Challenges

Uganda has made great strides in reducing the prevalence of anemia among women of reproductive age (WRA). Despite this progress, substantial challenges remain and can be categorized broadly as follows:

• The impact of natural disasters and climate change
• The lingering effects of social and economic inequality
• Effects of food insecurity, low dietary diversity, and body mass index
• System sustainability, including financing and monitoring

Current and future impacts of natural disasters and climate change

Subsistence agriculture is integral to Uganda’s people for their well-being, particularly in rural settings; 72% of Uganda’s workforce is employed in the agriculture sector.¹ However, the country is historically prone to large-scale natural disasters, including floods, droughts, earthquakes, and landslides.

These disasters have disrupted the livelihoods of the Ugandan population through damage to property, infrastructure, crops, and agricultural land, thereby worsening food insecurity. Widespread deforestation deepens the nation’s vulnerability to soil erosion, landslides, and other hazards; between 2000 and 2016, Uganda’s total forested area decreased by 14%.²

One factor that potentially acts as both a catalyst and result of widespread deforestation is human-driven climate change—a global crisis that Uganda has done very little to cause but that could have a disproportionately severe effect on the nation and its East African neighbors.

As the United Nations International Organization for Migration has observed, climate change has already disrupted seasonal patterns in Uganda, putting even more pressure on the drier parts of the country and heightening the risk of devastating floods.³

If these developments are not addressed in time, the gains Uganda has worked hard to achieve—including in such vital areas as nutrition and malaria reduction—could be threatened.

Lingering effects of social and economic inequality

While income inequality (as measured by the Gini coefficient) has narrowed,⁴ Ugandans continue to experience profound inequalities. Anemia prevalence is consistently lower among WRA from the richest, most educated, and urban households. Additionally, anemia prevalence among non-pregnant women increased from 22.1% in 2011 to 30.9% in 2016.^5,6

Disaggregating anemia prevalence by region, wealth quintile, urban and rural residence, and maternal education level reinforces this theme of inequality and may explain the observed increase in anemia prevalence from 2011 to 2016.

Regional disparities in health outcomes highlight inequalities in Uganda. The Northern Region saw the lowest decrease in anemia prevalence among WRA between 2006 and 2016, from 45% to 41%.^5,6 The relatively arid Northern Region has a persistently high anemia burden, and improvements in the region are occurring more slowly than elsewhere.

The maps in Figure 17 illustrate the progress of the regions in reducing anemia during the study period.

Gaps in anemia prevalence by wealth quintile and urban versus rural residence decreased in 2011; however, the gaps grew wider again in 2016. In particular, anemia prevalence among WRA in the lowest wealth quintile saw a sizable increase from 29% in 2011 to 41% in 2016.^5,6 Similarly, anemia prevalence among WRA living in rural areas increased from 24% in 2011 to 33% in 2016.^5,6

In contrast, gaps in anemia prevalence by maternal education narrowed both in 2011 and 2016; in parallel, mean years of education increased from 5.0 years in 2006 to 5.8 years in 2011 and to 6.5 years in 2016.^5,6,7 This may highlight the importance of improving outcomes across different dimensions of inequality. Improvements in maternal education led to improvements in anemia reduction, but it was not enough to offset widening gaps across regions, wealth quintiles, and urban versus rural residence. High school dropout rates remain high, compromising the long-term economic, social, and health prospects of many Ugandans for decades to come.

It is worth noting that even relative gains in areas such as sanitation and education are not yet universal.

Although improved sanitation has become more widespread, only about one-fifth of Uganda’s population has access to it.⁶

Dietary diversity, food insecurity, and body mass index

Like many lower-income countries, Uganda struggles with low dietary diversity, with lack of income and affordability of nutritionally diverse and nutrient-dense foods cited as contributing factors. Low dietary diversity can lead to widespread nutrient deficiencies, increasing vulnerability to diet-related disorders such as anemia.

A 2018 analysis found that while maintaining a balanced diet in Uganda was relatively inexpensive,^8,9 many people still face challenges in accessing it. Additionally, while Ugandan women receive nutritional counseling, they are often financially constrained from acting on that guidance.

Dietary diversity is further hindered by seasonality in some regions, affecting the food supply of nutrient-dense foods such as tubers, fruits, and vegetables. This often leads to overreliance on less nutritious staple crops. Cultural practices, such as soda-ash cooking, can also lead to loss of nutrients.

“During the dry season, there are no greens, but you are eating the dried potatoes every day with water only. Even fresh potatoes are not there right now. For us here in the village during the dry season, we chop sweet potatoes and dry them, someone cooks the dried sweet potatoes, brings a cup of water, and eats.” (Key informant, Pallisa District)

Broader economic factors, such as the rise of commercial agriculture, further reduce crop diversity and land available for household-level production. Instead of engaging in balanced small-scale agriculture for household consumption, many rural families feel compelled to engage in commercial farming—and often must sell what little produce they generate, which results in them buying nutrient-sparse foods to feed their families.

“There is a shift from cultivating food crops to cash crops. Like in most of these regions, most of these people are cultivating rice, so they put all their efforts on rice. In other places—not here, but places like in Busoga— they are cultivating sugar cane, and people are mostly consuming one type of food. The diversity or variety is not there.” (Key informant)

Food insecurity

Beyond low dietary diversity, Uganda also faces substantial food insecurity. According to the Food and Agriculture Organization of the United Nations, the three-year average prevalence of moderate or severe food insecurity in Uganda from 2014 to 2016 was 66.3%.¹⁰ This was partly due to natural disasters¹¹a like floods, landslides, and dry spells, which have led to crop losses and reduced livestock productivity.¹² The rise of diseases such as cassava brown streak and other banana-related diseases have further diminished food availability.

Population growth has also reduced agricultural land, exacerbating food insecurity. The decline in food production, coupled with the use of land for cash crops, has intensified the challenge for many families.

“[N]ow first food is scarce, and it is not accessible to everyone. This is because there are limited gardens, so some people are forced to buy food. Back in time food was there because [there] was a lot of land and cassava was also available and they never used to sell of their food but now the little is still being sold so people remain with nothing in their homes to eat.” (Focus group participant, Pallisa District)

Body mass index

At the other end of the spectrum of nutrition-related challenges is an increased incidence of overweight and obesity, which often accompanies rising urbanization and incomes. Although these developments have contributed to anemia reduction, they have also coincided with increased consumption of highly processed foods, which are often cheaper, readily available, and more aggressively marketed than more nutritious options. As Figure 19 illustrates, the proportion of Ugandan women who are overweight increased by 7 percentage points between 2006 and 2016.^6,7 The Ugandan health system is not currently equipped to respond to the increase in body mass index or the associated wave of noncommunicable diseases that will likely follow.

“In the urban areas, we see a shift because of refined foods. You find that they are not consuming what’s required and you find that they are eating more of the junk food, and they are not eating local food.” (Key informant)

System sustenance including financing and monitoring

One challenge for Uganda moving forward may be maintaining sufficient public spending to sustain progress in reducing anemia and addressing other major public health problems. In a low-income country such as Uganda, the levels of individual and household wealth may not be sufficient to ensure reliable access to necessary medical care.

Government expenditure on health per capita increased from US$32 in 2003 to US$56 in 2007.¹³ Since then, however, health expenditure per capita decreased to US$44 in 2011 and has remained relatively stagnant. Following a similar trajectory, out-of-pocket expenditure on health was US$12 in 2003, after which it increased to US$21 in 2007 and gradually decreased to US$18 in 2014 and has remained stagnant since. Out-of-pocket expenditure can result in greater financial strains, particularly for low- and middle-income populations.

As illustrated in Figure 20, health expenditure in Uganda decreased from 2007 to 2011, and has remained stagnant since 2011.

Budget allocations for nutrition-specific and nutrition-sensitive programs and policies are currently integrated within larger social and economic sector activities, with no dedicated budget line for nutrition. This has complicated the ability to track nutrition-specific budgets and expenditures and their associated performance indicators and intended program outputs. For instance, the amount of money allocated for water, sanitation, and hygiene or food production had been aggregated over several fiscal years in the last two decades.