Access to Maternal Health
Services Under a Decentralized
and Privatized Healthcare
System in Uganda
By
Guma Prince Karakire
7th Annual Scientific Conference 2010
Speke Resort Munyonyo
Background & Rationale (1)
Healthcare has undergone a number of
changes since independence
1. Beyond a centralized free and relatively
accessible healthcare in the 60s and
early 70s
Failed by the 1970s global recession,
economic decline and bad governments
Background & Rationale (2)
2. Toward a privatized and decentralized
health care
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More autonomy to decentralized districts
Raising local revenue for services
Bottom-up Vs. top down practice
Involving private missions
Adoption of user charges
Background & Rationale (3)
 Despite these developments, maternal mortality
remains unacceptably high.
 Estimates of 1990 figures were as high as 1200
deaths per 100,000 live births.
 Although maternal mortality needed to reduce by
5.5% per annum between 1990 and 2015, the
decline was only less than 1% in 2005
 Today, only about 38% of the deliveries are
attended to by trained personnel
Background and Rationale (4)
 Maternal mortality today stands at 435 per 100,000
live births in 2006
 Because majority do not deliver in health facility,
figures would likely be much higher
 This has a lot to speak about the accessibility of
maternal health services.
 Privatization and decentralizations seem incapable
of offering answers for persistent health service
questions
Objectives
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To establish the configuration of maternal health
services available and how these are accessed by
mothers in need in order to enhance approaches in
promoting their right to health in the wake of
decentralized and privatized healthcare services
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To understand the dynamics of how privatization and
decentralization interact and affect maternal health services
To examine the accessibility of the available maternal health
services with particular interest in rural areas
To outline the major challenges in the current system of
provision of maternal health services and how can they best
be overcome
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Method
 The study adopted a system-level
perspective on the Ugandan national
healthcare system:
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Secondary information: published journals,
Government publications, performance reports,
and Newspaper articles
Primary sources: qualitative - interviews with
primary respondents chosen from the study area.
The study benefited from Key Informants (KIs)
Decentralized Healthcare: a case
of bringing services closer? (1)
 Established by the LG Act 1997
 It was seen as a precondition for improving
basic healthcare services
 Extensive in nature: District Health Team at
the district – Health Sub District in an
existing hospital or HC IV – HC III – HC II VHT
Decentralized Healthcare: a case
of bringing services closer? (2)
 Uganda’s 82% of the population is in the rural
areas of whom more than 65% are women;
Only about 15% is urban
 Ideally, decentralized healthcare is a good idea but
the system is hardly sustained both at the helm and
at LG:
 Shortage of organizational and management skills
 Corruption
 Scarcity of resources at the local level
Privatized healthcare: Maternal health
care an ordinary commercial good?
 Privatized healthcare was a 1987 WB policy as
part of the agenda for financing public health
services
 Uganda has since then embarked on policies
that increase private provision of health
services while seeking to reduce on
government size in the field
 Ideal: Market forces, and PNFP and PFP missions
can deliver services with much more efficiency and
lower cost than government; and provide
competition as a way of shaking up the public
sector
 More than 40% of heath service facilities are private
Privatized healthcare: Maternal health
care an ordinary commercial good?
 Rural areas, do not appeal to many
investors. PFP facilities therefore, are
largely concentrated at the Town Council
level and the rest at Sub county
headquarters with little or minimum access
to rural areas.
 Relying on market forces ignores the reality
that rural women lack sufficient income to
access the market where quality maternal
health care is bought.
A framework for
Understanding
Access to Maternal
Health Services
under
Privatization and
Decentralization
Access under Privatization and
Decentralization: Challenges
Health practitioners tend to be consolidated in
urban areas
 Over 80% doctors and 60% of midwives and nurses
are located in hospitals which serve urban
populations
 Only 42% of the deliveries are attended by skilled
providers and of these only 37% are residents of
rural areas. About 23% of deliveries by women in
the least wealth quintiles are attended by
Traditional Birth attendants and healers.
Access under Privatization and
Decentralization: Challenges (2)
 The envisaged bottom-up approach is elusive
 Funding is chronically small – even as it has
been increasing, the population has increased
even faster
 User fees prohibitively high in regard to MCH
 Shortage of drugs - common practice: refer
women to private units
 Some districts have no hospitals
 Rural areas do not appeal to many investors
including PFP, PNFP
Conclusion (1)
 Although decentralization has devolved
powers of control and provision of services
to local governments; while privatization
has encouraged the conception of markets
as a place to purchase goods and services
with limited government intervention, they
are no panacea for all that was wrong
with the healthcare system. Rather, they
are only a means toward achieving health
service provision
Conclusion (2)
 Access to some poor may have be achieved,
BUT access for the very poor and marginalized
groups becomes even harder under the same
arrangements
 For Uganda to achieve its goals in line with MDG
goal5, it is imperative to consider equity issues
within the healthcare system and to enhance
approaches in promoting women’s rights to health
in child birth.
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Thank You