By Guma Prince Karakire 7 th Annual Scientific Conference 2010 Speke Resort Munyonyo

1. 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

2. Background & Rationale (1) Healthcare has undergone a number of changes since independence • 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

3. Background & Rationale (2) 2. Toward a privatized and decentralized health care • More autonomy to decentralized districts • Raising local revenue for services • Bottom-up Vs. top down practice • Involving private missions • Adoption of user charges

4. 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

5. 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

6. Objectives • 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 • 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

7. Method • The study adopted a system-level perspective on the Ugandan national healthcare system: • 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)

8. 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

9. 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

10. 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

11. 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.

12. A framework for Understanding Access to Maternal Health Services under Privatization and Decentralization

13. 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.

14. 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

15. 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

16. 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.

17. . • Thank You