Uganda: The Health of the Nation

Published online Nov. 4, 2012 in The Independent.

The Health of the Nation
By Melina Platas Izama

Since Uganda hit 50 recently, it seems as good a time as any to check its vitals. There is the heartbeat of the economy and the temperature of the masses, the pressure of the politics and the weight of history. The health of this nation in one word? Resilient.

The Jubilee celebration was not made up of unfettered jubilation, as one might expect at 50 years of independence, but instead doused with a heavy coat of introspection.

The pristine Kampala Road, captured in black and white photos, is hardly recognisable today – a bustling, grating and downright stressful stretch of earth.  Cynics wandered and wondered aloud, are we better off now than we were a half-century ago? Teachers are striking, projects stalling, health clinics leaking staff, money, and drugs. This version of events is familiar. We listen to it every morning and read it every day. Frankly, it’s exhausting.

The health of the nation is in part a function of the health of its people. And here we have some great stories to tell. The greatest story of all is the about the survival of children. In the last fifteen years, death in infants and young children has fallen by nearly 40%. The drop in child deaths was faster in the past five years than it has been in decades.  This is fantastic news.

When Uganda raised her flag for the first time, mothers across the newly birthed state could expect more than one in five of their children to perish before age five and 13% of newborns would not survive their first year. This year, as the flag was raised once more, the death of a child is not foreign, as it should be, but neither does it go hand in hand with motherhood.

The results of the most recent round of the Demographic and Health Surveys (DHS), which have been instrumental in documenting these trends, have just been released for Uganda. Conducted across the country in more than ten thousand households, the DHS has been conducted in 1988, 1995, 2000, 2006 and 2011. While there are a number of improvements to report, the story of child survival, particularly in the last decade, stands out. It is perhaps the greatest achievement of the new millennium in Uganda. Continue reading “Uganda: The Health of the Nation”

The ongoing perils of childbirth

Published online February 1, 2012.

A problem of supply in services is limiting further improvements in maternal health

Fertility rates in Rwanda have been falling steadily over the past several years, but this year close to 400,000 Rwandan women will become pregnant and give birth. Next door in Uganda, four times as many women will become pregnant, approximately 1.5 million. If recent trends hold, nearly 10,000 of these women will lose their lives during or shortly after their pregnancy. Many of them will suffer from bleeding and infections that can be treated or prevented.

Surveys show that pregnant women in both Rwanda and Uganda seek antenatal care at very high rates. Nearly 98% of women in Rwanda and 95% in Uganda have at least one antenatal visit during their pregnancy. These women want information about their pregnancy, and seek out health services that they believe will help them have healthy babies. But often the health system fails to provide these women with the information they need to take care of themselves, and far too many mothers lose their lives because they do not receive emergency care in time. Rwanda has been showing steady progress in improving maternal health, but Uganda has faired poorly.

Both Uganda and Rwanda continue to have high levels of maternal mortality, defined as the death of a woman while pregnant, or within 42 days after the termination of pregnancy (excluding accidents). Between 1985 and 1995 in Uganda, maternal mortality was estimated at 527 deaths per 100,000 live births. The following decade, from 1996 to 2006, maternal mortality was estimated at 435 deaths.Although these figures suggest a slight decrease over the past twenty years, the margin of error around these estimates are such that we cannot say with any confidence that maternal mortality rates have changed at all between 1985 and today. Thus, it appears pregnant women in Uganda today are equally likely to die in childbirth as they were 25 years ago, when the National Resistance Movement came to power.

Meanwhile, maternal mortality in Rwanda has fallen significantly, although rates in Rwanda have for some time been higher than those in Uganda. Between 1995 and 1999, maternal mortality in Rwanda was estimated at 1071 deaths per 100,000 live births, one of the highest rates of maternal death in the world. Between 2000 and 2004, however, it had dropped to 750. The most recent estimates should be available in the next year or so, and are likely to show even further decline.

Rwanda may have made greater strides than Uganda in reducing maternal mortality in the past decade or so, but both countries face significant challenges in improving maternal health. There is a long way to go. The good news is that unlike many types of preventive health behaviors, such as getting immunizations or sleeping under a bednet, seeking help during pregnancy has become very common, even natural. In other words, the demand for health care during pregnancy appears higher than for many other health issues. Unfortunately, while demand is high, supply of care during pregnancy is weak.

Although nearly all pregnant women seek antenatal services at least once during their pregnancy, not all clinics and health facilities are equipped and ready to meet their needs. In fact, most health facilities are lacking the basics when it comes to antenatal care. The Service Provision Assessment Survey 2007 found that only 31% of health facilities in Rwanda had all the items required for infection control, including running water, soap, latex gloves, and disinfectant, and only 28% had all the essential supplies for basic antenatal care, including iron and folic acid tablets, tetanus vaccines, and equipment to measure blood pressure. A mere 11% had all the medicines required to treat pregnancy complications, including antibiotics, antimalarial drugs, and medication to treat common sexually transmitted infections.

To make matters worse, very few women were given sufficient information so that they could take good care of themselves at home during their pregnancy. Only 8% of women in Rwanda were told about signs of pregnancy complications, while only 35% of women in Uganda were informed. It is perhaps not surprising that only 35% of Rwandan women and 47% of Ugandan women attend the recommended four antenatal visits. When women arrive in clinics, often without power or water, which do not provide the necessary equipment and information to help them with their pregnancy, there may be little incentive to keep going back.

Of course, the news is not all bad. On the contrary, the improvements that have been made in maternal health, particularly in Rwanda, are extraordinarily impressive. In just five years, between 2005 and 2010, the percentage of mothers whose delivery was assisted by a trained and skilled provider increased from 39% to 69%. The percentage of mothers who delivered in a health facility jumped an equally miraculous 28% to 69%. The increase in births under the watch of a skilled provider has likely played a large role in the reduction of maternal mortality. An estimated 15% of all pregnant women will encounter life-threatening complications, and trained nurses, midwifes, and physicians can help make sure these complications do not become fatal.

The fact that pregnant women appear to seek out services and information at high rates is a great opportunity for public health, but this opportunity is squandered if health facilities are poorly equipped to provide care. While Rwanda has made strides in improving the supply of care, there is less evidence of improvement in Uganda. The results speak for themselves.

Explaining health behavior

Pascaline Dupas has an excellent paper in the Annual Review of Economics: Health Behavior in Developing Countries. It’s well worth reading. Conclusion below:

Good health is both an input into one’s ability to generate income and an end in itself. As such, it is not surprising that a relatively vast literature is devoted to understanding the determinants of health behaviors. This literature has recently expanded to the study of health behaviors in low-income settings, for which good data are becoming increasingly available. This review is too short to be exhaustive, but it tries to present the most compelling evidence to date on this issue. The important thing to take away from this review is that when it comes to health behavior in developing countries, there are a substantial number of deviations from the neoclassical model. First of all, people seem to lack basic information, and sometimes have limited ability to process information, because of low education levels. Second, there are market imperfections and frictions, especially credit constraints, affecting people’s ability to invest in health. Finally, there seem to be some deviations from the rational model, with, as has been widely shown in developed countries, a nontrivial share of people exhibiting time-inconsistent preferences as well as myopia.
Overall, this suggests an important role for public policy when it comes to health. Above we identify four important demand-side policy tools: information, mandates, price subsidies, and financial incentives. All appear to have the potential to increase the sustained adoption of preventive behavior. But the success of these demand-side strategies is contingent on the supply side being adequate: on health services and products being available, with delivery and/or enforcement institutions that are effective. The issue of how to improve service delivery in health is outside the scope of this review, but it has been the focus of a number of recent and ongoing studies that will soon need a review of their own.

Gender and Development

A topic worth exploring. From the 2012 World Development Report, Gender Equality and Development:

The lives of girls and women have changed dramatically over the past quarter century. Today, more girls and women are literate than ever before, and in a third of developing countries, there are more girls in school than boys. Women now make up over 40 percent of the global labor force. Moreover, women live longer than men in all regions of the world. The pace of change has been astonishing—indeed, in many developing countries, they have been faster than the equivalent changes in developed countries: What took the United States 40 years to achieve in increasing girls’ school enrollment has taken Morocco just a decade.

In some areas, however, progress toward gender equality has been limited—even in developed countries. Girls and women who are poor, live in remote areas, are disabled, or belong to minority groups continue to lag behind. Too many girls and women are still dying in childhood and in the reproductive ages. Women still fall behind in earnings and productivity, and in the strength of their voices in society. In some areas, such as education, there is now a gender gap to the disadvantage of men and boys.

The main message of this year’s World Development Report: Gender Equality and Development is that these patterns of progress and persistence in gender equality matter, both for development outcomes and policy making.

Impact evaluation and RCTs in health

I am currently working on a proposal for a pilot of performance-based contracts (PBC) in Uganda’s health sector, and have been busy navigating the literature out there. Fortunately for me, there is also a lot of discussion on randomized controlled trials (RCTs) and impact evaluation in the development blogosphere of late.

Today I’ve been reading “Performance Incentives for Global Health,” published by the Center for Global Development, and available for purchase or downloadable chapter-by-chapter here. It has proven very useful so far in helping me think through the various ways in which PBC pilots could be designed. In Chapter 5, A Learning Agenda, the authors write:

Impact evaluation is more than a tool for gauging impacts at the end of a program and providing the inputs into a cost-effective analysis. It can also help a program to evolve. For example, in the initial phase of a pay-for-performance program, three contracts with different risk levels can be piloted. Based on the results from an early evaluation, the most effective contract can be scaled up. Several parameters lend themselves to this kind of experimentation, including the relative effects of supply versus demand interventions, the level of rewards offered for performance, and the balance of trade-offs between access and use.

Rwanda is often noted as a pay-for-performance (P4P) success story, and Chapter 10 is devoted to this case study. The original study by Basinga et al. (2010) is available here (and co-authored by Rwanda’s current Minister of Health, Agnes Binagwaho, also available at @agnesbinagwaho). The authors find that P4P has a significant effect on the number of deliveries in health facilities, quality of prenatal care, and number of preventive care visits for children, but they find no effect on the number of prenatal care visits or immunizations.

In Uganda, a similar pilot, this time of private-not-for-profit (PNFP) facilities, found no effect of bonuses on health facilities’ performance in achieving self-selected health targets. They did find that financial autonomy improved health facilities’ performance, however. The study, “Contracting for Primary Health Care in Uganda”, remains an unpublished World Bank manuscript, as far as I can tell (publication bias at work), but the slides from the 2007 CGD presentation are available here.

I’d like to examine the effect of PBC on health outcomes in the public rather than PNFP sector (hopefully using a few variations of the contract “treatment”), as well as better understand why performance-based pay (in the form of bonuses) did not seem to have an effect on health outcomes in the Uganda pilot. Finally, I am interested in understanding the relative efficacy of supply-side (such as PBC) vs. demand-side (such as conditional cash transfers) efforts in improving various health outcomes. More updates on this to come.

Why has Besigye gone to Nairobi?

Dr. Kizza Besigye was finally allowed to fly to Nairobi to seek treatment for his battering yesterday at the hands of (flower-print shirted, h/t Rosebell) plainclothes state security operatives. NTV has footage of his departure:

I am very glad Dr. Besigye was ultimately allowed to fly (@AndrewMwenda suggests maybe he needs to invest in a boat now that walking, driving and flying are forbidden), but let’s remember why he needs to go to Nairobi in the first place (apart from his brutal treatment). There are no hospitals in Uganda that come close to rivaling the best of those of Kenya or South Africa. Those who get care in Mulago or IHK are the luckiest.

Beyond the overburdened national referral hospital and private hospitals (the latter of which are impossibly expensive for most), the health sector in Uganda is in a pathetic state. Health worker absenteeism, drug leakage, and even ghost clinics are rampant. A 2007 survey found that only 6% of Uganda’s hospitals had the basic infection control elements (soap, running water, latex gloves, etc.). 1 in 8 children will not live to see their first birthday, meaning that nearly 500 of the 4000+ born each day will have died within the next five years. Maternal mortality has not improved by any statistically significant amount from 1995 to 2006, when the last Demographic and Health study was completed (Uganda DHS 2006 pg.282).

The failures of the health sector are to a large extent, a failure of governance.

Yes, it is terrible that security forces attempted to stop Besigye from seeking the medical treatment he so desperately needs and deserves. It literally added insult to a horribly unjust injury. But even more terrible is that Besigye is only one of millions of Ugandans who desperately need quality health care. And most aren’t getting it.

Why Don’t We Have a Global Fund for Maternal Health?

Well, cause someone would steal the money anyway. No? Ok, how about because the international community is preoccupied (is obsessed too strong a word?) by the much more exotic sounding tropical and infectious diseases (a virus that turns your insides to mush = exciting/terrifying, bleeding to death giving birth = boring). Not everyone gets Ebola or HIV or malaria, but most people either give birth or are the direct cause of someone else giving birth (and if nothing else, at least someone once gave birth to them). So maternal health is ordinary, banal, and just plain not-sexy. That is, unless it is tied to something exotic (see Prevention of Mother-to-Child Transmission of HIV — PMTCT)…

The wards described in the article of the Tanzanian hospital are not different from those in Uganda. In Mugalo Hospital, around 80 to 100 babies are delivered every day, and there are certainly not enough beds for all the mothers. One medical student working in the labour ward described to me how the “fluids” from one mother giving birth flowed into the ears of another mother who was sharing her mattress one night during his shift.

I don’t know what the solution is to the neglect of maternal health. In Uganda, maternal mortality statistics have barely budged in the past 20 years. The 2006 Uganda Demographic and Health Survey (depressingly) discusses the lack of improvement with regard to maternal mortality:

At first glance, it would appear that the maternal mortality ratio has declined significantly
over the last five years, from 527 maternal deaths per 100,000 live births for the ten-year period prior to the 1995 UDHS to 505 for the ten-year period before the 2000-01 UDHS, and to 435 for the ten- year period before the 2006 UDHS. However, the methodology used and the sample sizes implemented in these three surveys do not allow for precise estimates of maternal mortality. The sampling errors around each of the estimates are large and, consequently, the estimates are not significantly different; thus, it is impossible to say with confidence that maternal mortality has declined. Moreover, a decline in the maternal mortality ratio is not supported by the trends in related indicators, such as antenatal care coverage, delivery in health facilities, and medical assistance at delivery, all of which have increased only marginally over the last ten years.