How did Uganda implement?

Multisectoral commitment to nutrition

A hallmark of Uganda’s anemia policy is a comprehensive and multisectoral approach. The national government has drawn upon resources and ideas from a broad range of agencies and disciplines, and from actors across the private and public sectors.

The first manifestation of the country’s commitment to curbing anemia was the National Anemia Policy of 2002,¹ which several interviewees cited as a critical foundation for subsequent efforts, such as iron and folic acid (IFA) supplementation.

“The [National] Anemia Policy was very clear that addressing anemia among women of reproductive age and adolescents was important for national development, and if we helped mothers to reduce anemia, we would have fewer mothers dying as a result of medical complications—and it is the same policy that government employed to ensure that IFA is available at the facilities.” (Uganda Ministry of Health representative)

From this initial statement of national intent grew an eventual commitment to multisectoral collaboration. In 2011, Uganda joined Scaling Up Nutrition (SUN), an international alliance of governments, multinational agencies, corporations, and NGOs that aims to end all forms of malnutrition by 2030. As part of its participation in SUN, Uganda established the Uganda Nutrition Action Plan (UNAP), which aimed to address the primary causes of undernutrition through a diverse and locally tailored approach focused on the needs of mothers and young children.

Uganda made substantial progress in improving nutrition outcomes during the first phase of UNAP. From 2011 to 2016, the percentage of pregnant women receiving IFA supplementation increased from 75% to 88%,² while the proportion of women of reproductive age (WRA) taking iron supplements for more than 90 days increased from 4% to 23%.² These advancements were critical in addressing iron deficiency, a leading cause of anemia, and reducing its prevalence. Interviewees in our study—at the multinational, national, and district levels—highlighted UNAP as a vital mechanism for coordinating nutrition-related activities across sectors, helping to drive these improvements.

“The Uganda Nutrition Action Plan is quite comprehensive. It defines the action of a multisectoral approach among the different sectors, such as the Ministry of Health and Ministry of Trade, and their [respective] contributions to reduce maternal anemia.” (NGO key interviewee)

SUN and UNAP also established the multisectoral approach as the new expectation for how the country would address anemia and other nutrition-related issues. Alongside the development of UNAP, Uganda also created national-level coordinating bodies, including the UNAP Secretariat, the Multi-Sectoral Nutrition Technical Coordination Committee, and the Uganda Nutrition Coordination Forum, along with district nutrition coordination committees for subnational planning and implementation.

These institutions have their distinct roles, but they share an overarching mandate to foster collaboration among development partners, the private sector, and community social organizations in achieving UNAP’s objectives. For example, the Uganda Nutrition Coordination Forum—a gathering of governmental department heads, NGO administrators, and business leaders—meets twice a year to review implementation and provide guidance on nutrition policy.

National-level respondents in our study mentioned that a strength of Uganda in its efforts to reduce anemia is a broad receptivity to new ideas and innovations in nutrition, which may be related to its embrace of multisectoral strategies to improve nutrition outcomes.

Local tailoring of health and nutrition policymaking

Interviewees highlighted local tailoring of health and nutrition policies as a feature of Uganda’s anemia strategy that is closely related to the country’s multisectoral approach. In fact, the implementation of UNAP explicitly called for devolution of important decision-making responsibilities from the national to the local level.

This reflects a shift in Uganda’s approach to health policy and to governance more generally. By the mid-1980s, the nation’s health system was facing severe challenges . In response, officials began to implement a more localized approach to administration and patient care.

In 1995, the national constitution was changed to enable a sweeping transfer of powers from the central government to district and local authorities.³ Two years later, a new decentralization policy specifically provided for the delegation of governance authority to local governments.⁴

Interviewees reported that local tailoring of policies had enabled local governments to improve quality and access for essential services such as health care and education. In some cases, this was a relatively straightforward matter of increasing the number of health facilities and shortening the distance the average Ugandan had to walk to receive basic care.

“It [local tailoring] might have had an impact on the reduction of maternal anemia among women of reproductive age. There are no issues of transport, you just walk for your antenatal, you are screened, managed, treated, and you can even deliver from that health facility. Maternal service has changed. In the last 20 years we used to have only district hospitals. Imagine—previously the nearest hospital was over 70 kilometers [away] and mothers had to travel early to get maternal health care services.” (Hospital official, Mbale)

“[Local tailoring] has impacted maternal malnutrition positively. With decentralization came other private health providers like clinics and drug shops in communities that provide health services to the communities.” (Health office official, Buyende District)

Empowerment of local governments was central to the UNAP for 2011–2016,⁵ which called for local deployment of national strategies. To steer implementation, coordination committees linked central government officials with local public-sector and private-sector contacts.

Concurrently with that program, Uganda implemented Strengthening Decentralization for Sustainability from 2010 to 2015, a campaign funded by the US Agency for International Development to improve the effectiveness of devolved health services nationwide. Interviewees said the program provided financial support for community outreach efforts in areas such as nutrition and family planning.

While such initiatives suggest the lasting influence of local tailoring, Uganda faces numerous challenges in making this approach to governance truly effective. Inadequate staffing and resources has undermined efforts to devolve authority from the central government to more localized entities. The legally mandated joint annual review of the localization process was suspended in 2016 due to a lack of funding, and there is no standing institution dedicated to ensuring the effective implementation of the decentralization program.

As a result, outcomes have varied widely from district to district—and these variances have tended to favor districts that already enjoyed certain advantages. For example, districts without hospitals or large health centers could not benefit fully from some nutrition interventions (e.g., IFA supplementation) that were delivered through these facilities.

Deployment of village health teams

An important component of Uganda’s local tailoring of health and nutrition services is the village health team (VHT) program. Local empowerment gave the district and local levels heightened importance and authority in the overall delivery of such services, and VHTs are the first point of contact with patients at those levels.

Respondents repeatedly emphasized the importance of the role of VHTs in bringing critical health care services to the community—and the effectiveness of their efforts. They are crucial to the story of Uganda’s successes in anemia reduction and in several other areas of public health.

The Ministry of Health established the VHT program in 2001 to alleviate a health worker shortage and to improve equity in access to services.⁶ It is made up of volunteer health workers selected by their own communities. As of 2023, these individuals have worked on a volunteer basis, and in most cases, they maintain income-generating jobs alongside their VHT duties. Between 2001 and 2015, nearly 180,000 people were trained by the VHT program.

Development partners have played a crucial role in strengthening the VHT program. The US Agency for International Development,⁷ World Health Organization,⁸ and United Nations Children’s Fund (UNICEF)⁹ have contributed funding, technical assistance, and training to enhance VHT capacity, ensuring improved community health services in coordination with the Ministry of Health .

VHTs provide a variety of community-based preventive and health promotion services, including immunizations. They have played a central role across a range of interventions related to the prevention and treatment of anemia among WRA. These include nutrition education and health behavior change, an area where VHTs have made a notable difference.

“Bukedi is ranked among the poorest region and those days, the VHTs were not there, so when you go deep, deep in the villages, the feeding was actually very poor. So, when these VHTs were enrolled, they went deep there, and educated them on feeding and the food crops they should grow. So we saw things improving slowly.” (Uganda Ministry of Health representative)

IFA supplementation was another nutritional intervention in which VHTs played a prominent role.

“Previously, we were giving ferrous [treatment] and folic acid to the pregnant mothers at the health facilities alone, but now the VHTs conduct monthly community outreaches to improve blood-hemoglobin levels of the pregnant women.” (Hospital staffer, Pallisa District)

Antenatal care can be a crucial intervention, given the heightened anemia risks associated with pregnancy and childbirth. Interviewees also emphasized the value of VHT outreach in antenatal care.

“There is a great improvement in antenatal uptake in this community, and there is also a reduction in maternal anemia in this community. For antenatal [care], I think the improvement is due to the role played by the VHTs.” (Health center worker, Buyende District)

To prevent unintended pregnancies, VHTs provide family planning education and distribute contraceptives. In addition, they distribute bed nets, conduct malaria testing, and provide antimalaria medications, which are highly effective interventions due to malaria’s tendency to reduce the supply of red blood cells.

Through these and other engagements, VHTs have earned the trust of community residents and increased access to health care.

“There is a big difference. Previously … people would die a lot because of anemia. … But since [then] there has been a lot of health education or sensitization done, and the VHTs also have done a lot of work amongst us. They have gone on educating people, and there has been a change.” (Focus group participant, Buyende District)

A 2015 national assessment of VHTs by the Uganda Ministry of Health found that most rural community members recognized the presence of VHTs in their areas and considered their services highly relevant to local health needs.¹⁰ These services were credited with improvements in hygiene, sanitation, immunization, antenatal care, and HIV services, and a reduction in specific illnesses and deaths.¹⁰ These findings suggest that the VHT program is widely seen as effective and functional in addressing the health challenges faced by rural communities.

While the VHT program has made notable health impacts, it faces ongoing challenges. The program is heavily reliant on volunteerism, but funding is necessary for training, essential supplies like mosquito nets and medications, and transportation stipends. The 2015 Ministry of Health assessment found that the program’s implementation varies across districts, with declining government funding shifting financial responsibility to implementing partners .¹⁰ This has led to inconsistencies in transportation allowances and drug distribution. The assessment also estimated that approximately 30% of VHTs trained since 2001 have left the program. To improve retention and motivation, the Ministry of Health recommends increased government funding, standardized and equitable financial incentives, and better provision of resources like uniforms and bicycles.⁶

Advances in women’s empowerment

Our analysis reveals that another key intervention contributing to the decline in anemia prevalence among WRA is the overall empowerment of Ugandan women. There is evidence to suggest that the rising status of women in Uganda has had a positive effect on lowering the incidence of anemia. As women and girls become better educated and more empowered, they can participate more fully in decisions about their own health and that of their children. However, despite these gains, challenges such as inadequate funding, infrastructure limitations, and high school-dropout rates among girls continue to hinder equitable access to education, particularly for young women from disadvantaged backgrounds.¹¹

Beyond education, gender empowerment in Uganda has been shaped by broader social and political efforts. Uganda’s government and its partners have developed strategies and programs to foster gender equality. Notably, the 1995 constitution guaranteed women a set number of reserved parliamentary seats, and that quota has gradually increased in subsequent years. In 2007, Uganda’s National Gender Policy aimed to further strengthen women’s presence in decision-making by increasing their participation in administrative and political processes at all levels of government.¹² Partly as a result of such measures, the proportion of women in the Parliament increased from 18% in 2000 to 34% in 2016.¹³

A broad range of respondents at national, regional, and community levels said that strengthening economic skills was another way in which the government and NGO sectors encouraged female empowerment. Over the years, various poverty eradication programs have played a role in this effort.

Building on these efforts, the Parish Development Model, launched in 2022, takes a more localized approach to poverty reduction by focusing on household-level economic transformation. The Parish Development Model aims to boost household incomes and improve living standards by integrating subsistence farmers into the money economy.¹⁴ Notably, the model allocates 30% of its fund specifically to enhance women’s access to financial resources, thereby promoting their economic empowerment within their communities.¹⁵

These initiatives have equipped women with the financial and entrepreneurial skills necessary for greater economic independence and long-term empowerment. Strengthened economic skills—which are associated with higher levels of income—enable Ugandan women to afford and improve their nutrition habits, which has major implications for maternal and child health.

One example is a government initiative to develop community-level savings groups.

“There are women empowerment programs by the government; we have women being put in groups and government gives them funding so that they are able to provide for themselves.” (Health worker)

Focus group participants affirmed that such programs are helpful in reducing poverty.

“Saving circle groups have been helpful. The women, we have been in position to develop our homes. Because when you save money and you put [it] in that group you can borrow and solve a household problem.” (Focus group participant, Buyende District)

As a result, women in Uganda have higher levels of decision-making power within their own homes, related to fundamental issues, including family planning and major purchases, as illustrated in Figure 15.