganda as of 2013 is 360 out of 100,000 live births (Table 3). This has greatly improved since 1990 with a maternal mortality ratio of 780 out of 100,000 live births. Compared to its neighbors South Sudan with the highest maternal mortality ratio of 2,054/100,000, Kenya with the same ratio of 360 and Rwanda slightly lower with 340/100,000, Uganda is faring well on a regional level and is on a progressive and steady path toward even better maternal health 5. Ugandas infant mortality rate of 45 out of 1,000 live births is another significant improvement, from 111.4 in 1990 (Table 3). However, this improvement has not been seen equally across Uganda as its richest quintile benefits from the progressive health services far more than the poorest quintile. The top quintile experiences only a 47.7 infant mortality rate, with the poorest quintile at a steadily higher rate of 75.7 deaths/ Wright 6 1,000 live births the Ugandan poor do not receive the same maternal and child care as does the 17.3% of the population with higher economic status 4. The Three Delays Model delays in seeking, reaching and receiving care -- is incredibly relevant and useful to explain possible reasons for higher mortality rates within poorer quintiles. In each stage of the model, decision to seek care, identifying and reaching medical facility, receipt of adequate and appropriate treatment, poorer mothers are less successful in getting the health care they may need than are richer mothers facing the same health problems. As of 2012, the annual Rate of Reduction of Under-five Deaths is at 4.3% with the Under-five Mortality rate per 1,000 live births at 69 (Table 3). Similar to maternal mortality there is a trend between economic status and health care received. Once again the richer factions of the Ugandan population benefit more and have access to better health care and have lower mortality rates than do poorer populations. At 124 deaths per 1,000 live births, the Under five-Mortality Rate in the poorest quintile is close to double that of the highest quintile at 71 deaths per 1000 live births 4. This trend of inequality has been blatantly evident in Uganda since at least 1995. Low birth weight is yet another indicator of the difference in quality and access to health services between economic classes in Uganda. At a national average rate of 12% Low Birth Weight in 2012, Ugandans with poorer economic status are at a much higher level, around 45%, than the children born into richer families (Table 3) 4. Similarly, with a national average of 14.1% of children who are Underweight, a large portion of that 14% comes from poorer economic classes. A ratio of 17.2% Underweight children from the poorest quintile compared to less than half of that, at 8.5% for wealthier Ugandans, proves a debilitating trend in favor of the economically richer quintiles. The ratio of Wright 7 children moderately or severely stunted, averaging 33.7% nationally, at 53.5% for the poor and 25.7% for the wealthy shows the poorest quintiles are again suffering from lack of or substandard health care in relation to the richest (Table 3) 4. Again doubling the ratio of the rich quintile of wasted children at 3.1% compared to 6.4% in the poorest quintiles illustrates Ugandas serious health care inequality 4. Early nutrition is proven to be an important marker for good health outcomes. Ugandan children are exclusively breastfed for the first six months of their lives 57% of cases and 46% of children are breastfed until age two (Table 3). 82% of children are introduced to solid, semi-solid and soft foods between six to eight months of age. 99% of households consume iodized salt, greatly important in Ugandas hot climate where meat and other foods quickly go bad. 57% of households have full coverage of Vitamin A supplementation and 82% of children receive their measles immunization. However, a staggeringly low 34% of the population uses improved sanitation facilities as of 2013 (Table 3). The recurring trend of the richer factions of the population receiving more and better health care than poorer quintiles is blatantly apparent in each of these statistics as well, except for the consumption of iodized salt where the poorer quintiles do not vary from the richer. The HIV/ AIDS epidemic has decimated the continent of Africa with little sign of slowing down. Since the beginning of the epidemic, almost 78 million people have been infected with the HIV virus and about 39 million people have died of HIV worldwide. Within Uganda 7.2% of the adult population is infected with HIV and there is estimated to be 1,500,000 people of all ages living with the virus (Table 4). Women living with HIV make up nearly half of this number, at 780,000 these women risk mother to child Wright 8 transmission, further increasing the toll of HIV/ AIDS on the country. Children born and living with HIV figures around 190,000 (Table 4). Without increased education the number of those infected in Uganda will not drop, proven by the low levels of comprehensive knowledge of HIV within the younger population, all below 50% in 2012 and the corresponding increasing occurrence of HIV infection in Uganda. Because treatment is so costly, both economically and physically, only those with the resources to afford the drug and its potential continuing care are able to rid themselves of the deadly disease, leaving the poorest quintiles vulnerable to the deadly spread and infection of HIV/ AIDS. In the last two decades Uganda has made incredible improvements in the overall health of its people. From child mortality to the prevalence of breastfeeding Uganda is on the right path towards better health, however, in nearly every category exists economic inequalities that diminish the progress being made as a whole. Uganda must implement strategies that ensure all healthcare remains accessible and of equal and excellent quality for the entire population if the country wishes to improve the lives of each of its citizens by means of health. Uganda has several policies and action plans that address major population and development issues, yet none effectively deal with the country's fertility, which is among the highest in the world. Despite economic growth in the past decade, many Ugandans live in poverty and face social and economic inequities. Even though the country continues to improve the health of its people, Uganda will need to address its high fertility in rural areas, increase the number of youth who attend secondary school and higher, and foster job creation so that its families, communities, and the nation as a whole grow economically which will in turn improve health. Wright 9 Table 1: Demographic and Economic Indicators 2012 Indicator Latest year Value Source Population 2012 36,346,000 SOWC Crude Death Rate 2012 10 SOWC Crude Birth Rate 2012 44 SOWC Life Expectancy at Birth 2012 59 SOWC Total Fertility Rate 2012 6.0 SOWC Contraceptive Prevalence % 2012 30% SOWC Total Adult Literacy % 2012 73% SOWC GNI per capita $ 2012 $440 SOWC GINI Coefficient 2012 44.3 UNDPHDR Pop. Living < $1.25 % 2012 38.1% UNDPHDR Sources: UNICEF. The State of the Worlds Children 2014 in Numbers: Revealing disparities, advancing childrens rights, Every Child Counts. New York City, USA: United Nations Childrens Fund, 2014. Print. Hall, Jon. Human Development Reports. New York City, USA: Published for the United Nations Development Programme, 2014. Print. Wright 10 Figure 1: Population Pyramid of Uganda 2015 United States Census Bureau. "International Database Population Pyramid Graph - Custom Region - Uganda." United States Census Bureau. N.p., n.d. Web. 15 Oct.2015.. Wright 11 Table 2. Burden of disease for Uganda Uganda Value Population of your country 35,919 Total DALYs lost 25,597.7 Communicable diseases, maternal and perinatal conditions and nutritional deficiencies -- DALYs lost 16,310.9 Percent of total DALYs 63.7% Top three causes of DALYs lost 1. Infectious and Parasitic Diseases 2. HIV/ AIDS 3. Neonatal Conditions -- 9,871.7 3,841.6 2,876.2 Noncommunicable conditions -- DALYs lost 6,235.3 Percent of total DALYs lost 24.3% Top three causes of DALYs lost 1. Mental and Behavioral Disorders 2. Cardiovascular Disease 3. Congenital Anomolies -- 936.9 933.2 573.5 Injuries -- DALYs lost 3,051.5 Percent of total DALYs lost 11.9% Top three causes of DALYs lost 1. Unintentional Injuries 2. Intentional Injuries 3. Road Injury -- 2,361.8 689.7 677.6 Sources: World Health Organization. "Mortality and Global Health Estimates." World Health Organization Global Health Observatory data. N.p., n.d. Web. 15 Oct. 2015. . World Health Organization. "Health statistics and information systems." World Health Organizations Global Health Estimates. N.p., n.d. Web. 15 Oct. 2015. . Wright 12 Table 3: Maternal and Child Health and Nutrition Indicator Latest year Value Source Pregnant women who received 1+ antenatal clinic visit (%) 2013 95% World Health Report Pregnant women who received 4+ antenatal clinic visit (%) 2013 48% World Health Report Births attended by skilled health personnel % 2013 58% World Health Report Maternal mortality ratio (per 100,000 live births) 2013 360 World Health Report Annual rate of reduction of under-five deaths % 2012 4.3% SOWC Infant Mortality Rate per 1000 live births 2012 45 World Health Report Under Five Mortality Rate per 1000 live births 2012 69 World Health Report Infants Born Low Birth Weight % 2012 12% SOWC Children exclusively Breastfed < 6 months % 2013 63% World Health Report Intro of solid, semi-solid, soft foods 6-8 months % 2012 67% SOWC Children Breastfeeding at age 2 % 2012 46% SOWC Children Moderately or Severely Underweight % 2012 14.1 World Health Report Children Moderately or Severely Wasted % 2012 4.8 World Health Report Children Moderately or Severely Stunted % 2012 33.7 World Health Report Households consuming iodized salt % 2012 99% SOWC Vitamin A supplementation full coverage % 2013 57% World Health Report Children 1 y/o receiving measles immunization % 2012 82% World Health Report Pop using improved sanitation facilities % 2013 34% World Health Report Sources: UNICEF. The State of the Worlds Children 2014 in Numbers: Revealing disparities, advancing Wright 13 childrens rights, Every Child Counts. New York City, USA: United Nations Childrens Fund, 2014. Print. World Health Organization, comp. Global Health Observatory (GHO) data. N.p.: n.p., 2015. Print. Table 4: HIV/AIDS Indicator Latest year Value Source Adult HIV prevalence (%) 2012 7.2% SOWC People of all ages living with HIV (estimate) (thousands) 2012 1,500 SOWC Women living with HIV (thousands) 2012 780 SOWC Children living with HIV (thousands) 2012 190 SOWC Sources: UNICEF. The State of the Worlds Children 2014 in Numbers: Revealing disparities, advancing childrens rights, Every Child Counts. New York City, USA: United Nations Childrens Fund, 2014. Print. Wright 14 Works Cited 1. Federal Research Division of the Library of Congress. Uganda: a Country Study. 2nd ed. United States of America: Library of Congress Cataloging-in-Publication Data, 1990. Print. Area Handbook. 2. Transparency International. "Corruption Perceptions Index 2014: Results." Transparency International. N.p., n.d. Web. 14 Oct. 2015. . 3. "Timeline: Uganda's Fitful Path Toward Peace Under Museveni." The Christian Science Monitor: 10. Sep 13 2005. ProQuest. Web. 14 Oct. 2015 . 4. "Health Equity Monitor Country Profiles." Global Health Observatory Data Repository. World Health Organization, n.d. Web. 14 Oct. 2015. . 5. "Country Comparison > Maternal mortality rate." Index Mundi. N.p., n.d. Web. 14 Oct. 2015. .