Statistical Review of Progress to Inform the Mid-Term Review of the Uganda Health Sector Development Plan 2015/2016 2019/2020 - Ministry of Health

 
Statistical Review of Progress to Inform the Mid-Term Review of the Uganda Health Sector Development Plan 2015/2016 2019/2020 - Ministry of Health
Statistical Review of Progress to Inform the
Mid-Term Review of the Uganda Health Sector
 Development Plan 2015/2016 - 2019/2020

                          October 2018

                       Ministry of Health, Uganda

                          In collaboration with

            World Health Organization, Geneva and Brazzaville
           School of Public Health, Makerere University, Uganda
    Countdown to 2030 for Women’s, Children’s and Adolescents’ Health
                     University of Manitoba, Canada

                                    i
Statistical Review of Progress to Inform the Mid-Term Review of the Uganda Health Sector Development Plan 2015/2016 2019/2020 - Ministry of Health
Statistical Review of Progress to Inform the Mid-Term Review of the Uganda Health Sector Development Plan 2015/2016 2019/2020 - Ministry of Health
TABLE OF CONTENTS

Table of Contents.................................................................................................................................. ii
Figures ...................................................................................................................................................iii
Tables ....................................................................................................................................................iv
Foreword............................................................................................................................................... v
Executive Summary ..............................................................................................................................vi
1.0 Background ................................................................................................................................ 1
2.0 Data And Methods .................................................................................................................... 2
3.0 National Progress ...................................................................................................................... 4
3.1. Progress against HSDP targets .................................................................................................. 4
3.2. Comparative analysis of Uganda’s results................................................................................. 6
3.3. Discussion on findings by program area ................................................................................... 8
3.4. Health information system implications ................................................................................. 10
4.0 Overall mortality and morbidity levels and trends ................................................................. 11
4.1. Maternal and child mortality................................................................................................... 11
4.2. HIV, TB and malaria ................................................................................................................. 12
4.3. Under-5 mortality trends by subregion .................................................................................. 13
5.0 Progress towards the specific HSSP III health and disease targets......................................... 14
5.1. Fertility and family planning – good progress in rural women ............................................... 14
5.1.1. Fertility ..................................................................................................................................... 14
5.1.2. Contraceptive use .................................................................................................................... 15
5.1.3. Adolescent fertility .................................................................................................................. 15
5.2. Maternal and newborn care.................................................................................................... 15
5.3. Child immunization .................................................................................................................. 16
5.4. Child health and nutrition ....................................................................................................... 17
5.5. Malaria ..................................................................................................................................... 18
5.6. HIV/AIDS ...................................................................................................................................19
5.7. Tuberculosis ............................................................................................................................. 20
5.8. Sanitation Coverage ................................................................................................................ 21
6.0    Health system .......................................................................................................................... 22
6.1. Policies and strategies .............................................................................................................22
6.2. Financing ................................................................................................................................. 23
6.3. Health workforce .................................................................................................................... 24
6.4. Health infrastructure and service utilization ......................................................................... 24
6.5. Health service delivery ........................................................................................................... 26
6.6. Health information system ..................................................................................................... 27
6.7. District League Tables ............................................................................................................. 29
6.8. New challenges for the health system: NCD .......................................................................... 30
7.0     Hospital and Health Centre IV assessment ................................................................................                         31
8.0     Equity analysis ............................................................................................................................      34
8.1. General progress in reducing inequalities by wealth and place of residence ....................... 34
8.2. Subnational performance assessment by region ................................................................... 37
9.0    Appendix 1: Assessment of health facility data quality of the districts and subregions ........ 40

                                                                              ii
FIGURES

Figure 3-1: Percent of target population who received key RMNCH interventions, Uganda and 9 peer
countries. (Bar indicates the average score for the 10 interventions) ................................................................ 6
Figure 3-2: Percent distribution of health expenditure by source, Uganda and subregion ................................ 7
Figure 3-3: Main results, factors contributing to change and main implications for HSDP................................. 8
Figure 4.1-1: Adult mortality per 1,000 persons between ages 15 and 50 years................................................ 12
Figure 4.2-1: Malaria inpatient admissions per 1000 and deaths per 100,000 (left panel) and malaria.............12
Figure 4.3-1: Under-5 mortality per 1,000 live births, trends 2000-2015, UDHS, by subregion ......................... 13
Figure 5.1.1-1: Contraceptive use (modern methods) and family planning coverage rates............................... 14
Figure 5.2-1: Antenatal care (ANC 4 or more visits) and deliveries in health facilities:....................................... 16
Figure 5.3-1: DTP3 and Measles immunization coverage trends from UDHS and DHIS data ............................. 17
Figure 5.4-1: Stunting and underweight in children under 5 years (%), UDHS 2011 and UDHS 2016 ................ 18
Figure 5.5-1: Febrile children tested for malaria 2016......................................................................................... 19
Figure 5.5-2: Treatment received by febrile children........................................................................................... 19
Figure 5.6-1: Estimated Number of New HIV Infections .......................................................................................20
Figure 5.8-1: Households by type of sanitary facilities, UDHS 2011 and 2016 .....................................................21
Figure 6.4-1:          Figure 6.4-2: .......................................................................................................................25
Figure 6.6-1: Data quality score, by district, 2013-2017 data from HMIS / DHIS .................................................27
Figure 6.8-1: % of women and men 15-49 years overweight or obese, UDHS 2011 and UDHS 2016 .................30
Figure 8.1-1: Under-5 mortality per 1000 live births by wealth quintiles............................................................ 35
Figure 8.1-2: Under-5 mortality per 1,000 live births, by place of residence....................................................... 35
Figure 8.1-3: Stunting in children under 5 years by wealth quintiles................................................................... 36
Figure 8.1-4: Composite coverage index (CCI) for RMNCH interventions by wealth quintiles............................ 36
Figure 8.2-1: Under-5 mortality per 1,000 live births for the top and bottom three regions............................. 37
Figure 8.2-2: Stunting and CCI for the top and bottom three regions (average), UDHS 2011 and UDHS 2016.. 37
Figure 9-1: Number............................................................................................................................................... 41
Figure 9-2: Distribution of districts by relative difference between reported ANC1/DPT1.................................. 44
Figure 9-3: District reported numbers of DPT1 by ANC1, excluding Kampala and Wakiso .................................. 44
Figure 9-4: Distribution of districts by DPT1/ANC1 ratio with expected value of 90 ........................................... 45
Figure 9-5: Distribution of districts by DPT3/DPT1 ratio with expected value in the range of 75-90% ............... 45
Figure 9-6: Consistency of time series DPT1 and ANC1: number of districts in each category ........................... 46

                                                                               iii
TABLES

Table 2-1: Summary of Uganda health and health related surveys since 2010 .................................. 3
Table 3-1: HSDP 2015/16 – 2019/20 Indicators, with progress........................................................... 4
Table 3-2: Main strengths and priorities for action for the data sources and processes....................10
Table 6.6-1: Overall health facility data quality score by district, Uganda 2013-2017........................ 28
Table 7-1: Quality of data over time for fourteen regional and four large PNFP in Uganda .............. 32
Table 7-2: Hospitals/HC IV with data quality issues based on the presence of outliers...................... 32
Table 8.1-1: Inequality gaps in select indicators by residence, wealth and region.............................. 34
Table 8.1-2: Ranking of the regions according to rates of under 5 mortality, Stunting and CCI......... 38
Table 8.1-3: The percentage coverage of 8 interventions along 4 stages........................................... 39

                                                           iv
FOREWORD

The Ministry of Health in collaboration with all key stakeholders and health development
partners have conducted a Mid Term Review (MTR) of the progress in implementation of the
Health Sector Development Plan (HSDP). The HSDP was developed and approved as the
Health Sector planning framework within the National Health Policy and National
Development Plan II for the period 2015/16 – 2019/2020. The HSDP provides the overall
strategic and implementation framework for the Health sector and is aimed at contributing
towards Universal Health Coverage and overall Development goal of the Country in regard
to accelerating Economic growth and transformation as the country moves towards middle
income status.
The overall goal of the HSDP is To accelerate movement towards Universal Health Coverage
(UHC) with essential health and related services needed for promotion of a healthy and
productive life”. This was designed to be achieved by focusing on achieving Universal Health
Coverage through addressing four major strategic objectives: 1) To provide inclusive and
quality health care services through policy formulation and providing strategic direction,
planning and coordination of health care provision in Uganda. 2) To address the key
determinants of health through strengthening of inter-sectoral collaborations and
partnerships. 3)To enhance the health sector competitiveness in the region and globally; and
4) To increase financial risk protection of households against impoverishment due to health
expenditures.
Under each of the strategic objectives were key broad interventions and programs to be
implemented and targets to be met during the five year periods. The interventions were set
out in the HSDP compact with partners and in the annual aide memoires. As the sector is in
the 3rd year of implementation of the HSDP, it was necessary to review progress under each
program area. The extent to which the HSDP has been implemented and targets achieved is
reflected in the analytical report of the HSDP MTR report volume 1. The report identifies key
achievements, bottlenecks and proposes areas for modifications in the remaining life span of
the HSDP.
 I am delighted that the report was prepared through a consultative process and has
successfully been tabled to the health assembly. I would like to extend my vote of thanks to
the stakeholders and more so to The World Health Organisation, the external and local
consultants and the team from Ministry of Health for the good report. In a special way, I
thank Dr. Ties Boerma and team, Dr. Solome Bakera and the technical team from Policy and
planning Department, Ministry of Health for their invaluable efforts. May I appeal to all
stakeholders to use the recommendations herein to guide future planning in the health
sector.
In conclusion, I thank Government of Uganda for providing an enabling environment for the
sector to deliver quality and efficient health care.

For God and My Country.

Hon. Dr. Jane Ruth Aceng

                                            v
EXECUTIVE SUMMARY

1. HSDP 2015/2016-2019/2020 is an ambitious plan that aims for reaching all in Uganda
   with quality services, with a focus on control of infectious diseases and reproductive,
   maternal, newborn and child health. The IHP+ Joint Assessment of National Strategies
   (JANS) flagged the gap between ambition and financing as an area of concern. The
   HSDP midterm review is therefore an important moment to take stock of progress and
   performance and identify challenges.
2. This report contributes to the midterm review through an analytical review of
   statistical progress and performance of Uganda’s health sector during the first half of
   HSDP in comparison to the goals and targets of HSDP. It provides a synthesis of
   relevant data, including surveys, health facility and disease surveillance data, facility
   assessments, administrative resources data, policy data and research studies. It builds
   upon and complements the extensive monitoring system through annual health
   sector performance profiles.

3. Among the 41 HSDP indicators, 13 indicators were on track, 16 made progress but too
   slow to meet the target, and 10 were not on track. For two indicators no data could be
   obtained. Major areas of success included child mortality declines, child nutritional
   status improvements and HIV. Major areas of concern included neonatal mortality,
   maternal mortality and adolescent fertility.

4. The comparison with nine countries in eastern Africa showed that in general, Uganda
   occupies a middle position among the countries in the subregion, sometimes in the
   top half, sometimes in the middle but rarely in the bottom half. In terms of
   government contribution to health, however, Uganda ranks low (9/10).
5. There were sizeable inequalities in key health indicators by region, residence and
   socioeconomic status. However, inequalities in Uganda have generally reduced over
   time, reducing the gaps between regions, between urban and rural populations and
   between the poorest and wealthiest. Despite progress, important inequalities persist,
   and need to be addressed to achieve the Sustainable Development Goal of “Leaving
   no one behind”.
6. Uganda’s efforts to monitor performance is commendable, including extensive annual
   reviews with district league tables, efficiency assessments of all hospitals and Health
   Centre IV, 11 national health surveys in the last 5 years and efforts are made to
   improve the HMIS and CRVS systems.

7. Yet, there are major gaps in especially the quality of data. The review found evidence
   of some improvements in over reporting by districts, especially for immunizations, but
   much more is needed. There are also major differences in data quality between
   districts and subregions, which provide an opportunity for learning good practice
   from the better performing districts. Considerably greater investments in the HMIS /
   DHIS are necessary to develop and maintain a high-quality system that is useful at
   district                   and                      national                    levels.

                                             vi
1. BACKGROUND

This report provides a midterm analysis of the progress and performance of the Health Sector &
Development Plan 2015/2016-2019/2020 (HSDP). HSDP is the key Ministry of Health document
that provides the guiding framework for the detailed planning and implementation of health
sector activities. All available data up January 1, 2018 are considered to capture the levels, trends
and inequalities during the first half of HSDP.

The HSDP is monitored with 41 indicators with targets for 2019/2020, as well as intermediate
targets. Annual health sector reviews are conducted, informed by a health sector performance
report to assess annual progress towards the targets for the indicators of HSDP. In 2013, the
Ministry conducted an extensive midterm review, covering the previous HSDP.

The overall health sector review links to many other plans and reviews. These include plans that
have a broader development focus (e.g. Strategy to improve health service delivery 2016-2021 as
part of the NRM manifesto 2016-2021 aiming to become a middle-income country by 2021),
specific elements of health services (e.g. health financing strategy 2015/16-2024/25 and quality
improvement framework and strategic plan 2015/16-2019/20), and program-specific monitoring
and reviews (e.g. malaria midterm review of the Malaria reduction strategic plan 2014-2020,
conducted in 2017 and HIV Joint annual review 2016-17, published in the second half of 2017).

The Joint Assessment of National Strategies in 2015 concluded the following: “The HSDP is a very
ambitious plan. It will be implemented at a time when government policy aims at stimulating
economic growth through investments in communication, transportation and infrastructure,
even if this means less resources for the social sectors. The tight fiscal space is not expected to
expand in the plan period, and therefore government health expenditure is likely to remain at the
very low level of around 9 USD per capita. On this backdrop the substantial funding gap of the
HSDP will, in the view of the JANS team, severely undermine the feasibility of the plan.” The
midterm review is an important moment to assess whether health progress in Uganda is stalling
because of lack of finances or other issues.

The primary objective of this report is to review statistical progress and performance of Uganda’s
health sector during 2014 /15 to the end of 2017 in comparison to the goals and targets of HSDP.
It provides a synthesis of relevant data, including health and other household surveys, census,
health facility and disease surveillance data, facility assessments, administrative resources data,
policy data and research studies.

The analytical review was carried out as a desk review of technical reports including population
surveys, programme evaluation reports, policy documents and research studies, as well as
primary data analysis of existing survey and HMIS data. A core analytical team consisting of the
Ministry of Health, School of Public Health/Makerere University, University of Manitoba /
Countdown to 2030, and the World Health Organization conducted the analyses and prepared
the report. Two workshops were held (in February and in June) with the Ministry of Health
programs. At the first workshop programs presented their findings and shared data where
feasible. At the second workshop the core team presented their findings and discussions focused
on the interpretation and implications of these results for HSDP and the health information
system.

                                                 1
2. DATA AND METHODS

The analytical report is based on analysis and synthesis of existing data, including preliminary
data from recent data collection efforts. All existing reports and analyses were brought together.
While the focus is on the period 2014/15 - 2017 attention was also paid to the trends prior to
2014 to help interpret more recent data.

The main sources of data were:
Population health surveys
• Uganda Demographic and Health Surveys 1991, 1996, 2001, 2006, 2011, 2016
• Uganda HIV and Malaria Indicator Surveys 2009, 2014/15
• AIDS indicator surveys: 2011, 2016
• TB prevalence survey 2014/15
• PMA 2020 surveys (family planning, WASH): 2014, 2015 (2), 2016, 2017
• NCD risk factors (STEPS): 2014
• National Service Delivery Surveys: 2008, 2015
Health facility data and reports
• Core HMIS data base: 2012/13 – 2014/15; DHIS2 direct extraction 2015/16-December 1 2018
• Programme databases and annual reports of disease programs
Facility assessments
• SARA 2012 and 2013; National Hospital Census 2014
Administrative data
• Financing: National Health Accounts 2012/13, 2015/16
• Human resources: national reports
• Infrastructure: national database of health facilities (public) (DHIS2)

The two most important data sources are the Demographic and Health Surveys (UDHS) 2011 and
2016 and the health facility data. For several indicators, the UDHS provides current data and
therefore up-to-date information on the results achieved during HSDP (e.g. contraceptive use,
current breastfeeding or child illness treatment practices). For most other indicators, the UDHS
provides retrospective information (e.g. 3 or 5 years prior to the survey).

The health facility reports, often referred to as Health Management Information System (HMIS),
also provide critical information on a range of indicators and can be disaggregated to district and
regional level on an annual basis. Prior to HSDP the HMIS changed from a mixed paper and
electronic reporting system to a web-based system DHIS2. The recording and reporting by health
facilities is still paper based but districts are using the national DHIS2 and results are more
standardized and easily accessible. The DHIS2 had full mainland coverage from 2012/13 and data
for 2012/13 - 2017/18 were used for this analysis. The full year 2017/18 was obtained by
multiplying the data for July-Dec 2017 by two. Annex A describes how this report used the health
facility data, including a data quality assessment.

During HSDP implementation period new districts were established. This report focuses on survey
statistics by 15 subregions that were used in the UDHS 2016. We recomputed all statistics from
the UDHS 2011 for the 15 regions. For the facility data we focused on the 122 districts that were
in place by the beginning of HSDP. The logical results framework with all 41 indicators was used
to assess the achievements against the targets. In addition, the review focused on the extent to
which inequalities were reduced – by socioeconomic and geographic dimensions – as well as
compared the progress in Uganda to those of eight peer countries in the region.

                                                2
Survey name          Year Primary topic       SE   Main            Funding           Wealth/   Education Sex /    Urban/   Sub-        Sample   National Sample Sampling   Data public Report on
                                                       implementor     source            income              gender   rural    national    design   sample size (hh) errors    domain      web
    PMA2020 R6          2018 Family planning           Makerere        BMGF                                                    4 zones                          4,558
                                                       University
                                                                                           ●          ●        ●        ●                     ●       ●                                        ●
    PMA2020 R5          2017 Family planning           Makerere        BMGF                                                    4 zones                         4,503
                                                       University
                                                                                           ●          ●        ●        ●                     ●       ●                                        ●
    National            2016- Access/use,              Bureau of       Government                                              11 sub-                         6,888
    Household Survey     2017 expenditure, W&S
                                                  ●    Statistics
                                                                                                               ●               regions
                                                                                                                                              ●       ●                                        ●

    DHS                 2016 Health, esp.              Bureau of       Government,                                             15                             18,298
                             RMNCH                     Statistics      USAID, UN
                                                                                           ●          ●        ●        ●      regions
                                                                                                                                              ●       ●                 ●          ●           ●
    Population-based    2016 HIV                       Min of Health   PEPFAR                                                  10                             12,882                       Preliminary
    HIV impact
                                                                                                               ●        ●      regions                                                         only
    assessment
    PMA2020 R4          2016 Family planning           Makerere        BMGF                                                    4 zones                         4,840
                                                       University
                                                                                           ●          ●        ●        ●                     ●       ●                                        ●
    PMA2020 R3          2015 WASH, family              Makerere        BMGF                                                    4 zones
                             planning                  University
                                                                                           ●          ●        ●        ●                     ●       ●                                        ●
    PMA2020 R2          2015 Family planning           Makerere        BMGF                                                    4 zones                         4,257
                                                       University
                                                                                           ●          ●        ●        ●                     ●       ●                                        ●
    GAVI FCE            2015 Immunization              Makerere        GAVI                                                    19                              3,990
    Household survey                                   University                                                              districts
                                                                                                                                                                                   ●
    National Service     2015 Use, expenditure,        Bureau of       DFID,                                                   15 sub-                        10,101
    Delivery Survey           immunization,
                                                  ●    Statistics      government
                                                                                                               ●               regions
                                                                                                                                              ●       ●                                        ●
                              satisfaction,
                              WASH
    TB prevalence       2014- Tuberculosis             Min of Health   Global Fund                                                                           41,156

3
                         2015
                                                                                                               ●        ●                     ●       ●       (p)
                                                                                                                                                                        ●                      ●
    Malaria indicator   2014- Malaria                                                                                          10                             5,345
    survey               2015
                                                                                           ●          ●        ●        ●      regions
                                                                                                                                              ●       ●                 ●          ●           ●
    NCD Risk factors     2014 NCD                      Min of Health   Gov, UN                                                                                3,987
                                                                                                               ●        ●                     ●       ●        (p)
                                                                                                                                                                        ●                      ●
    PMA2020 R1          2014 Family planning           Makerere        BMGF                                                    4 zones                          4,802
                                                       University
                                                                                           ●          ●        ●        ●                     ●       ●                                        ●
    National Panel      2013- LSMS type;               Bureau of                                                                                               3,123
    Survey               2014 nutrition,
                                                  ●    Statistics
                                                                                                               ●                                      ●
                              coverage,
                              mortality
    Global Adult         2013 Tobacco use              Bureau of       CDC                                                                                     8,982
                                                                                                      ●        ●        ●                             ●                 ●                      ●
                                                                                                                                                                                                         TABLE 2-1: SUMMARY OF UGANDA HEALTH AND HEALTH RELATED SURVEYS SINCE 2010

    Tobacco survey                                     Statistics      Foundation, RTI

    National            2012- Use, expenditure,        Bureau of       Government                                              10 sub-                         6,887
    Household Survey     2013 W&S
                                                  ●    Statistics
                                                                                                               ●               regions
                                                                                                                                              ●       ●                                        ●
    National             2012 Immunization             Min of Health
    immunization
                                                                                                                                                      ●
    coverage survey
    National Panel      2011- LSMS; service            Bureau of       World Bank,                                             5 regions                       3,123
    Survey               2012 use/access
                                                  ●    Statistics      BMGF,
                                                                                                               ●                              ●       ●
                                                                       government
    DHS                 2011 Health, esp.              Bureau of       Gov., USAID,                                            10                              9,033
                             RMNCH                     Statistics      UN, UK, Ireland
                                                                                           ●          ●        ●        ●      regions
                                                                                                                                              ●       ●                 ●          ●           ●
    AIDS indicator      2011 HIV                       Min of Health   USAID,                                                  10
    survey                                                             government
                                                                                           ●          ●        ●        ●      regions
                                                                                                                                              ●       ●      11,340
                                                                                                                                                                        ●          ●           ●
    Global youth        2011 Tobacco use               Min of Health   Multiple                                                                             3450 (p)
    tobacco survey
                                                                                                               ●                                      ●
3. NATIONAL PROGRESS

                              3.1. PROGRESS AGAINST HSDP TARGETS

Table 3.1 shows the baseline, midterm target (2016/17) and achievements for the 41 indicators
of HSDP. The extent to which the target has been met, or to which the trend is positive, has been
colour-coded with three categories: on track, slow progress, not on tract.
TABLE 3-1: HSDP 2015/16 – 2019/20 INDICATORS, WITH PROGRESS, BASELINE, ACHIEVEMENTS AND
TARGETS.

      Target achieved / on               Slow progress                    Decline/No progress
      track
                 Indicator                    Progress      Baseline               Achieved     TARGET for
                                                                                   2016/17       2016/17
HEALTH IMPACT
Maternal Mortality Ratio (per 100,000)                   438 (DHS 2011)      368 (UDHS          425
                                                                             2016)
Neonatal Mortality Rate (per 1,000)                      27 (DHS 2011)       27 (UDHS 2016)     26
Infant Mortality rate (per 1,000)                        54 (DHS 2011)       43 (UDHS 2016)     50
Under five mortality rate (per 1,000)                    90 (DHS 2011)       64 (UDHS 2016)     64
Total Fertility Rate                                     6.2 (DHS 2011)      5.8 (UDHS 2016)    5.9
Adolescent Pregnancy Rate                                24% (DHS 2011)      25 (UDHS 2016)     23%
HEALTH & RELATED SERVICE TARGETS
Communicable disease prevention &
control
ART coverage                                             56% (2014/15)       57%                57%
HIV+ pregnant women receiving ARVs for                   72% (2013/14)       94%                87%
eMTCT during pregnancy, labour, delivery
and postpartum
TB Case Detection Rate (all forms)                       45% (2014/15)       50%                75%
IPT2 or more doses coverage for pregnant                 53.4% (2014/15)     54.4%              71%
women
Malaria cases per 1,000 persons per year                 408 (2015/16)       433                329
Under-five Vitamin A second dose                         26.6% (2013/14)     25.3%              60%
coverage
DPT3HibHeb3 coverage                                     71.5% (DHS          79.0% (DHS         95%
                                                         2011)               2016)
Measles coverage under 1 year                            75.8% (DHS          80% (DHS 2016)     92%
                                                         2011)
Essential clinical and rehabilitative care
Bed occupancy rate                                       HC IV 59%           60%                70%
(Hospitals & HC IVs)                                     (2013/14)
                                                         Hospital 50%        54%                60%
                                                         (2013/14)
Average length of stay                                   Hospital - 4        5.1                3
(Hospitals & HC IVs)                                     (2013/14)           3.2                3
                                                         HC IV - 3
                                                         (2013/14)
Contraceptive Prevalence Rate                            30% (DHS 2011)      39.0%              39%
Couple years of protection                               2,196,713           2,156,240          4.4 million
                                                         (2014/15)
ANC 4 coverage                                           48% (DHS 2011)      60% (DHS 2016);    40%

                                                     4
Indicator                    Progress       Baseline         Achieved        TARGET for
                                                                                2016/17         2016/17
                                                                            39% (HMIS)
Health Facility deliveries                                57% (DHS 2011)    73.0% (DHS         75%
                                                                            2016)
HC IVs offering CEmOC Services                            33% (2014/15)     45%                55%
HEALTH INVESTMENT OUTPUT TARGETS
Health infrastructure
New OPD utilization rate                                  1.2 (2014/15)            1.1               1.2
Hospital (inpatient) admissions per 100
                                                          6 (2013/14)              7.8               8
population
Population living within 5km of a health                  75%                      100%              80%
facility
Medicines and supplies
Availability of a basket of commodities in                64% (2014/15)            83.0%             100%
the previous quarter (% of facilities that
had over 95%)
Improving quality of care
Facility based fresh still births (per 1,000              16 (2013/14)             10.1              14
deliveries)
Maternal deaths among 100,000 facility                    132 (2013/14)            148               98
deliveries
Maternal death reviews                                    33.3% (2012/13)          24.0%             45%
Under five deaths among 1,000 under 5                     17 (2013/14)             20.2              17.3
admissions
ART Retention rate                                        79% (2014/15)            82%               84%
TB Treatment Success Rate                                 79% (2014/15)            80%               82%
Responsiveness
Client satisfaction index                         -       69% (2014/15)            no data           73%
Health information
Timeliness of reporting (HMIS 105)                        85% (2013/14)            88.1%             90%
Health financing
Out of pocket health expenditure as a % of                37% (2011/12)            37%               35%
Total Health Expenditure
General Government allocation for health                  8.5% (2014/15)           7.3%              12%
as % of total government budget
Human resources
Approved posts in public facilities filled                69% (2014/15)            73%               70%
with qualified personnel
Number of health workers (doctors,                        Doctors 1:24,725         1: 28,202         1:24,300
midwives, nurses) per 1,000 population                    (HSSIP MTR 2013)
                                                          Midwives 1 :11,000       1:6,838           1:10,500
                                                          (HSSIP MTR 2013)
                                                          Nurses 1:18,000 (HSSIP   1: 2,121          1:18,000
                                                          MTR 2013)
Social and economic determinants of
health
Children below 5 years who are stunted                    33% (DHS 2011)           29.0%             29.0%
Children below 5 years who are under                      14% (DHS 2011)           11%               14%
weight
Health promotion and environmental
health
Latrine coverage                                          73% (2013/14)              77%             78%

                                                      5
Indicator           Progress      Baseline         Achieved            TARGET for
                                                                        2016/17              2016/17
                                                    77% (2014/15)
Villages/ wards with a functional VHT       -       75% (2014/15)            no data              80%

Overall, 13 indicators were on track, 16 made progress but too slow to meet the target, and 10
were not on track. For two indicators no data could be obtained. Major areas of success included
child mortality declines, child nutritional status improvements and HIV. Major areas of concern
included neonatal mortality, maternal mortality and adolescent fertility.

                        3.2. COMPARATIVE ANALYSIS OF UGANDA’S RESULTS

The levels and progress in Uganda were compared with nine countries of similar socio-economic
status in the eastern and southern Africa region: Burundi, Ethiopia, Kenya, Malawi, Mozambique,
Rwanda, Tanzania, Zambia and Zimbabwe, based on survey data for coverage statistics and
comparable estimates of selected key indicators from WHO which are modelled based on
household surveys and other sources. The aim was to give an idea on where Uganda stands
among its peers in relation to specific indicators and targets.

Under-5 mortality rates were declining in all countries, and the WHO estimates showed that
Uganda had the third lowest under-five mortality after Rwanda and Kenya. Maternal mortality
estimates are heavily affected by the lack of data. According to the WHO estimates, Uganda had
the 5th lowest maternal mortality ratio among the 10 countries after United Republic of
Tanzania, Mozambique, Burundi and Rwanda in 2015, but these results do not yet take into
account the most recent UDHS 2016.

Figure 3.1 presents the coverage of 10 reproductive, maternal and child health interventions for
which comparable data were available, both for the individual interventions and for an index
calculated as the average of equally weighted rates of the 10 interventions. These data are based
on the most recent surveys from the 10 countries.
FIGURE 3-1: PERCENT OF TARGET POPULATION WHO RECEIVED KEY RMNCH INTERVENTIONS, UGANDA AND
9 PEER COUNTRIES. (BAR INDICATES THE AVERAGE SCORE FOR THE 10 INTERVENTIONS)

               100
                                                                        Maternal child health
                90                                                      index
                80                                                      ANC 4th visit
                70
                                                                        Skilled birth attendance
                60
     Percent

                50                                                      Institutional delivery
                40
                30                                                      FP needs satisfied with
                                                                        modern methods
                20                                                      Pneumonia treatment
                10
                 0                                                      Diarrhoea treatment

                                                                        Fever treatment

                                                                        Exclusive

                                                6
The index for Uganda for the period 2005-2016 was 62.8% which is the 5th highest among the 10
countries after Malawi, Rwanda, Zambia, Zimbabwe and Kenya. The Uganda performance is
affected by relatively poorer scores on the following indicators: family planning, care seeking for
diarrhea, ANC 4th visit, early initiation of breastfeeding, skilled birth attendance and institutional
delivery.

Health financing: in terms of percent of general government expenditure that is allocated to
health Uganda score relatively low among the 10 countries. In 2015, 5.6% went to health, and
only Mozambique had a lower proportion. Burundi and Malawi’s allocations were twice as high
as Uganda. Roughly 40% of current health expenditure comes from external sources (Figure 3.2).
This is slightly higher than the median of 38.5%. Within the domestic portion, Uganda has one of
the lowest percentages of expenditure from domestic general government sources with the
majority of domestic spending coming from private sources (78% of domestic spending is from
private sources).

FIGURE 3-2: PERCENT DISTRIBUTION OF HEALTH EXPENDITURE BY SOURCE, UGANDA AND SUBREGION

 100
  90
  80
  70
  60
  50
                                                                                         External
  40                                                                                     Private
  30                                                                                     Government
  20
  10
   0

In general, the health results show that Uganda occupies a middle position among the countries
in the subregion, sometimes in the top half, sometimes in the middle but rarely in the bottom
half.

                                                  7
3.3. DISCUSSION ON FINDINGS BY PROGRAM AREA

Table 3.3 summarizes the main findings by major program area. These findings were reviewed
and discussed by the participants in the second analysis workshop in June 2018 and enriched
with explanations of contributing factors as well as implications of these findings for the
respective programs at a high level.
FIGURE 3-3: MAIN RESULTS, FACTORS CONTRIBUTING TO CHANGE AND MAIN IMPLICATIONS FOR HSDP BY
PROGRAM AREA, AS DISCUSSED DURING THE SECOND ANALYSIS WORKSHOP.

                                                                                            Main implications for HSDP
 Program          Main results                      Factors contributing to change          part II
 Health           Government financing for          Economic growth leading to more         Strengthen development
 systems;         health low, not increasing (7%    money for health: total health          partner coordination; greater
 financing and    of gen.gov. budget); OOP high     expenditure per capita increasing       efficiency in resource use; fast
 governance       and not decreasing (37%); low     to $55; Multiple laws and policies      track NHIS establishment and
                  insurance coverage (
Main implications for HSDP
Program           Main results                      Factors contributing to change      part II
                                                                                        multisectoral approaches
TB                Stable treatment success rate     Program focused on health           Stronger focus on detection
                  at 80%;                           service-based detection of TB and   untreated patients in
                  Low case detection rates          treatment completion; high levels   community
                  (50%), based on new survey        of testing among HIV patients,      Further improvement of
                  results                           stronger HIV program benefits TB;   quality of care to reach higher
                                                    limited community focus             treatment success rates
Malaria           Improvements in prevention        High levels of coverage of core     Address stagnating progress
                  coverage and some reduced         interventions reached by program    with high coverage of all key
                  parasitemia and                   prior to HSDP; problems with ITN,   interventions for prevention
                  morbidity/mortality, but no       addressed in 2017 campaign          and treatment
                  further recent declines
HIV               Strong progress in HIV ART        Strong donor support, major         Continued emphasis on
                  and PMTCT everywhere; HIV         focus on treatment                  achieving the 90-90-90 targets,
                  incidence also likely going                                           but also greater attention for
                  down but slowly                                                       prevention measures to
                                                                                        further reduce incidence
Environmental     Latrine coverage stagnating,                                          Need for more indicators on
health and        with still about three quarters                                       environmental health,
health            of the households with                                                especially water and sanitation
promotion         inadequate sanitary facilities                                        related; indicators on
                                                                                        functional VHTs, CHEW
New               Increasing importance, major                                          Focus on risk factor reduction
challenges        differences within country
(NCD, injuries,   and socioeconomic groups;
mental            hypertension and diabetes
health)           common, obesity increasing
                  rapidly with much higher
                  levels among women; tobacco
                  use mainly men and not
                  increasing
Inequalities      Good progress in reducing                                             Attention for lack of urban
                  inequalities in coverage, but                                         especially Kampala progress;
                  differences within Uganda still                                       Focus on poorly performing
                  exist                                                                 districts
                                                                                        Main implications for HSDP
Program           Main results                      Factors contributing to change      part II

                                                          9
3.4. HEALTH INFORMATION SYSTEM IMPLICATIONS

Table 3.3 summarizes the main findings on the components of the health information system.
These findings were reviewed and discussed by the participants in the second analysis workshop
in June 2018 and enriched with establishing general priorities for action by the core MTR review
team.
TABLE 3-2: MAIN STRENGTHS AND PRIORITIES FOR ACTION FOR THE DATA SOURCES AND PROCESSES OF
THE HEALTH INFORMATION SYSTEM

Area              Main achievement                       Priority for action
Reviews           Good process of regular national       Build on tradition of comprehensive plans and
                  reviews with extensive reports,        documentation of progress to strengthen system of reviews
                  mainly based on facility and           starting at program and district levels, with synthetic overall
                  administrative data; some programs     program review
                  conduct thorough reviews of
                  detailed plan (HIV, malaria)
Surveys           Regular surveys provide wealth of      Gap in EMOC assessments
                  information
HMIS              Improved reporting by districts, but   Conduct data reviews at regional levels and regular DQA at
                  quality issues are many                the facility level; introduce EMR at high volume facilities;
                                                         complete and maintain master facility list; focus on local data
                                                         analysis and use
Birth and         Not present, mobile vital              Strengthen CRVS system; roll out ICD 10 and implement
death             registration developed in facilities   proper system of death certification; link to National
registration      (UNICEF)                               Identification and Registration Authority (NIRA)
Administrativ     HRH information system extensive,      More emphasis on sharing information and data
e data            but not easily accessible; NHA
                  becoming regular (institutionalized)
                  - high quality products
Disease           System in place for surveillance of    Strengthen maternal (and perinatal) death surveillance and
surveillance      notifiable diseases                    response system;
Analytical        National: Makerere University          Good capacity at national level; formalized partnerships
capacity          School of Public Health and Bureau     between MOH, Makerere University and UBOS desirable to
                  of Statistics; Ministry of Health      focus on analysis
                  Resource centre
                  Districts: limited capacity
District league   Annual system in place, transparent    Further investments urgently needed to be able to use its full
tables            methods, good dissemination            potential
                  Challenge is data quality
Hospital          Annual system in place, transparent    Further investments will be important to improve data
performance       methods, good dissemination            quality, analysis and use
(SoU)             Challenge is data quality

eHealth           Strategy in place                      Develop standards for EMR, compete review of current
                                                         practices

Data              Annual review and program reviews      Quarterly data review meetings in districts; annual data use
communicatio      are key vehicles for data use and      meetings; use of small set of indicators and scorecards
n and use         demand good statistics and analyses

                                                         10
4. OVERALL MORTALITY AND MORBIDITY LEVELS AND TRENDS

The number of deaths reported by health facilities was 51,640 for 2015/16, 44,989 for 2016/17,
and 57,700 for 2017/18 (based on the reports for the second half of 2017). A rough estimate of
the number of deaths occurring in Uganda in 2017 is about 200,000 (crude death rate 5.4/1,000),
which would mean that just under 30% of deaths take place in health facilities.

The health facility data may provide a general picture of the leading causes of morbidity and
mortality, but no standardized classification of diseases (ICD) is used. The most important statistic
that can be derived from these data is the relative levels and trends in malaria indicators. The
surveys provide critical population-based information on mortality and the prevalence of
infectious diseases.

                      4.1.         MATERNAL AND CHILD MORTALITY

Indicators HSDP                   Baseline      Target    Achievement    Comments
                                                midterm
Maternal mortality per            438             425     336            Decline according to UDHS
100,000 live births               (UDHS 2011)             (UDHS 2016)    but data refer to 7 years
                                                                         before survey
Neonatal mortality per 1,000      27              26      27             No decline; UDHS rates refer
live births                       (UDHS 2011)             (UDHS 2016)    to 5 year period before
                                                                         survey
Infant mortality per 1,000 live   54              50      43 (UDHS       Decline; UDHS rates refer to
births                                                    2016)          5 year period before survey
Under-5 mortality per 1,000       90              64      64             Decline; UDHS rates refer to
live births                       (UDHS 2011)             (UDHS 2016)    5 year period before survey

Good progress in infant and under-5 mortality but not for neonatal mortality: Infant and under-5
mortality declined rapidly between the Uganda DHS surveys in 2011 and 2016, based on the 5-
year period rates (2007-2011 and 2012-2016). Neonatal mortality however did not decline at all
and was still at the same level in the UDHS 2016, as in the UDHS 2006 and UDHS 2011: 27 per
1,000 live births.

Maternal mortality lower during 2010-2016 than before, but not significantly so: In the UDHS
2016, maternal mortality per 100,000 live births was 336 (95% confidence interval 272-401) for
the seven years before the survey (2010-2016). This was lower than in the UDHS 2011 when
maternal mortality was 438 (95% CI: 368-501) but the difference is not statistically significant.
The percent of adult female deaths 15-49 years that were pregnancy-related remained the same
in both UDHS surveys: 17.5% in 2016 and 18.1% in 2011.

Adult mortality declined rapidly for women and men: The probability that a 15-year-old would die
before age 50 years declined rapidly in Uganda, especially for women which have considerably
lower mortality than men at these ages. HIV mortality is likely to be an important contributor to
this decline in adult mortality.

                                                  11
FIGURE 4.1-1: ADULT MORTALITY PER 1,000 PERSONS BETWEEN AGES 15 AND 50 YEARS FOR MEN AND
WOMEN, UGANDA DHS SURVEYS 2000-2016 (7-YEAR PERIOD PRECEDING THE SURVEYS).

                                                           400

                         Deaths per 1000 person aged 15
                                                           350
                                                           300
                                                           250

                                    by age 50
                                                           200
                                                           150
                                                           100
                                                             50
                                                                 0
                                                                       UDHS 2000 UDHS 2006 UDHS 2011 UDHS 2016

                                                                                   Men              Women

                                                            4.2.                   HIV, TB AND MALARIA

HIV prevalence and incidence on the decline: the 2016 Uganda Population HIV Impact
Assessment shows that 6.0% of adults aged 15-49 years are living with HIV, down from 7.3% in
2011. Children under 5 and 5-14 years both had HIV prevalence of 0.5%. Adult HIV prevalence
was higher among women at 7.5% compared to 4.3% among men, and higher among urban
compared to rural areas (7.1 and 5.5% respectively). The program has estimated that the number
of new infections has been halved during this period.

TB higher than expected: according to the 2014-15 TB prevalence survey: the number of persons
needing TB treatment was about 1.5 times higher than expected based on previous monitoring
through health facilities (and tuberculin surveys), implying that about 89,000 persons get TB
every year in Uganda.

FIGURE 4.2-1: MALARIA INPATIENT ADMISSIONS PER 1000 AND DEATHS PER 100,000 (LEFT PANEL) AND
MALARIA INPATIENT ADMISSIONS AND DEATHS AS % OF TOTAL ADMISSIONS (RIGHT PANEL), BASED ON
HMIS DATA SUBMITTED TO WHO.

30                                                                                         75%

20                                                                                         50%

10                                                                                         25%

 -                                                                                             0%
     2010   2011    2012            2013                  2014       2015   2016   2017              2010    2011    2012   2013   2014   2015   2016    2017

      Malaria inpatients per 1,000                          Malaria deaths per 100,000                      Malaria Inpatients %      Malaria Deaths %

                                                                                          12
Malaria progress stagnated in recent years: malaria remained a leading cause for admission and
cause of death among inpatients: just over 10% of inpatient deaths are due to malaria and about
25% of admissions. The increase in reported number of malaria cases per 1,000 persons from 408
in 2015/16 to 433 in 2016/17 wasmainly driven by increased rates of diagnostic testing with the
annual blood examination rate reaching almost 60% in 2017, one of the highest rates globally.
Test positivity rates have been stable since 2014. The 2016 UDHS and the 2014 UMIS show that
malaria and anemia prevalence in children under 5 have remained stable since 2014 at about
30% (through RDT).

            4.3.        UNDER-5 MORTALITY TRENDS BY SUBREGION

The UDHS 2016 sample used, for the first time, 15 subregions to assess mortality and health
indicators. New calculations were done with the UDHS 2011 and previous surveys after alignment
of the cluster samples in the survey with the UDHS 2016 subregions. The reference period used
was the 5 years before the survey to capture recent changes. For 2011-2016 Karamoja still had
the highest under-5 mortality (108), followed by Busoga, Bunyoro, North Central and West Nile
(all over 70) and Tooro (66). All other 9 nine subregions had under-5 mortality rates in the narrow
range of 48-57 per 1,000 live births. Confidence intervals around the 5 years regional mortality
rates are wide, but in general the differences are smaller in UDHS 2016 than before.

FIGURE 4.3-1: UNDER-5 MORTALITY PER 1,000 LIVE BIRTHS, TRENDS 2000-2015, UDHS, BY SUBREGION

                                                13
5. PROGRESS TOWARDS THE SPECIFIC HSSP III HEALTH AND
                        DISEASE TARGETS

      5.1.           FERTILITY AND FAMILY PLANNING – GOOD PROGRESS
                                   IN RURAL WOMEN

Indicators HSDP                  Baseline         Target     Achievement Comments
Total fertility rate among       6.2                 5.9     5.4              Target achieved, rural
women 15-49 years                (UDHS 2011)                 (UDHS 2016)      population driving the
                                                                              decline
Contraceptive prevalence rate    30%                39%      39%              Modern methods 34.5% in
(among married women 15-         (UDHS 2011)                 (UDHS 2016)      UDHS 2016, 32.3% in PMA
49)                                                                           2017
Couple Years of Protection       2.2 mln (DHIS     4.4 mln   2.8 mln (DHIS    Increase in CYP according to
                                 2014/15)                    2017/18)         DHIS data; target not
                                                                              plausible
Teenagers who have begun         23.8%              23%      24.8%            No decrease in adolescent
childbearing (under 20)          (UDHS 2011)                 (UDHS            fertility
                                                             2015/16)

                                         5.1.1.              FERTILITY

•   The total fertility rate (TFR), the number of children a woman would have at age 50 by
    current fertility rates, declined modestly during HSSP III from 6.2 to 5.4, driven by a decline in
    rural fertility from 6.8 to 5.9. Urban fertility rates increased slightly from 3.8 to 4.0.
•   TFR was lower in southwestern Uganda, and highest in the eastern and northeastern part of
    the country.
•   TFR declined in 15 of the 21 regions during HSSP III. The six regions with no decline included
    Dar es Salaam and Kilimanjaro, the two lowest fertility regions.

FIGURE 5.1.1-1: CONTRACEPTIVE USE (MODERN METHODS) AND FAMILY PLANNING COVERAGE RATES
(DEMAND SATISFIED) AMONG MARRIED WOMEN 15-49 YEARS, 2011-2017.

                60           Contraceptive prevalence rate
                             Demand satisfied
                50

                40

                30

                20
                     2011,                         2014,      2015, 2015, 2016, 2016, 2017,
                      DHS                          PMA        PMA PMA DHS PMA PMA

                                                     14
5.1.2.        CONTRACEPTIVE USE

•   Six national surveys were conducted since 2014. Modern contraceptive use among married
    women, the main determinant of fertility, increased from 30% to 35% during HSDP (Figure 1).
    The demand satisfied for family planning with modern methods (family planning coverage)
    increased to 48%.
•   Traditional methods are not very common. The increase is largely due to more use of
    implants and IUD visits according to PMA surveys and DHIS data.
•   The increase in contraceptive use occurred almost exclusively among rural women (23% to
    33% during 2011-2016).
•   The overall CYP increased from 2.2 million 2015/16 and 2016/17 to 2.8 million in 2017/18
    (DHIS). The target is not met, but also unlikely high.

                                   5.1.3.        ADOLESCENT FERTILITY

•   25% of girls 15-19 years were either mother or pregnant in 2014/2016, similar to 5 years
    earlier (24%). Teenage fertility is twice as common among girls in the poorest quintile (34%)
    than among girls in the richest quintile (15%).

                         5.2.          MATERNAL AND NEWBORN CARE

Indicators HSDP                     Baseline     Target  Achievement Comments
                                                 midterm
ANC 4 visits coverage among         44% (UDHS     43%    60% (UDHS,     Major progress in survey,
pregnancy women                     2011); 38%           2016); 39%     but not in HMIS
                                    (HMIS                (HMIS 2017)
                                    2014/15)
Deliveries in health facilities     57% (UDHS     58%    73% (UDHS      Increase, target surpassed,
                                    2011); 55%           2016); 60%     but major difference
                                    (HMIS,               (HMIS, 2017)   between survey and HMIS
                                    2014/15)
Fresh still birth rate in health    10.8%         13%    9.7%           Overall stillbirth rate
facilities per 1,000 deliveries     (2015/16)                           remains 21/1,000 deliveries
                                                                        in health facilities
HC IV offering CEmOC                37%           57%    45% (HMIS,     Better for Caesarean section
services                            (2013/14)            2016/17)       than blood transfusion

•   There is a major increase in both ANC4+ and institutional deliveries during 2009/11 and
    2014/16 according the UDHS 2011 and UDHS 2016.for the three-year periods preceding the
    2011 and 2016 surveys. According to the UDHS 2016, 73% of women delivered in a health
    facility.

•   The HMIS data confirm an increase in institutional deliveries rates during the first year of
    HSDP but no increase in the percent of women delivering in 2016/17 and the first half of
    2017/18, stagnating at about 60%.

                                                   15
•   ANC4 coverage is much lower according to the DHIS data – about 40% - and no progress is
    observed during HSDP. The cause of the difference is not clear: UDHS may have
    overreporting of visits by women or HMIS may miss many 4th visits.

•   The overall stillbirth rate remained at 21 per 1,000 deliveries in 2016/17 and the first half of
    2017/18. The fresh stillbirth rate was slightly lower than in 2015/16: 10.2 and 9.7 per 1,000 in
    2016/17 and first half of 2017/18 respectively.

•   Caesarean Section rates increased gradually from 5.8% to 7.0% per 1,000 births in the
    population in 2014/15 in HMIS, and the rate was very close to the UDHS of 6.2% for 2014-16.

•   The percent of HC IV facilities offering CEmOC increased to 45% which was still well below
    target. The target was met for Caesarean sections (70% of HC IV) but not for blood
    transfusion (47%).

FIGURE 5.2-1: ANTENATAL CARE (ANC 4 OR MORE VISITS) AND DELIVERIES IN HEALTH FACILITIES: UDHS
2011, 2016 and HMIS.

                  100
                                                                   73
                   80      57
                   60
                   40
                   20
                    0
                        UDHS 2011/12 2012/13 2013/14 2014/15 2015/16 2016/17 2017/18
                        2011

                                  ANC4 - UDHS 2011       Deliveries - UDHS 2016
                                  ANC - HMIS             Deliveries - HMIS

                               5.3.         CHILD IMMUNIZATION

Indicators HSDP                 Baseline       Target  Achievement Comments
                                               midterm
DPT – Hib – HepB 3 coverage     93% (HMIS        95%     79% (UDHS,          No evidence of progress
(among 12-23 months)            2013/14)                 2015/6)             after UDHS in HMIS
Measles vaccination coverage    87% (HMIS        95%     80% (UDHS           UDHS under 1 yr: 72%; no
(under 1 year)                  2013/14)                 2016)               evidence of progress in
                                                                             HMIS

•   UDHS survey in 2016 provides data for 2015/16 and shows a modest increase since UDHS
    2011 for DPT3 (from 71% to 79%) and for measles coverage among children 12-23 months
    (from 76% to 80%). The percent children who received measles vaccination before their first
    birthday is 72%, well off the HSDP target of 95%.

•   HMIS data show much higher coverage rates, but this is likely to be due to overreporting of
    immunization data. During the first half of HSDP the numbers of vaccinations (DPT3 and
    measles) have declined and the coverage rates estimated from the HMIS have therefore also

                                                 16
declined. This however may be due to more accurate reporting, and it cannot be concluded
    that this is an actual decline of coverage.

FIGURE 5.3-1: DTP3 AND MEASLES IMMUNIZATION COVERAGE TRENDS FROM UDHS AND DHIS DATA

      120
      100
            72 76                                      76 80
       80
       60
       40
       20
        0
            2010/11 2011/12 2012/13 2013/14 2014/15 2015/16 2016/17 2017/18

              DPT3 UDHS      Measles - UDHS     DPT3 - DHIS     Measles - DHIS

                     5.4.        CHILD HEALTH AND NUTRITION

Indicators HSDP              Baseline         Target  Achievement Comments
                                              midterm
Stunting among children      33.4% (UDHS        29%     28.9% (UDHS,
under 5 years                2011)             (end)    2015/6)
Underweight among children   13.8% (UDHS        10%     10.5% (UDHS
under 5 years                2011)             (end)    2016)
Vit A coverage (2nd dose)    27% (HMIS          62%     37% (HMIS        First dose coverage is 60%
children 6-59 months         2013/14)                   2017 Jul-Dec)

•   Child growth is improving and on target according to the UDHS survey in 2016. Stunting levels
    decreased to 29% and underweight to 10.5% of children under 5 years of age.

•   Vitamin A supplementation among children 6-59 months was not increasing fast enough to
    reach the HSDP target. The HMIS data show 60% coverage of the first dose and 37% of the
    second dose in the second half of 2017, similar to the levels in 2015/16. According to the
    UDHS there was a slight increase from 57% to 62% of children 6-59 months who had received
    a dose of vitamin A in the last 6 months preceding the survey.

•   Additional indicators from the UDHS on breastfeeding practices and treatment seeking
    patterns for sick children show that in general child health practices did not change much
    during 2011-2016 and remained fairly good. Anemia however remained very common.

Indicator                         2011 2016 Indicator                                2011 2016
Exclusive breastfeeding 0-5       63.2% 65.5% Care seeking for ARI                   78.7% 80.4%
months                                        symptoms
Initial breastfeeding < 1 hour    52.5% 66.1% Care seeking for fever                 80.1% 81.6%
Moderate and severe anemia        27.0% 29.2% Care seeking for diarrhoea             72.4% 70.5%

                                                17
FIGURE 5.4-1: STUNTING AND UNDERWEIGHT IN CHILDREN UNDER 5 YEARS (%), UDHS 2011 AND UDHS
2016

           40.0
                           33.4
                                      28.9
           30.0

           20.0
                                                            13.8
                                                                     10.4
           10.0

              -
                                Stunting                    Underweight

                                     UDHS 2011      UDHS 2016

                                             5.5.          MALARIA

Indicators HSDP 2015/16-          Baseline          Target  Achievement Comments
2019/20                           2014/15           2016/17 2016/17
In-patient malaria deaths per     22 (2015/16         13        20.2 (HMIS)    Little change in deaths but
100,000 persons per year          HMIS)                                        total admission rates
                                                                               increased.
Malaria cases per 1,000           408 (2015/16       329        433 (HMIS)     Increase mainly due to an
persons per year                  HMIS)                                        increased diagnostic testing
IP 2 or more doses coverage       53.4% (HMIS)       71%        54.4% (HMIS)   Little change from HMIS, but
for pregnant women                                                             small decline from surveys

•   Taking into account all sources of data, the incidence of malaria appears to have been stable
    since 2014, though this national trend is likely to conceal local increases and decreases.

•   IPT2 coverage is used as a proxy for IPT3 in HSDP monitoring as IPT3 is not currently tracked
    in DHIS2. It has changed little and was 54% in 2016/17. However, according to recent MIS
    and DHS, IPT2 coverage decreased from 49% in 2014/15 to 46% in 2016 while IPT3 decreased
    from 28% to 17%.

•   Vector control: 61% of the population slept under an ITN or were protected with IRS in 2016,
    compared to 70% in 2014/15. The decrease observed in 2016 can be explained by the
    obsolescence of ITN, about 2 years after the 2014 ITN mass distribution campaign. Another
    mass distribution of ITNs was completed in 2017 so coverage rates have probably recovered.
    Populations aged 5-19 are less likely to sleep under an ITN than other age groups which may
    be of concern since parasite prevalence may reach a peak in children over 5 years of age.

•   Testing and treatment: according to the DHS 2016 37% of children with fever in the previous
    2 weeks attended a public health facility, 44% attended a private facility, while 18% do not
    attend any facility. More children in public facilities received a diagnostic test and 72%
    received an ACT. Given that recorded test positivity rates are less than 50% these results
    suggest over-treatment of fevers with ACTs in both the public and private sectors (i.e. less
    than half of those tested should receive an ACT).

                                                      18
FIGURE 5.5-1: FEBRILE CHILDREN TESTED FOR MALARIA 2016                                                                              FIGURE 5.5-2: TREATMENT
                                                                                                                                    RECEIVED BY FEBRILE CHILDREN

                            50%                                                                                     50%

                            40%                                                                                     40%
                                                                                                                                                                  No medicine
    % of febrile children

                                                                                            % of febrile children
                                                                                                                                                                  Unknown
                            30%                                                                                     30%
                                                                                                                                                                  Other
                                                                          Not tested
                                                                                                                                                                  Analgesics
                            20%                                           Diagnostic test                           20%
                                                                                                                                                                  Antibiotics
                                                                                                                                                                  Other antimalarials
                            10%                                                                                     10%                                           ACT

                            0%                                                                                      0%
                                  Public   Private   Informal   No care                                                   Public   Private   Informal   No care

                                                                          5.6.                                      HIV/AIDS

Indicators HSDP 2015/16-                                        Baseline               Target  Achievement Comments
2019/20                                                         2014/15                2016/17 2016/17
ART coverage among adults                                       56%                         65%                           67%                ART coverage exceeded
living with HIV                                                                                                                              target
HIV+ pregnant women not on                                      68.3%                       87%                           90% (AHSPR)        Pregnant women using ARVs
HAART receiving ARVs for                                        (2015/16                                                                     for eMTCT exceeded target
eMTCT                                                           AHSPR)
during pregnancy, labour,
delivery
and postpartum
ART retention rate                                              79% (HMIS)                  84%                           82% (HMIS)         Increase in ART retention
                                                                                                                                             rate; Target not far from
                                                                                                                                             being achieved

ART coverage and retention rates
• There are 1,300,000 adults living with HIV in Uganda of which 73% know their HIV positive
   status. Of those who are HIV positive, there are 67% who are on ART and close to 60% are
   virally suppressed.

•                           ART retention increased to 82% in 2016/17 from 79% in 2014/15 short of the HSDP target of
                            84%.

eMTCT coverage
• There has been scale up of PMTCT services and there are more than 95% of mothers
   accessing the EMTCT services. HIV+ pregnant women not on HAART receiving ARVs for
   eMTCT during pregnancy, labour, delivery and postpartum was 90% (38,243/42,467) in
   2016/17 which was above the 68% (34,357/50,323) in 2015/16 and above the HSDP target of
   87%.

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