Uganda

Audit Report: Global Fund Grants to the Republic of Uganda

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I. Background

Uganda is one of the members of the East Africa Community. The country has a population of approximately 34.9 million and has one of the highest population growth rates in the world at 3.03%.(1) Approximately 82% of the population lives in the rural areas. The country has sustained one of the world’s fastest economic growth rates of the last two decades, averaging over 6% per annum(2). However, Uganda remains one of the least developed countries in the world with a gross national income per capita of USD 680 in 2014.(3) Poverty levels remain high with half of the population subsisting on less than USD 1.25 per day.

The country was ranked 164th out of the 187 countries in the United Nations Development Program (UNDP) Human Development Index (HDI) report for 2014. Transparency International’s 2014 Corruption Perception Index ranks Uganda as number 142 out of 175.(4) The country’s total health expenditure per capita has continued to increase marginally from USD 53 in 2011, USD 57 in 2012 and USD 59 at the end of 2013(5).

The health system in Uganda is composed of the public, private-not-for-profit and private-for-profit providers as well as traditional practitioners. Fifty two per cent of all the hospitals and health facilities in the country are public, 41% are private not for profit and 7% are private for profit.(6) Uganda runs a decentralized health system with national and district levels. Considerable disparities exist in the quality and coverage of health services across the districts. The lowest rung of the districtbased health system consists of level 1 health services. The next levels are Health Center II-IV which progressively service a larger number of people.

The three diseases in Uganda

HIV

Uganda accounts for 5 percent of the global HIV burden. The country has a generalized epidemic with 1.5 million people living with HIV and an estimated prevalence rate of 7.3%.(7) The country has made great headway in the control and treatment of HIV/AIDS as demonstrated below:

  • reduction in new infections from 140,000 in 2010 to less than 100,000 at the end of 2014;
  • sustained decline in HIV/AIDS mortality from 50,000 in 2010 to 33,000 in 2014;
  • increase in the proportion of adults and children receiving antiretroviral therapy from 21% in 2010 (260,866) to 50% in 2014 (749, 308);
  • decline in the proportion of infants born to HIV infected mothers who become HIV infected from 10.6% in 2012 to 7.1% in 2014; and
  • retention of people on antiretroviral therapy after 12 month of initiation on treatment has increased from 70% in 2011 to 85% at the end of 2014.(8)

At the time of the audit, the country was planning to undertake an HIV impact assessment to gain better insight on HIV incidence as well as prevalence.

Tuberculosis

Uganda accounts for 1 % of tuberculosis (TB) global burden and ranks 20th among the 22 high burden countries. Available World Health Organization estimates indicate that Uganda has experienced a decline in TB incidence, prevalence and mortality and is one of the 7 amongst the 22 high burden countries that attained Millennium Development Goal 6.(9) However, it is also widely acknowledged that the uncertainty around the estimates, a weak surveillance system coupled with lack of vital registration, limit the country’s ability to make firm conclusions regarding observed trends. At the time of the audit, the country was finalizing its TB prevalence survey, which is expected to provide an updated picture of the TB burden in Uganda.

Malaria

Ugandans are the fifth largest population at risk of malaria in the world and the country accounts for 4% of the global burden. The country is ranked 3rd out of the 18 countries that account for 90% of P. falciparum infections in Sub-Saharan Africa.(10) Uganda has made significant progress in reducing malaria burden as shown by:

  • malaria prevalence in under 5 children decreasing from 42 percent in 2009 to 19 percent in 2014/15; and
  • increase in household ownership of at least one bed net from 47% in 2009 to 90% in 2014/15. Bed net usage among children under 5 increased from 33% in 2009 to 74% in 2014/15.

However, malaria remains a major public health problem accounting for 30%-50% of the outpatient cases, 15-20% of admissions and 9-14% of inpatient deaths in Uganda.(11)