A Report on the

PUBLIC DISCUSSION ON

PERSISTENTLY HIGH INFANT AND CHILD MORTALITY RATES IN UGANDA- A FUNCTION OF POVERTY?

Held at the Grand Emperial Hotel, Sasa Hall June 20th 2002 Sponsored by POLICY Project

Persistently High Infant and Childhood Mortality in Uganda: A Function of poverty?

A public discussion on Persistently High Infant and Child Mortality Rates- Function of Poverty? was held at Sasa Hall at the Grand Imperial Hotel on the 20th of June. Infant and child mortality rates in Uganda have persistently increased despite the various interventions aimed at curbing the mortality rates. Although there seemed to be a decline between 1991 and 1995, the infant and child mortality rates rose again between 1995 and 2000. The Population Secretariat therefore organized a public discussion to stimulate dialogue on infant and child mortality issues in order to attract the attention of the decision makers and other stakeholders to the problem, as well as attract funding to departments that are partners in solving the problem. The purpose of the debate was to identify possible causes for the persistently high infant and childhood mortality rates in Uganda, and to suggest policy and program interventions. Participants were drawn from Policy makers, Programmers in the field of Population and Reproductive Health, Legislators, Medical Practitioners, Development Partners and the general public.

Remarks from the Director, Population Secretariat

Dr. Jotham Musinguzi, Director Population Secretariat welcomed participants and thanked them for responding in large numbers to participate in the debate. The Director further commended the partnership between the Ministry of Health and Population Programs. Finally, he emphasized that persistently high infant and child mortality rates are of such great concern, that even the President of Uganda HE Y.K. Museveni had expressed his concern about the same issue.

Remarks from the Director General of Health Services

Professor Francis Omaswa, the Director General of Health Services gave a brief background on the child mortality situation in Africa. He said that the situation is worsening in Sub-Saharan Africa, whereas it is getting better for other countries outside the region. He further emphasized that even other developing countries are way ahead of Uganda; some countries have single digit figures whereas Uganda double digits. 2

Presentation by Andrew Mukulu

Andrew Mukulu of Uganda Bureau of Statistics (UBOS) made a presentation based on data from Population censuses (1948-1991), Uganda Demographic and Health Surveys (1988/89 2000/01), Uganda National Household Surveys (1992/93-1999/2000) and Health Management Information System. In summary his power point presentation elaborated the following;

Childhood mortality indicators

Neonatal mortality (the probability of dying within the first month of life). Post-neonatal mortality (the arithmetic difference between neonatal mortality and infant mortality). Infant mortality (the probability of dying between births and the first birthday). Child mortality (the probability of dying between the exact age if 1 year and the fifth birthday).

Early childhood mortality rates

Type of mortality Neonatal mortality Post-neonatal mortality Infant mortality Child mortality Under-five mortality
Source UDHS 2000

Deaths per 1000 live births 33 55 88 69 152

Regional variation in mortality

The central and eastern regions have the lowest mortality rates, whereas the western and northern regions have relatively higher mortality rates. Region Infant mortality Under-five mortality Central 72 135 Eastern 89 147 Western 98 176 Northern 106 178 Uganda 88 152
Source UDHS 2000

Trends in infant mortality rates (IMR)

According to various census data, trends in infant mortality decreased gradually from 200 deaths per 1000 live births in 1948 (which is the year Uganda held its first census) until 1980 when it fell to 122 deaths per 100 live births. The 1995 UDHS shows that there was another fall in the IMR in 1995 (81 deaths/1000 live births). In 2000 however the IMR rose again to 88 deaths/1000 live births. Year 1948 1959 1969 1980 1991 1995 2000 (Census) (Census) (Census) (Census) (Census) UDHS UDHS deaths per 1000 live births (IMR) 200 160 120 115 122 81 88

Trends in childhood mortality rates by region

Basing on the 1995 UDHS, the UDHS 2000 shows that all regions had a decrease in child mortality rates apart from western region. It is believed that the increase in child mortality rate at the national level was as a result of an increase in child mortality rates in the western region. The northern region had the highest infant and child mortality in both 1995 and 2000 UDHS. Deaths per 100o live births Region 1995 2000 Northern 190 178 Western 131 176 Eastern 176 147 Central 141 135
Source UDHS 2000, UDHS 1995

Clinical causes of child mortality Malaria HIV/AIDS Acute Respiratory Infections Tuberculosis Diarrhoea Measles

Infant And Mortality Rates Have Remained Persistently High! Could This Be Due To Poverty?
Poverty was given a number of definitions, some of which were; a. Lack of income and material goods b. Absence of social support c. Powerlessness d. Insecurity e. Deprivation of basic human rights

Income poverty
The Ministry of Finance, Planning and Economic Development defines poverty as the situation where household expenditure is less than the poverty line, that is living on less than one dollar a day. It is this definition of poverty that was used to correlate mortality levels.

Trends in National Poverty Levels

Year 1991/92 1993/94 1994/95 1995/96 1997/98 1999/2000 Poverty Levels 56 51 50 49 44 35

Regional variation in poverty

The regional variation in poverty shows a decline in all regions except the eastern region, which had its poverty level rise slightly from 53% to 54%. Region Central Western Eastern Northern Percent below poverty line (1992/93) 46 59 53 72 Percent below poverty line (1997) 26 43 54 60

Kitgum and Gulu districts had been excluded in the study in Northern Uganda due to insecurity in the areas.

Poverty Levels in Uganda (1991-2000)

60 50 40 30 20 10 0 1991/92 1993/94 1994/95 1995/96 199798 1999/2000 56

51

50

49

44 35

Between 1991 and 1995, UDHS results showed IMR had risen from 81deaths/1000 live births to 88 deaths/1000 live births; in the same period poverty levels had declined from 56% in the 1991-1995 period to 44%.

Trends in Infant Mortality rates (1991-2000)

90 88 86 84 82 80 78 76 1991-95 1996-2000 81 1991-95 1996-2000 88

Poverty and Persistently High Mortality Between 19912000, were they linked?
There is a negative relationship between poverty indices and child mortality i.e. while poverty was falling, child mortality was rising. Indicator IMR Poverty 1991-1995 81 56 1996-2000 88 44

100 90 80 70 60 50 40 30 20 10 0

81 56

88

44

poverty level IMR

1991-1995

1996-2000

Previous birth interval length

Birth interval < 2 years 2 years 3 years 4+ years IMR 126 67 35 66 Under-5 mortality 203 135 116 111

Infant mortality by medical maternity care

Type of service ANC and delivery ANC or delivery Neither IMR 64 83 119

Women empowerment status

Women empowerment status No decision making powers Some decision-making powers IMR 131 87 Under-5 mortality 196 155

Mr. Mukulu, in his presentation also showed how IMR and child mortality was positively related to lower mothers education level Very low and high maternal ages at birth First birth order and high birth order Other factors affecting IMR and child mortality rates are; Sanitation Access to safe water Immunization of both mother and child Recommendations Revive the Community Health Care Programs Revamp the immunization campaign Address poverty at house hold level Increasing pregnancy and childcare Reviving preventive health practices.

Remarks from the discussant

Director of Population Secretariat gave an elaboration of the two approaches of computing infant mortality rates. He said the infant mortality rates of 1995 (81) and 2000 (88) were derived by the direct method, which involves use of actual mortality figures such as those collected from the UDHS. The indirect method of deriving IMR involves using data on children ever born and children surviving. The indirect figures of IMR for the years 1995 and 2000 are 97 and 101 respectively. These indirect figures make comparison with the census data much clearer since the census estimates are obtained from the indirect method. Mr. Lars Christian Moeller from the Ministry of Finance, Planning and Economic Development, Poverty Monitoring and Analysis Unit gave the following remarks:

Infant Mortality Rate is very high in the western region because of: Poor protection against malaria Small percentage of deliveries in hospitals High level of malnutrition among children Low tetanus toxoid immunizations The discussant also mentioned that about 34% of all under- five deaths occur because of malnutrition. Malnutrition affects childrens immune systems in that the childrens bodies are already weak and unable to fight illnesses, which attack them. He also said that although teenage pregnancy has fallen between 1995 and 2000, from 43% to 31%, it is still high. Commenting on whether the persistently high infant and child mortality levels were due to poverty, the discussant said that it depends the definition of poverty. Income poverty can be estimated by measuring household property. Other definitions of defined poverty include absence of social support, creating a condition of isolation. IMR is not only a function of poverty, but other issues as well, such as: Maternal and household characteristics Mothers age at birth Mothers marital status, such as separated, widowed, divorced. Children born in marriages where both parents are together have higher survival chances. High fertility rates Low birth intervals Use of modern contraceptives Sanitation Access to safe water Immunization of the mother and children Unsupervised births Mothers education achievement Rural/urban dwelling of the mother Migration - mothers who migrate experience high IMR. Insecurity could be one reason why. Women with no decision-making powers experience high IMR. Domestic violence Poverty is therefore multidimensional. Some of the above mentioned factors have no relation with income, for instance, gender relations, migration, low birth intervals, teenage pregnancies and unsustainable marriages. These can be both experienced by the rich and the poor. During the period 1995 to 2000, poverty levels went down, where as IMR

went up. Poverty decreased in the western region, but IMR increased too. So are poverty and mortality linked?

Recommendations
Increase birth intervals Reduce teenage pregnancies Increase Contraceptive Prevalence Rate Treat diarrhea immediately (it directly causes death through dehydration). Reduce mother to child transmission of HIV/AIDS Immunize children Provide safe drinking water Reduce MMR Improve status of womens education Improve gender balances

Conclusion
Most of these recommendations are health related. The major constraint faced in implementing the above recommendations is poverty. The government has no capacity to implement the recommendations. There is need for increased staff, increased health facilities, and supplies, all of which require increased funding. The answer therefore to the question whether child mortality is linked to poverty is YES. The Ministry of Health has for instance failed to subsidize mosquito nets for malaria control; there is also poor transport communication to facilitate an effective referral system.

Remarks by Dr. Kadama

Dr. Patrick Kadama is a Health Economist in the Ministry of Health had the following remarks: He gave a reflection on economic trends in Uganda, which in turn have a bearing on child mortality rates. Trends in economic reforms Brisk economic reforms in the 1990s Global economic growth slow-down at the dawn of the new millennium Global decline in improvement on social indicators. In the late 1990s, there was under investment in social services Retrenchment encroached on the vaccinators and only those who were aware of the benefits of vaccination services looked for them.

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Neonatal mortality Dr. Kadama defined neonatal mortality as death in the first 28 days of birth, and the major contributor to childhood mortality. Nearly half of the children, who die in the first year, die in the first month. He observed that the increase in neonatal mortality is what caused the overall increase in infant mortality between 1995 and 2000. Aetiology in Neonatal Mortality (causational) Aetiology Condition Likely Causes Plans and prospects SEPSIS (up to 30%) to improve Poor obstetric HSSP access trained care services, supplies and Immune facilities suppression Birth Trauma Poor obstetric care HSSP to improve access trained services, supplies and facilities Pre-maturity and low Poor nutrition HSSP and UPE birth weight Anaemia HSSP to improve Secondary access bleeding Services, Poor obstetric Trained supplies and facilities care

Other causes of neonatal death include: Late feeding of premature babies Birth abnormalities Dr. Kadama emphasized that although there is an effort to increase access to trained services, supplies, and facilities, there must be enough investment in obstetrics in order to ensure that pregnancy is safe. He commended Universal Primary Education (UPE) as an important factor in reducing the number of infants and children that die as a result of no education among mothers. He added that tetanus has ceased to be the leading cause of neonatal mortality, although it used to be a major contributor.

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Critical actions for a turn around

-Development of a Health Financing Strategy to Finance HSSP -Provision of adequate resources to correct for under-investment in health sector for support of expanding access for obstetric care -Sustained UPE initiative -Plans for expanded secondary education and health care referral services

Public Discussions

The following were some of the ideas from the public following the presentations. Reduce the burden on women by encouraging men to be partners in taking their children for immunization. Women are over burdened with work that taking a child for immunization could be over looked. Shared parenthood should be promoted. Men should be brought on board since they are the decision-makers in homes. Address issues of powerlessness, migration and insecurity that discourage child welfare programs to be implemented in a particular region. There is an ignored relationship between insecurity and high child mortality. Insecurity takes away lots of resources, which could have otherwise been utilized for health services, and again the population is always on the move. The adolescent pregnancy rates are high yet the Adolescent Reproductive Health Policy has been in a draft form for a very long time. An appeal was made to the Parliamentarians to approve the draft policy for debate. High adolescent pregnancies increase infant mortality rate. National leaders who publicly speak out against immunization and encourage women to produce many children should be sensitized further on negative implications of their comments. If they still persist, then strict measures should be taken against them, because they are indirectly campaigning against good health. Campaigns to lower the age of consent for sex, should be discouraged, because the lower the age of consent the higher the teenage pregnancies, and consequently, the higher the infant mortality rates.

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An investigation should be made to establish what lead to the collapse of the training of the Traditional Birth Attendants (TBAs). Trained TBAs are very essential in preventing maternal and infant mortality especially in the rural areas where poor access to health care is highly felt. Communities must be empowered to own health facilities and services. Poor households are characterized by malnutrition, poor sanitary conditions, yet these were not quoted. No single factor/program/intervention alone can reduce infant mortality; there is need for networking. A multi-sectoral approach is needed, the government and other structures such as NGOs and the private sector all need to come on board. The ministry of Gender, Labor and Social Development has community workers, who could be utilized to extend heath messages and services. The persistently high maternal mortality rates also contribute to neonatal mortality and IMR in general. Infant mortality rates are rising yet a lot of money has been spent on Integrated Management of Childhood Illnesses (IMCI), there is a need to investigate where the program is going wrong. Increased access to PMTCT services by taking the drugs nearer to the people. The effect of decentralization of the local government on the health sector should be checked. There is resistance to family planning and lack of support from the political leadership yet presentations clearly indicated that high birth orders, poor spacing, high frequency of births, are linked to high infant mortality. There is poor implementation of policies at the local levels. Programs should not focus on just one ailment such as malaria, instead they should offer a complete package catering for various ailments.

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The district health services should have supervision from the central areas frequently. Take the health care services to the rural areas as well. The Poverty Eradication Action Plan (PEAP) is not child focused; there was no focus on the needs of people below 18 years. Participants were however informed that PEAP is under review, issues of lack of child sensitivity can be considered. There is high mistreatment of women at health centers, which could be resulting from poor pay of health workers. The welfare of health workers should be looked into. LC women affairs can for instance be trained to pass on information such as how to detect a fever, manage malaria and the like. There is high IMR in low income, middle income and high-income households.

Concluding Remarks
Prof. Francis Omaswa re-iterated his popular message that health is made at home, but only repaired in health facilities. He advised that all sectors and the communities have a role to play a role, through the multi-sectoral approach to ensure disease free lives. He re-echoed the need for committed political leaders, health workers and proper management of society and enforcement of laws. He added that national poverty is a major constraint to reduction of infant mortality rates. Prioritization of funding is also an issue to be addressed. Dr. Omaswa requested POPSEC to publish the report and circulate it widely. Dr. Jotham Musinguzi, the Director, Population Secretariat, in his concluding remarks thanked all participants for the good contributions and presenters for the excellent papers delivered. He noted that the public debate was the first in a series; there was an intention to continue consultations with partners and stakeholders. He cautioned participants not to think that only the health sector will solve the child mortality problems. He mentioned that there is need for lobbying for more resources and the need for all the people of Uganda to

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be supportive, emphasizing that the people of Uganda deserve a better life. Dr. Musinguzi finally promised not only to publish the report, but also to bring it out in the news media.

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Program for public discussion Thursday 20 June 2002, Grand Imperial Hotel, Sasa Hall
th

1:30-2:00pm 2:00-2:30pm 2:30-2:45pm 2:45-3:00pm 3:00-4:00pm 4:00-4:30pm 4:30-5:00pm Topic

Registration of participants Presentation by Andrew Mukulu Remarks by discussant Remarks by Dr. P. Kadama, Ministry of Health Discussions Recommendations and way forward Refreshments and departure Persistently Poverty? High Infant and Child Mortality Rates in Uganda: A Function of

Chairperson

Prof. Francis Omaswa Director General of Health Services, Ministry of Health

Discussant

Mr. Lars Christian Moeller Poverty Monitoring and Analysis Unit, Ministry of Finance

Master of Ceremonies

Dr. Jotham Musinguzi Director Population Secretariat

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