The determinants of persistent child mortality trend in Uganda

A Thesis submitted to Maastricht Graduate School of Governance in partial fulfillment of the requirement for MSc. in Public Policy and Human Development (MPP)

Nestar Lakot Okella (i480827) January, 2009 Maastricht Graduate School of Governance Maastricht University Supervisor: Treena Wu

Abstract

Uganda has had significant growth in the economy over the last decade with an average annual GDP growth rate of 6.6 per cent (World Bank, 2008). However, there are increasing concerns that most social indicators including infant and child mortality rate have not improved over these years; at least not at a rate that corresponds to the countrys rate of economic growth. The infant and child mortality rate of the country still remains one of the highest both in the African and the world at 134/1000 live births in 2006 (World Development Indicators, 2006).

This study is guided by the problem of the persistent trend in observed child mortality rate in Uganda despite the countrys sustained rate of economic growth over the last decade. Specifically, it aims to review the determinants of the countrys persistent child mortality trend with particular focus to those mortality determinants theorized in Deaton et al, 2005 that are applicable to the country. These theorized determinants in Deaton et al, 2005 are explored using national data from secondary data sources especially using databases of various institutions like the World Bank, United Nations, Uganda Bureau of Statistics, New York University and others.

The key findings of the study identifies education level of households (particularly women), access to public health services particularly improved water and sanitation, access to medical care, diseases especially malaria as well as the level of government expenditure on health and education and general poverty levels of majority of the countrys population to be the major determinants of persistent level of child mortality. However, contrary to the theories reviewed, immunsation coverage, access to prenatal care and nutritional status seem to be less significant in explaining the persistent rate of observed trend in child mortality in Uganda.

Key words: Infant and child mortality, economic growth, education, public health, income levels and Uganda. 2

Acknowledgements
This thesis owes its completion to the contributions and support of of some individuals and institutions. First of all, I would like to express my sincere appreciation and gratitude to my supervisor Treena Wu for her invaluable and constant advice and guidence at every stage of this thesis preparation. Her enthusiasm and uncompromising quest for excellence has greately shaped my analytical skills. I also acknowledge the valuable comments of Anne van Arragon Hutten. I would also like to thank instututions like the World Bank, New York University, Uganda Bureau of Statistics and the United Nations which provided the data and information used in the analysis of this paper. Imporatantly, I owe a great debt of gratitude to MGSoG for providing me with the opportunity and funding to pursue the MPP program that has equipped me with knowledge and skills necessary to be a part of my countrys development. Not forgetting Lyle and Linda Stucky as well as Anne van Arragon Hutten for both their financial and emotional support durung the year. I also thank my family for their enduring love and support throughout the year. I thank my dad Abiuda Lawoko Okella who unfortunately passed away during this study year and in whose memory I dedicate this work and my son Gideon whose birth during this same time inspired me to work even harder. And to the family of Mieke and Jan Jonkers, thank you for offering your valuable time to take care of Gideon while I was away at school and for hosting us. Finally, I thank my colleagues in the MPP programme for 2008/2009 for their coorperation and team spirit throughout the year. But above all, I thank the almighty God for strength, good health and unconditional love that has always sustained and inspired me in my improbable lifes journey. Nestar Lakot Okella January, 2009 3

Table of Contents
Acknowledgements ........................................................................................................3 CHAPTER 1: INTRODUCTION ..................................................................................6 1.1 Background ..........................................................................................................6 1.2 Problem Statement ...............................................................................................8 1.3 Study objectives ...................................................................................................9 1.4 Research Question ................................................................................................9 1.5 The Purpose of the study ....................................................................................10 1.6 Method ...............................................................................................................10 1.7 Outline of Research ............................................................................................10 CHAPTER 2: LITERATURE REVIEW .....................................................................11 2.1 Main Determinants of Child Mortality...............................................................11 2.1.1 Education .....................................................................................................13 2.1.2 Nutritional Status.........................................................................................14 2.1.3 Diseases .......................................................................................................15 2.1.4 Public Health including medical care..........................................................19 2.1.5 Income levels...............................................................................................20 CHAPTER 3: METHODOLOGY AND DATA SOURCES .......................................21 3.1 Methodology ......................................................................................................21 3.2 Data sources .......................................................................................................23 CHAPTER 4: RESULTS AND ANALYSIS OF FINDINGS .....................................24 4.1 Results and analysis of findings: ........................................................................24 4.2 Infant and child mortality in Uganda .................................................................24 4.3 Level of education of the households .................................................................25 4.4 Nutritional status ................................................................................................27 4.5 Public health care ...............................................................................................28 4.5.1 Access to improved water sources and sanitation ...........................................28 4.6 Maternal Care / reproductive health care ...........................................................29 4.7 Measles immunization among children (ages 12-23 months) ............................31 4.8 Malaria ...............................................................................................................32 4.9 Government expenditure on health and education: ............................................34 4.10 Availability and coverage of Health care facilities ..........................................37 4.11 Poverty/income level ........................................................................................39 4.12 Review of Overall findings ..............................................................................42 CHAPTER 4: CONCLUSIONS...................................................................................46 4.1 Conclusions ........................................................................................................46 BIBLIOGRAPHY ........................................................................................................50 4

Tables Table 4.1 Primary completion and secondary enrolment rates in Uganda...............26 Table 4.2 Prevalence of children under-five years of age who are underweight in Uganda .....................................................................................................................28 Table 4.3 Percentage of the population with access to improved water and sanitation ..................................................................................................................29 Table 4.4 Skilled personnel birth attendance and mothers receiving prenatal care .30 Table 4.5 Immunization coverage 2003-2007..........................................................32 Table 4.6 Distance to the nearest health facility by region ......................................39 Table 4.7 Recurrent Expenditure 2002/03 2006/07 (by percentage) ....................41 Graphs Graph 1.1 Ugandas annual GDP growth rate (percentage).......................................7 Graph 1.2 Child Mortality trend in Uganda (per 1000) .............................................8 Graph 2.1 Estimated Number of Measles Deaths by Region ...................................18 Graph 4.1 Infant and under-five mortality rate in Uganda (5 year interval) ............25 Graph 4.2 Female Literacy rate as percentage of 15+ populations ..........................26 Graph 4.3 Measles immunization (percentage of children ages 12-23 months) ......31 Graph 4.4 Annual trends in reported malaria cases .................................................33 Graph 4.5 Trend in Reported Malaria Cases by Age in Uganda..............................33 Graph 4.6 Total population trend .............................................................................34 Graph 4.7 Uganda's sectoral expenditure .................................................................35 Graph 4.8 Health facilities by region in Uganda ......................................................38 Graph 4.9 Poverty Trend in Uganda ........................................................................40 Figures Figure 2.1 Conceptual Framework: Determinants of Persistent high level of child mortality in Uganda ..................................................................................................13 Figure 2.2 Ways in which malaria kills children .....................................................16 Figure 3.1 Map of Uganda .......................................................................................23 Figure 4.1 Expenditure by sector 2003/2004 ...........................................................36

CHAPTER 1: INTRODUCTION
1.1 Background
CHAPTER 1 I#TRODUCTIO# Uganda is a landlocked country situated in the Eastern part Africa with a total area of 241,038 Square Kilometers (United Nations Development Programme - UNDP, 2007). It is bordered by Kenya in the East, Tanzania in the South, Rwanda in the South West, Democratic Republic of Congo in the West and Sudan in the North. Ugandas total population is estimated to be 30.4 million (CIA, 2008) with over 90 per cent of the population living the countrys rural area. Agriculture is the major economic activity in the country employing more than 80 per cent of the population as well as contributing more than 30 per cent of the countrys GDP with coffee being the main export of the country. Administratively, the country is divided in to four regions which include Central, Eastern, Northern and Western region.

Uganda remains one of the poorest countries of the world with an estimated GDP per capita (purchasing power parity) of US$ 900 in 2007 (Department of International Development (DFID), 2008) despite statistical evidence that the countrys economy has been growing significantly over the last decade. Empirical studies supported by the World Bank shows that between 1992/93 and 1996/97, Uganda managed to reduce its poverty rate by 18 percentage points, from 56 to 44 per cent. This was a result of the countrys economic growth leading to improvements of some welfare indicators particularly primary education with a substantial increase in the net rate of enrolment, while other indicators like child mortality have not improved much. One in seven Ugandan children dies before reaching her or his fifth birthday.

Hoping to gain support from the international community through foreign aid to address these poverty issues, Uganda signed an agreement with the International Monetary Fund (IMF) and World Bank (WB) to implement an economic structural adjustment program in 1987. Ugandas debt burden is quite high and the country is still highly dependent on foreign aid. In 1998, Uganda was the first developing country to qualify for, and benefit from, the Highly Indebted Poor Countries (HIPC) Debt Initiative. The countrys effective poverty reduction strategy using the resources of this original HIPC initiative via Ugandas Poverty Eradication Action Plan (PEAP)

which focus on, among others, the involvement of civil society in the formulation of its poverty reduction strategy as well as continued governments commitment to macroeconomic stability. With this effective strategy, Uganda became one of the first countries to be declared eligible for enhanced HIPC Initiative (WB, 2008).

Over the last decade, Ugandas economy has been growing significantly with an estimated annual GDP growth rate of 5.3% (UNDP, 2007). Although the annual rate of economic growth has been fluctuating since 1990 (for reasons that will not be mentioned as they are beyond the focus of this paper), the economy has had a sustained growth when compared to the annual GDP growth figures in the 1980s. The main reasons for economic growth during this period include, among others, the countrys sound economic policies that came as a result of economic structural adjustments Uganda embraced in 1987 which led to increases in the sales of agricultural products, as well as growth of direct foreign investments and private sector investment. Also, the country witnessed a substantial increase in remittances from its nationals living abroad and reprioritized its spending of donor funds to the public sector particularly in the provision of social services. Looking at GPD annual growth figures for Uganda between 1990 and 2003 or even beyond, the country attained an average growth rate of 6.6 per cent as shown in the trend of GDP annual growth rate in the graph below.

Graph 1.1 Ugandas annual GDP growth rate (percentage)

Uganda's annual GDP Growth rate (%)
14

12

10

% GDP Growth

8 GDP Growth 6

0 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 Years

Source: New York University (NYU), 2008

1.2 Problem Statement

Despite Ugandas annual GDP growth of 5.3 per cent as mentioned in the background above, the reduction in child mortality rate leveled off in the 1990s. Until then, child mortality had been decreasing at very steady rate -a pace that is slower than the countrys rate of economic growth. Although child mortality rate in Uganda is not as high as in other Sub-Saharan African countries like Niger and Sierra Leone where the percentage of under-five mortality for instance is 262/1000 live births (2003) and 284/1000 live births (2003) respectively as compared 140/1000 live births (2003) in Uganda, the trend in child mortality in the last decade has been decreasing but very steadily as compared to the countrys sustained annual economic growth since 1990. (NYU, 2008)

Looking back on earlier decades, Ugandas infant and child mortality rates rapidly decreased in the 1960s and 1970s, from 224/1000 births in 1960 to 170/1000 live births in 1970 ( NYU, 2008) but it leveled off by the mid-1990s. By 2006, the numbers had dropped from 160/1000 live births in 1990 to 134/1000 live births, remaining among the highest in the continent of African and in the world in general despite the fact that the average annual GDP growth rate over this period has been estimated at 6.6 per cent 1. The graph below shows the trend in child mortality in Uganda between the year 1990 and 2003.

Graph 1.2 Child Mortality trend in Uganda (per 1000)

Source: NYU, 2008

Data retrieved from Millennium Goals Development Indicators, 2008; WHO mortality database and World Health Statistics, 2006 and World Development Indicators database, April 2006
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As shown in the two graphs above, the decrease in child mortality is slow compared to the pace of the countrys GDP growth rate. One would expect when an economy is growing, the growth should be reflected in other social indicators like child mortality. Therefore, for the case of Uganda, child mortality should have been reducing at an inversely corresponding rate with economic growth which has not been the case in Uganda. This can be evidenced by Deaton et al, where they argued that there is a positive relationship between health and income (Deaton et al, 2005:2). This study is therefore; influenced by the argument that growth in an economy leads to improvement in other social indicators in the economy. With this background, this paper will explore Ugandas persistently high rate of child mortality despite the countys sustained annual economic growth since 1990. Specifically, it will review reasons for the countrys child mortality situation.

1.3 Study objectives

While investigating the determinants of persistent child mortality rates in Uganda, it is important to first of all identify some social, economic, political, cultural and geographical factors that could be responsible for the child mortality. The objective of this study is to review some of the above mentioned categories of determinants of child mortality that are applicable to Uganda with particular focus on those theorized in Deaton et al, 2005 while showing trends in some of the determinants of child morality over the years. Precisely, this paper aims at: reviewing the major determinants of child mortality as discussed in academic literature specifically Deaton et al (2005) focusing on those that are applicable to Uganda and; identifying and analyzing the trend in these determinants of child mortality in Uganda despite the countrys level of economic growth over the last few years.

1.4 Research Question

The major research question of this study is; what are the determinants of persistent child mortality trend in Uganda despite the countrys economic growth over the last

decade? While answering the main research question stated above, the study also answers the following sub-questions: What are the major determinants of child mortality discussed in Deaton et al (2005) literature are applicable to Uganda? How have these determinants affected child mortality over years in the country despite over a decade of Ugandas economic growth? How is the child mortality trend in Uganda over the last years associated with these determinants? Does economic growth necessarily lead to a reduction in child mortality?

1.5 The Purpose of the study

This study will help policy makers and other relevant stakeholders to understand the determinants of the persistent trend in child mortality in Uganda despite the countys economic growth

1.6 Method
This study is descriptive and the researcher analyses the determinants of persistent trend in child mortality in Uganda using data from secondary data sources particularly using databases of the UN, NYU, World Bank, Uganda Bureau of Statistics (UBS). It focuses on reviewing some of the determinants of mortality theorized in Deaton et al, 2005 which are applicable to Ugandas context as specifically highlighted in detail in chapter three (methodology and data sources).

1.7 Outline of Research

This study consists of several chapters; Chapter one contains introduction to the research topic; chapter two reviews available literature on the topic focusing particularly on some of the determinants of mortality theorized by Deaton et al, 2005 that are applicable to Ugandas context to give an understanding on the subject and identifies some available gaps that need to be bridged through further research, if there is any; chapter three discusses the methodology and data sources; chapter four discusses the analysis of the trend of the determinants of child mortality theorized in chapter two. At the end, of the analysis, findings are presented in chapter four. Finally, chapter five gives conclusions on this topic. 10

CHAPTER 2: LITERATURE REVIEW

2.1 Main Determinants of Child Mortality
Under-five mortality (U5MR), the probability of dying between birth and age 5 expressed per 1000 live births, and infant mortality (IMR), the probability of dying before age one expressed per 1000 live births, have been used as measures of children's well-being for many years. Data indicate that some eleven million children under the age of five die annually in the world as a whole, of whom, over ten million are in the developing world. Sub-Saharan Africa is the region most affected and accounts for more than one-third of deaths of children under age of five (Hill et al., 1999). Nearly three-quarters of the child deaths in the developing world are caused by diseases (predominantly acute respiratory infections, diarrhea and malaria) for which practical, low cost interventions exist, including immunization, ORT use, and antibiotics (Agbessi Amouzou and Kenneth Hill, 2004).

During the UN General Assembly (2000) where the UN Millennium Declaration was adopted world leaders pledged to reduce child mortality rate by two thirds by the year 2015. Although there has been a global reduction in child mortality using the year 1990 as a base year, it appears obvious now that most Millennium Development Goals - MDGs (if not all), especially that of reducing child mortality by two thirds by the year 2015, will fail to be achieved, particularly in Sub-Saharan Africa. Uganda, for instance, like most other Sub-Saharan African countries has had a steady decline in child mortality from 260/1000 births in 1960 to 140/1000 births in 2005 (NYU, 2008). However, as already noted in the first chapter, Ugandas economy has been growing at an average of 6.6 per cent during this same period. To reverse the above trend in child mortality in an effort to work towards the commitments made by world leaders in 2000 to reduce child mortality by two thirds by the year 2015, we need to understand some of the major determinants of persistent mortality rate in Uganda despite the countys economic growth.

It is important to note that Uganda has marked differences in its child mortality rate among the different regions of the country, as the regions are quite diverse in terms of available infrastructure, political situation, culture, rainfall pattern, natural resource endowments etc. The Uganda Demographic and Health Survey (UDHS), 2000-2001 11

confirms these marked regional differences in child mortality rates, with the Central and Eastern regions having lower mortality rates than the Northern and Western regions. The survey cites under-five mortality rate in the Central Region at 135 deaths per 1,000 live births while the Northern Region has 178 deaths per 1,000 live births2. Despite these regional differences, this paper focuses on discussing some of the determinants of Ugandas persistent level of child mortality in the face of the countrys significant economic growth using national data, while focusing on those advanced by Deaton et al, 2005 as the major literature.

It is understandable that Deaton et al theorized many determinants of mortality. This is because their theory was advanced to cover many regions (countries) of the world which are at different stages of development and have different socio-economic, political and cultural context. This paper, however, focuses only on Uganda and zooms down to those theories of mortality advanced by Deaton el al that are applicable to the countrys context. It specifically focuses on three major factors which include public health care systems, education levels and income levels and how these factors influence nutritional status, birth interval, age of the mother at child birth, disease prevalence, availability and accessibility of health care facilities, improved water and sanitation as well as human and financial resource availability to result in the level of observed mortality rate in Uganda despite the countrys level of economic growth over the last decade as discussed in detail in the methodology in chapter three of this paper. The figure below shows a conceptual framework of the determinants of persistent child mortality rate which helps to guide the analysis of this paper as further discussed in chapter three (methodology).

UDHS, 2001-2002:101

12

Figure 2.1 Conceptual Framework: Determinants of Persistent high level of child mortality in Uganda
Nutritional status

Level of Education

Birth intervals Age of the mother at child birth

Public Health

Diseases Malaria Measles Health care facilities Resource (Human and Finance)

Child Mortality

Income Level

Water and Sanitation

2.1.1 Education Studies have shown that there is a strong correlation between education and health. A womans education, specifically, is an important determinant of her childs health and mortality. As an Indian cross-sectional and panel studies confirmed, there is a strong correlation between a womans education and implementation of health behaviors that can improve her childs health (Deaton et al, 2005:19). The same source (Deaton et al) quoted a study carried out in developing countries (with the exception of China) by Preston between 1930s and the last 1960s to show a strong correlation between improved social indicators like education and reduction in mortality in these countries. Another empirical study of Child Mortality and Socioeconomic Status in Sub-Saharan Africa illustrates that illiteracy accounts for two-thirds (67%) of the variation in under-five mortality rate; a 10 percent point reduction in womens illiteracy rate reduces under-five mortality by 13 per cent (Agbessi Amouzou and Kenneth Hill, 2004:7).

Findings from empirical studies imply that educated mothers tend to have healthier babies and a higher probability that these babies will survive to adulthood than their 13

uneducated counterparts. This is because an educated mother is most likely among others things to complete her childs immunization, have greater knowledge of the childs health (causes and prevention of disease), practice good hygiene for her baby and family at large, and gives her baby good nutrition as she is more likely to be knowledgeable on the nutritional values of the foods she feeds her baby. She is also more likely to be able to afford the above mentioned items for her household since most educated women in developing countries are more likely to have their own source of income, as will be discussed later.

2.1.2 Nutritional Status The quantity and quality of food a child eats affects his/her health and survival (mortality) especially before his/her fifth birthday. As scientific studies have proved, the ability of a child to resist most bacterial infections and recover from such infections is greatly affected by how much and well he/she eats. Thomas McKeown, a British physician and demographer, for instance, is quoted to have been the first to argue that nutrition play an enormous role in the improvement of health and reduction of mortality (Deaton et al, 2005). This is because a well-nourished child tends to be healthier both during his or her childhood and adulthood. Similarly, a well-nourished woman/mother faces fewer risks during pregnancy and childbirth, and her child therefore has better chances of surviving into adulthood, with better physical and mental development (UNICEF, 2007). Support for this theory can be found in Robert Fogels experimental study in Europe (1994 and 2001). He not only found that in Europe, the increased caloric intake (by one-third) between the middle of the eighteenth century and the present explains the 10 centimetres or more increase in height seen in the population across most of the continent, but also that the improved nutrition between the eighteenth and nineteenth century coincides with the reduction in mortality during this period (Deaton et al, 2005:4-5).

Infants and young children as well as mothers in their reproductive years, particularly pregnant and breast feeding mothers, are the most nutritionally vulnerable groups of the population. This seems to be especially true in Sub-Saharan Africa. When a child is for instance undernourished, he/she is most likely to have lower resistance to infection and is more likely to be susceptible to dying from diseases like diarrhea, 14

malaria, respiratory infection. Undernourished children who survive these diseases are more likely to experience a frequent recurrence of these diseases.

It is estimated that about half of global child deaths are caused by malnutrition and its related consequences (UNICEF, 2007). At the same time, it is estimated that the prevalence of underweight children under-five years of age in Sub-Saharan Africa only dropped from 33 percent in 1990 to 29 percent in 2005 (3). This figure shows that malnutrition is still a big contributor to child mortality in the region, which remains high. Although lower than the average for Sub-Saharan Africa, the prevalence of underweight children under-five years of age in Uganda has not reduced over the years with an estimated 20.4 per cent in 2006.

2.1.3 Diseases Much as malnutrition contributes to a high percentage of child mortality; there seems to be is a two-way traffic in the interaction between disease and nutrition. Some scholars have argued that a child who is always malnourished suffers from poorlycontrolled infectious diseases. For example, when diarrhea prevents food intake from nourishing the body of a child with continuous diarrheal relapses, that child may not be able to absorb more than 20 per cent of the nutrients he/she does consume, even when the quantity and quality of the food are adequate. In such a scenario, if the child dies, it was the diarrhea rather than poor nutrition which would have contributed to the childs death (Deaton et al, 2005:6). This example illustrates that that disease is a significant determinant of child mortality along with nutritional issues.

A large number of African children still die from largely preventable diseases. Malaria, measles, diarrhea, respiratory infections, and AIDS are among the major diseases that cause death among under-five children in Africa in general and Uganda in particular. However, this paper only focuses on malaria and measles, which arguably are the major causes of child mortality in Uganda as one in five children under the age of five years die due to these diseases (CRIN, 2007). Measles is said to be the deadliest disease globally against which children can be immunized and a major cause of child mortality in Uganda (UNICEF, 2001; CRIN, 2007).
3

Data retrieved from the MDGs Indicator site of the UN, 2008

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2.1.3.1 Malaria Studies have shown that malaria is a leading cause of death in Sub-Saharan Africa. Worldwide, an estimated 350-500 million or more clinical malaria disease episodes occur annually (WHO, 2006). Over 60 per cent of these cases and 90 percent of malaria deaths (the majority of them children) occur among people in Sub- Saharan Africa (WHO Malaria Report, 2003; 2006). According to a study carried out by Rowe et al (2000), an estimated 100 million of the 111 million children in Sub-Saharan Africa live in malaria prone areas. Deaton et al (2005) note that malaria remains problematic even in the now developed countries despite measures taken there after World War ll to control the situation by cleansing the environment of many vectors. Among these were the anopheles gambiae mosquitoes that transmit malaria. Deatons study posits that irrespective of the region, malaria prone areas are more liable to have high levels of mortality than areas which are less prone to malaria.

Basically, child deaths due to malaria can occur in three different ways. First, the acute infection which manifests itself as a coma and is clinically referred to as cerebral malaria is the most direct and quickest way in which malaria may kill a child. Secondly, frequent or chronic malaria infection develops into severe anaemia which has a high risk of death. Thirdly, malaria during pregnancy results in low birth weight of a child which increases the childs chance of dying during the first month. In addition to these factors, repeated or chronic malaria increases a childs susceptibility to other diseases such as acute respiratory infection or diarrhea, which in combination cause the child to die, as illustrated in the figure below (WHO Malaria Report, 2003; 2006).

Figure 2.2 Ways in which malaria kills children

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Figure 2.2 Ways in which malaria kills children Infection in pregnancy Acute febrile illness Chronic/Repeate d infection

Low birth weight Preterm delivery

Cerebral malaria Respiratory distress Hypoglycaemia

Severe Anaemia

Death Adopted from WHO Malaria Report, 2003 An estimated 40 per cent of all outpatient visits, 25 per cent of all hospital admissions and about 14 percent of all in-patient deaths in Uganda are attributed to malaria. The burden of the disease is greatest among under-five children and pregnant women. Malaria is estimated to account for 20-23 per cent of total deaths among under-five children most of whom are at risk because they lack access to timely and appropriate malaria treatment. Acute malaria disease needs a timely and appropriate treatment (something which most health facilities in Uganda may not effectively provide) as it may only take a child twenty-four hours to die from this condition (WHO, 2008). 2.1.3.2 Measles Of all the vaccine preventable diseases, measles is the most deadly worldwide (UNICEF, 2001). According to Deaton et al (2005), it is the availability of vaccination which determines the rate of child mortality. When a child is born, he/she has to be vaccinated against diseases like measles, polio, whooping cough, diphtheria, yellow fever, tuberculosis, leprosy and others. Deaton et al says the fact that child mortality is highly influenced by vaccination as evidenced by the reduction in high morbidity from these kinds of diseases in the now developed countries after the introduction of vaccines against the diseases, especially during the 1900s (Deaton et al, 2005). However, despite safe and effective vaccine availability in the past 40 years, measles still remains one of the leading causes of death among young children 17

globally. The World Health Organisation (WHO) estimates about 242,000 deaths due to measles globally in 2006 which means about 663 deaths daily and 27 deaths hourly. The majority of these deaths (more than 95%) occur in developing countries. SouthEast Asia and Africa are the regions with the highest number of measles deaths, as illustrated in the figure below (WHO, 2008):

Graph 2.1 Estimated Number of Measles Deaths by Region

Source: WHO, 2008 The studies cited above have shown that measles is one of the major causes of child mortality in Uganda. According to CRIN, more than a quarter of all under-five deaths in the country are attributable to measles (CRIN, 2001). Deaton et al (2005) also noted that, as was the case with malaria, child mortality due to measles is greatly influenced by the availability and accessibility of the vaccines against measles as evidenced by reduced child mortality rate in the now developed countries after the introduction of vaccines. Vaccinations cause children to become immune to these diseases. Conversely, when children are not vaccinated against these kinds of diseases they become susceptible to them and child mortality rates increase.

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2.1.4 Public Health including medical care According to Deaton et al (2005), public health factors such as filtering and chlorinating water supplies, building sanitation systems, draining swamps, pasteurizing milk, undertaking mass vaccination campaigns, boiling bottles and milk, protecting food from insects, washing hands, ventilating rooms and keeping childrens vaccinations up to date all influence child mortality. By the same token, poor sanitation or housing conditions, along with a lack of access to clean water are some of the major causes of diseases such as diarrhea and cholera which as mentioned earlier are among the major cause of child mortality

In addition to immunization, the availability and affordability of adequate medical care when disease erupts also determine the child mortality rate. When a sick child is unable to access medical treatment, the risk of dying is obviously much higher than when he/she is able to access the right treatment.

Unfortunately, most developing countries have poor quality health service delivery because of limited resources having been allocated to healthcare. This poor quality health service delivery is manifested by high levels of absenteeism among medical staff, especially in the rural areas. According to a survey result carried out in Uganda, 37 per cent of health workers may not turn out for work in the primary health centers (Chaudhury et al, 2006). Much as publicly funded doctors are more likely to be qualified than those of private health care providers; they are also more likely to be absent, and to have insufficient time or medicines to provide effective treatment. Private providers are more likely to have unqualified personnel who are bound to over treat patients through for example giving every patient an injection of antibiotics without any prior tests. Most developing countries have challenges of providing effective public healthcare as well as lack the institutional ability to regulate and to monitor the private sector due to limited expenditure on health care (Deaton et al, 2005:18).

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2.1.5 Income levels The level of income at national, household and individual levels affects the health of its member(s). Higher incomes seems to make provision of public health infrastructure, such as improved water sources and sanitation facilities, as well as better nutrition, better housing and healthcare easier. Critics who disagree with this theory have argued that, at the national level, many countries tend to have remarkable improvements in health despite little or no economic growth, while others with high economic growth tend to have had a deteriorating or unimproved health care. The same situation seems to be witnessed in Uganda where child mortality reduced significantly during the 1970s and 80s when the economy was relatively stable but leveled off since 1990 despite the countrys relatively high economic growth.

A child from a family with high income is more likely to receive adequate health care than a child from a low income family. In most developing countries as well as in some developed countries, a child from a wealthier family is more likely to access different physicians or even hospitals than is a child from a poorer or less wealthy family. Using the United States as an example, some studies like those quoted by Deaton et al (2005) have shown that health care standards seem to be lower in hospitals that are used mostly by blacks. Although the causal relationship between income and good health seems unclear in developed countries, (as noted in the historical determinants of mortality in these countries) the reverse could be true in developing countries.

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CHAPTER 3: METHODOLOGY AND DATA SOURCES

3.1 Methodology
This paper explores some of the determinants theorized in Deaton et al, 2005 particularly those that are applicable to Ugandas context and uses national data from secondary data sources like the World Bank, NYU, UN, UBS to analyze and present findings. Specifically, it explores how education levels, public including medical health services and level of incomes interact with other immediate factors like nutritional status, age of the mother at birth, birth intervals, diseases, availability of health care facilities and resources (both human and financial) as well as access to improved water and sanitation facilities to influence child mortality levels in Uganda as illustrated in the conceptual framework (figure 2.1) in Chapter two above.

As already mentioned in chapter two and shown in figure 2.1 (conceptual framework) in the same chapter, this study focuses on investigating whether and how income levels, education and public health influence nutritional status, birth interval, age of the mother at child birth, disease prevalence, health care facilities, access to improved water and sanitation as well as human and financial resource availability to result in the observed child mortality level in Uganda.

Income levels is chosen as an underlying determinant of child mortality in Uganda due to the fact that the country still remains one of the poorest countries not only in Sub Saharan Africa but also in the world at large with a heavy dependency on foreign aid. In 1998, Uganda was one of the first Developing countries to qualify for HIPC Debt Initiative. Statistics show that the proportion of Ugandas population living below $1 a day was as high as 51.5 in 2005 (UN, 2008). Just before the HIPC Debt relief, Ugandas infant and child mortality rates specifically in 1995 was relatively higher 92/1000 and 156/1000 live births respectively compared to 85/1000 and 145/100 live births in 2005 during implementation of the HIPC under the countrys Poverty Eradication Action Plan framework (PEAP). Additionally, infant and child mortality rate reduced by 7 and 11 percentage points respectively within the 5 year period between 1995 and 2005 which are higher than the 1 and 4 percentage points reduction in the preceding 5 years. One could therefore argue that the increase in 21

national accounts as a result of HIPC debt relief which indisputably improved households income could have contributed to the high infant and child mortality reduction rate between 1995 and 2005 as opposed to low reduction rates between 1993 and 2005 before the initiative.

Education and health are chosen because they are not only the most productive human assets but also a prerequisite for unlocking countries full potential of their workforce which in turn leads to an improvement in social indicators including child mortality. This means that high levels of education and health improves human capital and an improvement in human capital increases productivity in an economy. Therefore, education influence nutritional status, birth interval, age of the mother at child birth, and to some extent prevalence of some diseases like diarrhea while availability and accessibility of public health care influence usage of health care facilities, prevalence of disease and access to improved water and sanitation facilities as discussed in detail in chapter four of this paper.

Although income levels may not directly influence all the determinants presented in figure 2.1 in chapter two, all these determinants are in one way or another influenced by income levels as illustrated below. High level of income both at household and national levels could lead to increased levels of education and health which would lead to improved nutritional status of the households, use of family planning facilities (adequate child spacing and age of the mother at child birth), reduced disease prevalence, increased access and usage of health care facilities as well as increased accessibility to improved water and sanitation facilities while the reverse could be true in case of low income both at national and household level. A high level of income also increases availability of human and financial resources. One could therefore argue that availability of human and financial resources should have been included among the major determinants of child mortality and therefore presented in the same order in figure 2.1 (conceptual framework) with income levels, education and public health. However, it is included among the factors that this paper refers to as intermediate determinants of child mortality for purpose of analysis as it helps in answering the last research question of whether economic growth necessarily lead to a reduction in child mortality.

22

Figure 3.1 Map of Uganda

Source: CIA, 2008

3.2 Data sources

This research uses secondary data sources. It particularly draws data from the database of the New York University (NYU) on Social Indicators, World Bank, Uganda Bureau of Statistics (UBS) Uganda Demographic and Health Survey (UDHS) and the United Nations (UN). Other secondary data sources used in the analysis of this paper includes among others, the Global Fund and World Health Organization.

23

CHAPTER 4: RESULTS AND ANALYSIS OF FINDINGS

CHAPTER 4- RESULT A#D A#ALYSIS OF THE FI#DI#GS

4.1 Results and analysis of findings:

In this chapter, findings collected from secondary data sources are presented. The chapter analyses the determinants of persistent level of child mortality in Uganda despite the countrys level of economic growth. It focuses in particular on how health, education and income influence the other determinants of child mortality described in academic literature (with particular review of Deaton et al, 2005), as presented in the conceptual framework in chapter two. While analyzing these determinants, the chapter answers the research questions presented in chapter one of this paper.

4.2 Infant and child mortality in Uganda

The infant and child mortality rate in Uganda has leveled off since the 1990s. Infant mortality rate was reduced from 93 deaths per 1000 live births in the year 1990 to 79 deaths per 1000 live births in the year 2005. This is an improvement of only 14 deaths per 1000 live births over these 15 year period, representing, on average, a reduction of less than one death per 1000 live births annually. The rate of reduction was even lower with observed under-five mortality over this same period. Under-five mortality reduced from 160 deaths per 1000 live births in 1990 to 136 deaths per 1000 live births in 2005. Again this is a reduction of only 24 deaths per 1000 live births over the 15 year period, or 1.6 fewer deaths per 1000 live births per year as shown in the graph below. As noted earlier, it is within this same time period that Uganda has been experiencing a significant economic growth evidenced by an average annual GDP growth rate of 6.6 per cent over this 15 year period as illustrated in graph 4.1 below.

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Graph 4.1 Infant and under-five mortality rate in Uganda (5 year interval)

Source: World Bank, 2007

As mentioned earlier, this chapter analyses how the factors reviewed in chapter two such as educational level, public health care systems (both preventive health measures and medical heath care, diseases, income/poverty level of the households and government resource allocation to the health and education sectors in Uganda might explain the observed trend in infant and child mortality in the country, as will be discussed below.

4.3 Level of education of the households

As reviewed in chapter two, education largely determines the role parents, particularly mothers, play in a household. An educated mother is more likely to make healthy lifestyle choices for her family in general and her child in particular. This is because of the fact that an educated mother has greater knowledge of the causes of disease for her child and how to prevent these; greater recognition of the importance of completing her childs vaccination against the preventable diseases as well as having better knowledge on the nutritional values of food that she feeds her child. Also, an educated mother is aware of the advantage of child spacing and more likely to have longer birth intervals, as she would have better knowledge of the significance of family planning than her uneducated counterpart.

However, it can be noted that the level of illiteracy is still high in Uganda. The percentage of women accessing and completing primary education has simply not 25

improved over the years. On average, about half of the women in Uganda have failed to complete primary education over the years, and the rate of womens enrolment in secondary education is even considerably lower. Of all the women that graduated from primary school between 1997 and 2006, only 11 per cent enrolled in secondary education. The rate did increase slightly from 7 per cent in the late 1990s to about 15 percent in the mid 2000 as shown in table 4.1 below.

Table 4.1 Primary completion and secondary enrolment rates in Uganda

Year 1999 Primary 51.3 Secondary 6.8 2000 51.3 12.2 2001 51.3 12.5 2002 54.5 14.7 2003 51.4 14.4 2004 51.8 14.1 2005 51.5 14 2006 51.5 15.4

Source: World Bank, 2007

Women of ages 15 years and above are focused on because they are the ones who are active in the reproductive and productive roles in the household which affects the health and morbidity of their children. The literacy rates among women from the age 15 years and above in Uganda increased from 44 per cent in 1990 to about 58 per cent in the early 2000. Much as the rate of literacy in the country has increased between the above mentioned years, the percentage point increase is insignificant when compared with Ugandas rate economic growth over these years. Actually the trend leveled off from the mid 1990s to 2006 at about 58 per cent while the economy continued to grow significantly during these periods as shown in graph 4.2 below. Basing on this trend, it can be argued that the steady level of illiteracy in Uganda over the years partly explains the persistent level of the countrys high child mortality rate.

Graph 4.2 Female Literacy rate as percentage of 15+ populations

26

Source: World Bank, 2007

4.4 Nutritional status

Generally, the prevalence of malnutrition among children under the age of 5 years is relatively low in Uganda compared to other countries like Ethiopia and Niger. For instance in 1995 the prevalence of children under 5 in Uganda who were moderately or severely underweight was 25.5 percent compared to 46.6 and 42.6 per cent in Ethiopia and Niger respectively. In 2006, moderately or severely underweight children in Uganda reduced to 20.4 per cent. This 5.1 percentage point reduction over 11 years period with sustained economic growth is relatively low. Of these, 6.7 per cent of children under the age of five were severely underweight in 1995. The rate reduced by 1.1 percentage point to 5.6 per cent in 2006 as illustrated in table 4.2 below despite the fact that the country achieved a significant growth in the economy over these years. From this figures, it can be concluded that malnutrition among children under-five years of age in Uganda has relatively remained unimproved or it has improved at a slower pace than the countrys sustained growth in the economy. Although lower than the average for Sub-Saharan Africa, it can be argued that the persistent prevalence rate of underweight children under-five years of age in Uganda could partly contribute to the countrys child mortality situation over these years. On the other hand, it could also be argued that malnutrition may not be a significant factor that contributes to the persistent rates of child mortality in Uganda as the rates are low compared to other countries in the continent like those mentioned above. Much as this finding confirms the theory that malnutrition is one of the major contributor to child mortality accounting for about half of the global child deaths, it 27

can also be argued that the low rates of malnutrition especially the rate of severely underweight children under the age of five years in Uganda compared to other countries in the continent could be contrary to the above theory.

Table 4.2 Prevalence of children under-five years of age who are underweight in Uganda
Year Children under five severely or moderately underweight, percentage Children under-five severely underweight, percentage Source: UN, 2008 1995 25.5 6.7 2001 2006 22.8 20.4 5.1 4.6

4.5 Public health care

As discussed in the literature review, access to public health services, which for the purposes of this paper includes both preventive and medical health care services greatly influenced child health and mortality. Under the heading of health care, the study will therefore include access to improved water source, improved sanitation facilities, access to immunization, and treatment of diseases, reproductive health services, and availability of health personnel as well as the financing of the health sector/health care.

4.5.1 Access to improved water sources and sanitation

The percentage of the population (pop.) of Uganda with access to improved water sources has increased from 44 per cent in 1990 to about 60 per cent in 2004, as presented in table 4.3 below. Much as the number of people with access to clean water has increased within the last years, the 16 percentage point increase over the 15 year period is slow compared to the countrys rate of economic growth over these years. It can be concluded that an estimated 40 per cent of the population of Uganda have no access to improved water sources. This segment of the population is exposed to a high risk of using unimproved water source, threatening the health of their households in general and children in particular and therefore, leading to increased risk of acquiring diseases like diarrhea and cholera, which may result in higher child mortality.

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Table 4.3 Percentage of the population with access to improved water and sanitation
Year % of pop. with improved water source % of pop. with access improved sanitation facilities Source: WB, 2007 42 43 43 43 1990 44 1995 49 2000 55 2004 60

The situation is even much worse when we examine the populations access to improved sanitation facilities. From 1990 to 2005, the percentage of the population with access to improved sanitation facilities had leveled off at about 44 per cent. It can therefore be argued that between the year 1990 and 2005 more than half (an estimated 57 per cent) of the population of Uganda lacked access to improved sanitation facilities hence their increased risks of diseases like respiratory infections, diarrhea, and malaria. As noted in the literature reviewed earlier, the latter (malaria) is estimated to be the major cause of child mortality in Uganda, being responsible for one in five deaths among children in the country.

4.6 Maternal Care / reproductive health care

This paper considers attendance by skilled health personnel during the prenatal, birth and postnatal periods as indicators of maternal/reproductive health care in Uganda. With this in mind, the study found that the percentage of pregnant mothers receiving prenatal care is actually quite high in Uganda since 1995. This is evidenced by more than 90 per cent of pregnant women attending prenatal care clinics as illustrated in table 4.4 below. Good prenatal care guards and improves the health of a pregnant mother, increasing her probability of having a safe delivery as well as giving birth to a healthy baby. Adequate health care this has a positive influence on reducing both maternal and child mortality. In the case of Uganda, it can be argued that most pregnant mothers in the country have access to prenatal care in one way or another. This high level of access to prenatal care would suggest that the persistent level of child mortality over the years in Uganda is due to other factors than the absence of prenatal care received by Ugandan women. 29

Table 4.4 Skilled personnel birth attendance and mothers receiving prenatal care
Year Births attended by skilled health staff (% of total) Pregnant women receiving prenatal care (%) Source: WB, 2007 38 91 39 92 42 94 1995 2001 2006

Unfortunately, the prenatal care does not result in good health care when it comes to giving birth. In fact, most pregnant women in Uganda including those that received prenatal care give birth to their babies without being attended by skilled health personnel. This is evidenced by the following statistics: in 1995, only 38 per cent of pregnant women were attended to during childbirth by skilled health personnel. Within a period of five years, this number has increased by only one percentage point to 39 per cent in 2001, while in 2006 this figure had risen to only 42 per cent as shown in table 4.4 above. The numbers show that most child births (over 58 per cent of the total childbirths) in Uganda are not attended by skilled health workers.

The low birth attendance by skilled health personnel can be attributed to the poverty situation of the mothers. Most mothers, especially those living in rural areas, cannot afford to pay for the cost of health care as well as meet the transportation costs of visiting the nearest health centre to give birth. This is largely due to long distances to the nearest health facilities in most rural areas of the country, as will be discussed later under the heading of access and use of health facilities.

It posits that sometimes, if traditional birth attendants help with child delivery in the community, the mothers who cannot afford to pay them with money do pay them with gifts such as soap and chicken. It can therefore be concluded that limited access to skilled health personnel to attend mothers during childbirth could be one of the determinants of persistent levels of child mortality, particularly neonatal child mortality in Uganda. Since access has not improved over the past ten or twelve years, and the child mortality rate has also not been reduced much during this period, this study conclusion confirms what Deaton et al, 2005 found in their study, namely that 30

improvement in public health reduces mortality. The reverse is true for the unimproved rate of birth attendance by skilled health personnel in Uganda over the years.

4.7 Measles immunization among children (ages 12-23 months)

The number of children between the ages of 12 to 23 months getting immunized against measles has increased over the years. Although the percentage point increase of children between the above age brackets immunized against measles was quite steady in the 1990s, there has been a strong increase from the year 2000. It reached a peak in 2004 when an estimated 91 per cent of children aged between 12 to 23 months were immunized against measles, as illustrated in graph 4.3 below. It can therefore be argued that the reduction of infant and child mortality from respectively 85 and 146 deaths per 1000 live births in 1990 to 79 and 136 deaths per 100 live births respectively in the year 2000 could be explained by the increased number of children (ages 12-33) who underwent measles immunization.

Graph 4.3 Measles immunization (percentage of children ages 12-23 months)

Source WB, 2007

Generally, statistics show that vaccination has had a wider coverage in Uganda over the years as illustrated in table 4.4 below. Between 2003 and 2007 for instance, over 92 per cent received the BCG vaccine, 86 per cent were immunized against measles, 31

83 per cent got DPT vaccine, 83 per cent had OPV3 83 immunization, 52 per cent had TT2+ (Pregnant) and 12 per cent had TT2+ (Non-Pregnant) vaccine. Except for TT2+ vaccine which has a lower immunization coverage, the rest of the other killer diseases have seen a widespread immunization over the years, as can be seen in the trend illustrated in table 4.5 below.

Table 4.5 Immunization coverage 2003-2007

Vaccine BCG Measles 2003 96 83 2004 101 91 88 86 54 11 2005 94 87 85 85 56 14 2006 82 86 77 78 48 12 2007 89 85 85 83 57 12

DPT-HepB+Hib 3 81 OPV3 TT2+(Pregnant) TT2+(NonPregnant 82 48 10

Source: UBS, 2008

It is therefore argued that immunization coverage does not have a strong correlation with the persistent trend in child mortality in Uganda. However, one could also conclude that the reduction in child mortality in the country over the years could partly be attributed to the wider coverage of immunization. On balance, this study concludes that the level of immunization coverage does not explain the persistent trend in child mortality in the face of economic growth in Uganda over the years.

4.8 Malaria
As discussed in the literature review, malaria still remains a biggest threat particularly to child health in Uganda. This can be inferred from the annual trend of reported malaria cases in the country over the last decade or so. The number of cases has risen from about 2.5 million people in 1992 to over 12.3 million people in 2003. During the earlier years of this decade the number of cases increased slowly from 2.5 million to about 3 million, but in 2000, there was a tremendous increase in reported cases of malaria, as shown in graph 4.4 below. 32

Graph 4.4 Annual trends in reported malaria cases

Source: WHO, 2007

The persistent trend in malaria cases could be due to limited allocation of resources to the health sector in general or even within the health sector itself, there could be limited allocation of resources to the prevention and treatment of malaria for instance in 2008,over 70.3 million dollars was allocated to HIV/AIDS while only 51.4 million dollars (Global Fund, 2002-2008) was allocated to malaria unyet the incidence of malaria is much higher tan HIV/AIDS in the country. With the above trend, it could be argued that the persistent trend in child mortality in Uganda could be caused by the general increased risk of malaria and limited resource allocation on the prevetion and treatment of malaria within the health sector in the country as chidren under the age of five years are one of the most vulnerable groups of the population susceptible to die due to malaria. The graph below shows the incident of death due to malaria by age group over the last few years (2000 to 2003). It can be deduced that children under five are the majority of the population group to die from this disease. However, the increased trend in malaria cases could be due to more people having access to health care facilities to test for malaria cases over the years as more people become aware of the importance of accessing health care services.

Graph 4.5 Trend in Reported Malaria Cases by Age in Uganda

33

Source: WHO, 2008

4.9 Government expenditure on health and education:

Since child health and mortality is greatly influenced by education and public health care as discussed both in the literature review and in the findings above, resource allocation on these sectors could greatly influenced child health and mortality. Ugandas national expenditure on health and education has been stable over the years despite the countrys growth in the economy as well as her persistent annual population growth rate of an average of 3.2 per cent since 1990 as shown in the graph below.

Graph 4.6 Total population trend

34

Source: WB, 2007

Ugandas population has been growing at an average of 3.2 per cent per annum since the 1960s but health and education expenditure has remained stable over the years. Betweeen the years 2002/2003 and 2005/2006,Ugandas national expenditure on the education sector is estimated at 21.5 per cent of the national budget, but dropping to 13.1 per cent in the 2003/2004 financial year when the country spent more than 50 per cent of the national budget on servicing of debt. The health sector expenditure is even much lower at an average of 7.7 per cent over the same year period with only 4.8 per cent in the 2003/2004 financial year as illustrated in graph 4.7 below.

Graph 4.7 Uganda's sectoral expenditure

Souce: UBS, 2008

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The national budget figures for the 2003/3004 financial year could demonstrate how the governments resource allocation priorites influence child health and mortality. Uganda spends a substantial proportion of the national budget on servicing debt especially in the financial year 2003/2004, where more than half (55 per cent) of the countrys expenditure went for debt servicing, as shown in the pie chart on figure 4.1 below. Also, defence funding seems to be a priority, taking up a substantial proportion of the countrys national budget. It can therefore be argued that Ugandas limited resource allocaton to education and health, known to to be the fundamental factors influencing child mortality, could explain the peristent high rate of child mortaliy.

Figure 4.1 Expenditure by sector 2003/2004

Source: UBS, 2008

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4.10 Availability and coverage of Health care facilities

It is worth noting that health care facilities cover all the regions of Uganda although there are district imbalances in the level of the facilities. While some districts like Kotido, Dokolo, Koboko and Amuria have no hospitals at all, others have more than one hospital. Kampala, for example, has more than 10 hospitals. However, the reaons for this regional variation in the number of health care facilities is beyond the scope of this paper. The emphasis on availability of health facilities may miss the point on access and usage of this facilities. Facilities (the pysical structures) may exist but when there are no health personnel, medical equipment, or drugs, the availability of these facilities becomes pointless. In Uganda, many health facilities particularly health centres (which constitute the largest proportion of health facIlities as shown in the graph below) lack both the human and financial resources to function properly. Most of the health centres are located in rural areas of the country where the majority of the population live, but many of these, except for A few grade IV health centres (Health Centre IV) which have a doctor or a clinical officer, have only nurses and midwives in charge. In most cases, physicians can only be accessed in the hospitals or some of the private health facilities located mainly in the district headquarters (towns). This is partly because there are so few pysicians in the country, as evidenced by the ratio of less than one physician per ten thousand people. Dentists and pharmacists density is also estimated at less than one per ten thousand people respectively. The staff shortages continue to be seen with other medical personnel: The ratio of nurses and midwives (including traditional birth attendants) for insatnce is 7 per 10,000 population, and 2 per 10,000 population for other health service providers. These ratios are estimates for the year 2004 (WHO, 2006). In addition, even in health facilities where qualified/skilled health personnel exists (pysicians, dentists, phamacists, clinical officers, nurses and midwives), there is a high level of absenteeism especially in the rural areas where some of the health workers live in towns and commute to their work places; they can be absent from duty anywhere from a few hours to days. A study carried out by Chaudhury et al, 2006 showed that 37 per cent of health workers in Uganda do not show up at work. The ratio is said to be higher with powerful and high ranking providers like doctors (39 per cent) and lower with other health personnel (31 per cent). This high level of absenteeism can be

37

explained by the low level of incentives for Ugandan medical personal, as evidenced by the low salaries paid to health personnel. This insufficient reward is due to limited resource allocation to the health sectors, as discussed earlier

Graph 4.8 Health facilities by region in Uganda

Source: UBS, 2008

In addition, the long distance to the nearest health facilities particularly in the rural areas contributes to the low usage of the facilties. On average the distance to the nearest health facility in Uganda increased from 4 kilometers in 1996 to 5 kilometers in 2000 because of insecurity in the Northern part of the country. In 1996, the average distance to the nearest health facility in Northern Uganda was 5 kilometers but it increased to almost 6 kilometers in 2000. Nationally, only 49 per cent of Ugandans reside within 5 kilometers to a health facility. This signifies that more than half of Ugandas population travels more than 5 kilometers to the distance to the nearest health facility. Moreover, many people cannot afford to transport themselves to the health facilities and end up not using the health facilities or may have walk to these health facilities in order to access them, as indicated in table 4.6 below; 38

Table 4.6 Distance to the nearest health facility by region

Year Region Distance to the nearest health facility (km) UBS, 2008 5 4 5 3 4 4.8 4 5.8 5.2 1996 2000 East North West

Central East West North Uganda Central

This finding confirms what Deaton et al (2005) theorized that most developing countries not only have difficulty providing effective public health care but also lack the institutional ability to regulate and monitor the private sector due to limited expenditure on health care as is the case in Uganda discussed above.

4.11 Poverty/income level

As noted earlier in chapter one, Uganda remains one of the poorest countries in the world despite more than a decade of economic growth. The poverty head count for the country (the number of poor people) between 1989 and 2002 for instance, (using Organisation for Economic Coorperation and Development (OECD) poverty line as the percentage of the population living below $1 a day and the World Bank default poverty line of $32.74 per month) was estimated to be stagnant at more than 80 per cent (taking the percentage of the population living on less than 1 dollar a day). The percentage of the population living in household with income or consumption per person below the poverty line increased from 87.6 per cent in 1989 to 90.3 per cent in 1992. It decreased only to 87.9 per cent in 1996 and eventually to 82.2 per cent in 2002, as indicated in graph 4.9 below. It is argued thatUgandas growth in the economy has only lifted very small proportion of the population (only 5.5 percent) out of poverty which is appromixately 0.4 percentage point a year.

39

Graph 4.9 Poverty Trend in Uganda

Source: WB, 2008

In addition to this slow trend of graduation out of poverty, the mean distance below the poverty line (poverty gap) has not improved much over the years. Perhaps the rich in Uganda are getting richer while the poor remain poor or are even getting poorer. In 1989 the poverty gap was 52.7 per cent; it was reduced to 43 per cent in 2002 as shown in graph 4.9 above. This is only a 9.4 percentage point reduction in poverty gap in Uganda over a 13 year period. It can be deduced that income accrued from Ugandas growth in the economy mostly lands only in the hands of the people living above the poverty line, While poor people have on average remained poor with only a few graduating above the poverty line (out of poverty). It is posited that child mortality rates are generally higher among poor people than among rich people as evidenced by the high level of child mortality rate in low income countries, as compared to the low rate in high income countries. Therefore, it can be argued that Ugandas persistent rate in child mortality could partly be explained by the persistent level of poverty in the country. This leads to the last research question: does economic growth necessarily mean a reduction in child mortality?

Basing on the above findings, it can be argued that economic growth does not, in fact, necessarily mean reduction in child mortality. When there is growth in an economy but the income accruing from the economic growth does not improve the lives of poor people, as is the case in Uganda where the poverty head count (the number of people

40

living on less than 1 dollar a day) between 1989 and 2002 was only reduced by 5.5 percentage point over the 13 year period. Perhaps Ugandas GDP growth over the years has only lifted a few people out of poverty while a majority of poor people in the country still remain poor. In addition, the gap between the rich and the poor has not been reduced as much over the years. Again, it is argued that the rich in the country are getting richer as a result of Ugandas economic growth while the poor have remained poor or even getting poorer. In this kind of situation, it is worth recognizing that even when there is growth in an economy, social indicators like child mortality rate do not necessarily improve and hence, Ugandas economic growth ceases to be what Ravallion, 2004 referred to as pro-poor growth since the poverty level of the majority of the population or of the population already living below the poverty line has not improved. This study confirms the argument documented by Vandemoortele, 2004 that higher average income does not necessarily lead to less poverty.

As noted earlier, Ugandas economy and population has been growing significantly over the years. However, despite these growths, government expenditure on social sectors particularly health and education remained steady over the years. With an annual population growth rate of over 3 per cent over the years since the 1960s, the per capita expenditure on social services particularly on health and education have definitely increased over these years. But as evidenced by Ugandas recurrent expenditure between 2002/02 and 2006/07, funding for education and health has on average remained at 21 per cent and 7.7 per cent respectively (UBS, 2008), as shown in table 4.8 below, despite the countrys significant economic and population growth rate.

Table 4.7 Recurrent Expenditure 2002/03 2006/07 (by percentage)

Function classification Education Health (UBS, 2008) 2002/03 2003/04 2004/05 2005/06 2006/07* 24.2 9.1 13.1 4.8 23 8.4 23.2 8.6 23.8 7.8

41

With limited government expenditure on education and health which are key basic social services for ensuring equitable growth, the child mortality rate just like other social indicators remains persistent as this study as well as previous studies including Vandemoortele, 2004 confirm.

4.12 Review of Overall findings

Key findings can be summarized by each determinant as follows:

Infant and child mortality rate Infant and child mortality rate in Uganda were only reduced from 93 deaths per 1000 live births in the year 1990 to 79 deaths per 1000 live births in the year 2005 and from 160 deaths per 1000 live births in 1990 to 136 deaths per 1000 live births in 2005 respectively.

Level of education of the households Between 1997 and 2006 on average, about 50 per cent of women in Uganda completed primary education; however, only 11 per cent of women were enrolled in secondary education. The secondary enrolment rate only increased in the late 1990s from 7 per cent and steadily leveled off at over 14 per cent from the early 2000s.

The literacy rate among Ugandan women from the age 15 years and over increased from 44 per cent in 1990 to about 58 per cent in the early 2000 and has leveled off since then.

Access to improved water source and sanitation Access to improved water sources increased from 44 per cent in 1990 to about 60 per cent in 2004. This is only a 16 percentage point increase over the 15 year period compared to the countrys sustained rate of economic growth while a significant

42

proportion of Ugandas population (about 40 per cent) still lack access to a source of clean water.

Sanitation facilities remained poor in Uganda over the years; for instance from 1990 to 2005, the percentage of the population with improved sanitation facilities remained at 44 per cent despite the countrys growth in the economy over this period.

Maternal Care By far, the majority of pregnant women in Uganda have received prenatal care since 1995. In 1995, 91 per cent of pregnant mothers received prenatal care and the rate increased to 94 per cent in 2006.

But contrary to the above, only 38 per cent of all pregnant women had the birth of their babies attended to by skilled health personnel in 1990. By 2001, the rate had increased to 39 per cent while in 2006, 42 per cent of births were attended by skilled health personnel.

Measles immunization among children (including other childhood immunizable diseases) Immunization against measles among children ages 12 to 23 months increased significantly over the years from 52 percent in 1990 to 91 per cent in 2004 although the trend dropped a bit from 2005 and 2006. This same trend (increase) applies to other childhood immunizable diseases: between 2003 and 2007, over 92 per cent of the children got BCG vaccine, 86 per cent were immunized against measles, 83 per cent got DPT vaccine and 83 per cent had OPV3 83 immunization.

Malaria Although there was a slight decrease in reported cases of malaria in Uganda in the early 1990s as evidenced by a decrease from 2.4 million patients in 1992 to 1.4 million patients in 1995, the overall number of cases has been increasing significantly

43

over the years. From 1997 to 2003, the number of reported malaria cases shot up from 2.3 million to over 12.3 million patients.

The reported number of cases of malaria is higher among children under the age of five, as evidenced between the year 2000 and 2003, when 30 per cent of reported cases of malaria during this period were found in children under five.

Government expenditure on health and education Government expenditure on education and health in Uganda has remained steady over the years despite the countrys significant growth in the economy and annual population growth. Education expenditure dropped from 24.2 percent of the national budget in 2002/2003 to only 13.1 per cent in 2003/2004 but rose again to 23 per cent from 2004/2005 to 2006/2007.

However, the health expenditure dropped from 9.1 per cent in 2002/2003 to 4.8 in 2003/2004, then rose to over 8 per cent from 2004/2005 to 2006/2007.

Availability and coverage of Health care facilities Health care facillities discussed in this study included hospitals and health centres, health personnel, medical eqipment including drugs. Although hospitals and health centres cover all regions in Uganda, they have limited resources for proper functioning. Using the ratio of health personel to the number of people/patients as a proxy indicator for health care facilities, and focusing on estimates for the year 2004 which is representative of the other years as well, the ratio of physicians, dentists, and pharmacists is <1 per 10,000 population respectively; 7 per 10,000 population for nurses and midwives (including traditional birth attendants) and 2 per 10,000 population for other health service providers. Also, the level of absenteesm among health workers in the country is arguably high at 37 per cent.

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Income/poverty levels The poverty level in Uganda has not improved much since the late 1980s. Taking a poverty head count, the number of poor people has only been reduced from 87.67 per cent in 1989 to 82.28 per cent in 2002. Also the poverty gap had only decreased from 52.72 per cent in 1989 to 43.3 per cent in 2002.

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CHAPTER 4: CONCLUSIONS
The summary of key findings and conclusions are presented in this chapter of the paper.

4.1 Conclusions
Uganda has been experiencing a significant growth in the economy since 1988 while the under-five mortality only decreased signficantly in the 1970s and 1980s, leveling off since the 1990s even when the countrys economy continued to grow. Although empirical studies have shown that there is a huge regional variation in under-five mortality in Uganda, with the Northern and Wetern part of the country having high under-five mortality while the Central and Eastern region has a relatively low child mortality rate, this study focuses on child mortality numbers for the whole country.

The main purpose of this study is to understand the determinants of a persistent rate of child mortality in Uganda over the years despite the countrys level of economic growth while factoring in the determinants of mortality discussed in Deaton et al, 2005 literature particularly reviewing those determinants that are applicable to Uganda.

In the end, the study is expected to contribute to a better understanding of the determinants of persistent rate of child mortality in Uganda while suggesting ways of improving the effectiveness of already existing interventions to reduce child mortality in the country as well as to suggest steps that could help in designing other appropriate intervention strategies to better address the problem of child mortality in the face of a growing economy.

All the determinants discussed in Deaton et al, 2005 as reviewed in chapter two of this paper, which included among others public health, medical factors, educational levels, nutritional status, disease, and income have in one way or another contributed to child mortality in Uganda. However, this study identifies educational level of households (women), access to public health services and medical care, access to improved water and sanitation, diseases particularly malaria as well as the level of government expenditure on health and education to be the major determinants of 46

persistent level of child mortality in Uganda despite the countrys sustained growth in the economy over the last decade or so, as summarized below.

EDUCATON LEVELS - the level of education of the household, particularly womens education, is an important factor that influences the health of her household in general and the health and mortality of her child in particular. However, more than 40 percent of women ages 15+ in Uganda have remained illiterate over the years. The rate was much higher in the early 1990s (55 percent), then was reduced to and has remained at about 42 per cent since 1995. This study concludes therefore that the illiteracy rate among women of age 15+ specifically and low levels of education among Ugandan women in general over the years partly explains the persistent high rate of child mortality despite the countrys significant growth in the economy over the last decade.

ACCESS TO IMPROVED WATER AND SANTITATION - the proportion of Ugandas population with access to improved water sources increased from 44 per cent in 1990 to 60 per cent 2004, but more than 40 per cent of the population have lacked access to improved water over this period. In addition, sanitation facilities remained poor over the years as the percentage of the population with access to improved sanitation facilities remained at 44 per cent since 1990 despite the countrys growth in the economy over this period. This study concludes that limited access to improved water sources and sanitation facilities is the major reason for diseases like diarrhea, cholera and malaria in the country over the years despite Ugandas economic growth, and these factors are partly responsible for the persistently high rate of child mortality in Uganda.

MATERNAL CARE - majority of pregnant women in Uganda (about 60 percent) have births to their babies unattended to by skilled health personnel since 1990. This study found that the percentage of births unattended to by skilled health personnel as not improved in Uganda over the years despite countrys sustained economic growth over the years and concludes that this factor partly explains the persistent trend of infant mortality in particular and child mortality in general in Uganda over the this period.

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MALARIA - overall, reported cases of malaria in Uganda over the years has increased from 2.4 in 1990 million to over 12.3 million in 2003 with some variations in the figures in the early 1990s despite the countrys sustained growth in the economy over these years. The reported cases of malaria are even higher among children under the age of five as evidenced by an estimate 30 per cent of reported malaria cases among under-five children between 1990 and 2003. This study therefore concludes that malaria could be a major disease that explains the persistent trend in child mortality in Uganda over the years.

GOVERNMENT EXPENDITURE ON HEALTH AND EDUCATION - the study found that government expenditure on education and health in Uganda has been relatively low over the years despite the countrys significant growth in the economy and annual population growth. Except for 2003/2004 when much of the government expenditure (52 per cent) went towards debt servicing significantly affecting other sector including education and health; Ugandas expenditure on education and health over the years has averaged about 23 and 8 per cent respectively despite the sustained economic and population growth in the country. The study concludes that the limited government resource allocation to education and health over the years explains Ugandas trend in child mortality.

AVAILABILITY AND COVERAGE OF HEALTH CARE FACILITIES the study used hospitals and health centres and health personnels as proxy indicators for availability and coverage of health care facilities. It found that the coverage of hopitals and health centres does not explain Ugandas persistent trend in child mortality. However, using health personnel as proxy indicator, the ratio of health personels to the number of people as a proxy indicator for health care facilities the study shows that the ratio of physicians, dentists, and pharmacists is <1 to 10,000 population respectively; 7 to 10,000 population for nurses and midwives (including traditional birth attendants) and 2 to 10,000 population for other health service providers. Basing on the above ratio, the study concludes that limited accessiblity and number of health personnels partly explains the persistent trend in child moratlity in Uganda over the years.

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POVERTY/INCOME LEVELS - the persistent high levels of poverty since the late 1980s considering both poverty head count and poverty gap could partly explains the persistent trend in child mortality in the the face of a growing economy in Uganda. The poverty head count remains at more than 80 per cent from 1989 to 2003, and the poverty gap decrease by only 9.4 per cent within this same time period.

However, the coverage of immunisation of children against measles including other immunisable childhood diseases, nutritional status of children under-five and access of prenatal care seem to be less significant in explaining the observed persistent trend in child mortality in Uganda. This is contrary to the theory explained in chapter two in the literature review.

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