Challenges

Inequity

Although stunting has decreased across Uganda, inequalities persist. Research indicates a slight narrowing of inequalities during our study period, but at the current pace of progress, it will take decades for the gaps to close.

We can examine inequities across several axes. First, inequities occur geographically. In 2016, regional stunting rates ranged from 35 percent (Western) to 24 percent (Eastern). This gap is slightly smaller than the gap in 2000 because the Western region, although still the most stunted region in the country, also experienced the most improvement during our study period, as measured by average annual rate of change. At the district level, the ranges are much wider—as low as 5 percent (Kween) and as high as 85 percent (Bududa). Reasons for these regional inequities are many, including different cultures and traditions around food, varying levels of access to health and education, and different levels of political commitment and effectiveness.

Second, inequities exist according to wealth. Although children in the richest wealth quintile are least likely to be stunted and children in the poorest wealth quintile are most likely to be stunted, this inequality has narrowed over time. In 2000, the difference in stunting prevalence between the richest and poorest wealth quintiles was 20 percentage points, but by 2016, the difference had declined to 14 percentage points.^{1, 2} There are also two composite indices that measure the extent of socioeconomic inequality in stunting burden: the slope index of inequality (SII) and the concentration index (CIX). SII values, and to a lesser extent CIX values, improved between 2000 and 2011, suggesting a reduction in inequalities during that period.³ However, according to both indices, inequalities increased between 2011 and 2016.

Third, inequities can be examined by place or residence. Disparities between children living in urban and rural areas have existed for the entire study period but have declined over time, from a 14 percentage-point gap in 2000 to a 7 percentage-point gap by 2016. Unfortunately, one reason for this narrowing gap is that stunting increased in urban areas between 2011 and 2016,^{2, 3 ,4} a sign that accelerating urbanization may be placing unsustainable pressure on urban economies.

We conducted another analysis using kernel density plots to shed light on stunting and inequality over time.³ These graphs represent the full distribution of child growth height-for-age scores in a population in any given year. Ideally, over time, the curve moves to the right and gets taller and narrower, signifying an increase in the average score and a higher concentration of children at a healthier mean, and thereby increased equity. Uganda’s curves follow this ideal pattern. Although the 2011 curve is flatter than the 2006 curve, the 2016 curve is taller and narrower than the 2011 curve—and much more so than the 2000 curve, indicating an increase in equity over time.

In other Exemplar countries, we have seen examples of interventions with a focus on narrowing inequalities, usually by geography or wealth or income. Uganda has had some success with similar interventions such as its anti-poverty programs, which are targeted by district. Donors have worked overwhelmingly in the troubled Northern region, which has kept stunting rates down in that region compared with the Western region, which receives less attention from donors. In addition to targeting, fully supporting the process of decentralization can lead to more equitable outcomes by ensuring that local governments have the resources to function efficiently.

Breastfeeding and complementary feeding

Our analysis of Uganda’s child growth curves suggests that improved practices in breastfeeding and complementary feeding remain challenges.³ Although babies were born progressively larger over time, probably in large part because of improved maternal health and nutrition, they continued to experience immediate growth faltering in the first 6 months, which suggests inadequate breastfeeding practices. More recent curves show some catch-up growth over time, but the curve still shows a steep drop until 20 months, the time frame during which complementary feeding becomes key to growth and development.

Other data supports these findings. In Uganda, the prevalence of exclusive breastfeeding has remained relatively stagnant over time; in 2000, 63 percent of infants under six months were exclusively breastfed, compared with 66 percent of infants in 2016. The average duration of breastfeeding in Uganda was also unchanged, equaling 19.7 months in 2000 and 19.8 months in 2016. Early initiation of breastfeeding, however, increased considerably, from 30 percent of infants in 2000 to 66 percent in 2016.^{1, 2} Indicators of complementary feeding in Uganda declined during our study period. In 2016, only 15 percent of infants ages 6 to 23 months achieved the minimum acceptable diet to ensure optimal growth and development, a decline from 24 percent in 2006.

For the past generation, the government has attempted to encourage breastfeeding.^{5, 6} In 1995, Uganda introduced the Baby Friendly Hospital Initiative to improve hospital procedures to support optimal breastfeeding practices, and respondents agreed that the initiative has played an important role. However, progress plateaued, and national-level respondents noted that some private facilities encourage child formula feeding. Most health- and nutrition-related policies and programs mention feeding practices, but many of these strategies have fallen short in meeting their objectives due to a lack of training among health workers, gaps in human resources, and inadequate financial resources.

In our qualitative analysis,³ key stakeholders and mothers repeatedly touched on the importance of health workers and facility visits for providing education and counseling on good breastfeeding practices. Despite this improved knowledge of infant and young child feeding, there are many barriers to proper breastfeeding. In poor households, mothers are forced to leave infants at home with older children or helpers to search for work. Mothers in Tooro, where stunting has remained stagnant, cited issues with not producing enough milk. In addition, the indirect effects of improved women’s education and empowerment have meant that more mothers have gone back to school or are working away from the home, particularly in cities, so infants may not receive breast milk routinely. Even in communities like Teso where stunting has declined, cultural norms discourage breastfeeding while pregnant, and therefore properly spaced births become even more important. Future policies and programs should focus on maternity leave and other rights-based approaches to ensure that mothers can adequately care for their infants while maintaining their roles in the economy.

Our qualitative findings also supported the idea that there are challenges associated with complementary feeding in Uganda. Overall, the timing of complementary feeding, which ideally begins around 6 months, was noted to be poor; some mothers introduced foods early (at about three months of age) and some late (around eight or nine months), with nutritional consequences in both cases.

Recent multisectoral initiatives, such as the National Agriculture Policy (2013) and the Harvest Plus Meals for Nutrition in Uganda Project (2016), show promise for improving stunting rates by using a combination of tools, including community engagement, systems strengthening, expansion of nutrition-sensitive agriculture, and increased nutritional education to improve dietary diversity and complementary feeding. However, there is a need to involve men in the intervention strategies to reduce stunting because they play an important decision-making role in households.

Climate change

Uganda is particularly vulnerable to the effects of climate change, both because extreme weather is increasingly common and because, as a society that relies on rain-fed agriculture, this extreme weather is devastating to people’s livelihoods.⁷

Since the 1960s, the average temperature in Uganda has increased by 1.3°C, annual and seasonal rainfalls have decreased, and droughts have become more frequent and longer lasting.

In addition, although Uganda has always been at a high risk of natural disasters, that risk is increasing.⁸ Between 1990 and 2018, the country experienced 20 floods, 9 droughts, and 5 landslides. Between 2004 and 2013, droughts affected almost 2.5 million people, and given that the droughts destroy harvests, the losses are significant. In the particularly bad years of 2010 and 2011 alone, economic losses amounted to US$1.2 billion. Meanwhile, floods, which are more common in urban areas, affect approximately 50,000 people and cost roughly US$62 million each year.

Our interviews were perhaps better at capturing the threat of climate change than aggregate statistics.³ A key informant in Kasese District in Western Uganda said that while farmers there “are trying to be hardworking,” they suffer “because floods come, they take; landslides come, they take, but also the little that remains, you have dry spells,” so there is “nothing to harvest at the end.” A mother in Kasese said, “We have the knowledge to feed our children well because we have been educated by our nurses and other organizations to feed our children well, but now, you plant crops, and the floods take away the crops.” A national-level informant called Kasese “a natural catastrophe.”

Out-of-pocket health expenditure

Health care in Uganda is financed by the government, health development partners, and individuals making out-of-pocket payments to private providers. The largest share—40 percent of the total—comes out of pocket, a reflection of the shortcomings of the public health system.⁹ That figure is higher than the sub-Saharan African average of 34 percent, and these out-of-pocket payments create economic hardship for families. According to a study that used data from the 2016/2017 National Household Survey, 14 percent of Ugandan households were forced to make catastrophic health payments that exceeded 10 percent of their income.¹⁰ Furthermore, 3 percent of households were driven into poverty by health costs.

Out-of-pocket payments are a challenge across low- and middle-income countries, but catastrophic payments were found to be more common in Uganda than in peer countries such as Kenya, Rwanda, Zambia, South Africa, Tanzania, and Ghana.¹⁰

COVID-19

As of March 2022, approximately 165,000 Ugandans have been infected with COVID-19, and approximately 3,500 have died from the disease.¹¹

Although the direct impact of the disease is slightly lower in Uganda than in some neighboring countries (potentially due to previous success containing Ebola), the indirect impacts have been devastating, especially in the three areas highlighted in this report as key to the recent stunting decline: poverty reduction and food security, health, and education. Although good data is hard to come by, it is clear that poverty and food insecurity have risen, health care is harder to access, and schools have been closed. School closures have not only led to a lost year of learning, they have also had devastating ripple effects, including a 20 percent spike in teen pregnancies¹² and an increase in child labor.¹³

According to the World Bank, “the COVID-19 shock caused a sharp contraction of the economy to its slowest pace in three decades.”¹⁴ The country’s GDP contracted by 1.1% in 2020. The urban informal sector was hit particularly hard, and many Ugandans shifted to the agricultural sector to support themselves. This transition, the World Bank says, has “heightened the urgency for the country to enhance sustainable use of natural resources.”

Before variants began to emerge, the Ugandan economy appeared to be recovering, with GDP growth of 3.3 percent during the 2021 fiscal year. It remains to be seen whether variants will stop this recovery. It also remains to be seen how quickly Uganda can procure the supplies it needs—especially the vaccines—to end the pandemic and return to its growth trajectory.