How did Uganda implement?

Women’s empowerment

Women’s empowerment and development outcomes are mutually reinforcing. Empowerment can lead to positive development outcomes, as women are able to make more decisions about health, education, nutrition, and spending overall. Similarly, positive development outcomes can lead to women’s empowerment because women who are healthier, wealthier, and better educated are more likely to fulfill their potential and, in some cases, challenge constraining norms.

Empowerment is difficult to measure quantitatively, but we can examine changes in proxy indicators, including maternal education, fertility, age at first marriage, and age at first birth. In the case of all these proxies, Uganda’s performance has improved significantly since the turn of the millennium. Age at first marriage increased slightly from 17.8 years in 2000 to 18.9 years in 2016; the total fertility rate declined from 6.9 births in 2000 to 5.4 births in 2016; child marriage, or the proportion of women 20 to 24 years who married by age 18, decreased from 54 percent in 2000 to 34 percent in 2016; and the adolescent fertility rate declined from 167 births per 1,000 girls in 2000 to 132 in 2015.¹

Our qualitative research may provide more insight into the changing role of women in families and communities over time. All respondents cited empowerment as a facilitator of stunting reduction. Women in Teso, a community that has seen substantial improvements in stunting, discussed how their increased financial autonomy, in many cases facilitated by the proliferation of well over 20,000 Village Savings Groups, led to greater decision-making authority about family spending. “The people’s well-being has improved these days since both women and men are engaged in money-making activities, unlike the previous years,” said one mother. Another said that women’s earning power “has enabled them to work together [with their husbands] to educate their children, who have successfully completed their studies and got jobs.” One mother put it succinctly: “As I speak now, women can stand in for their families and feed their children.” In Uganda overall, survey data confirms these sentiments. Between 2000 and 2016, women who reported making family planning decisions jointly with their husbands increased from 45 percent to 62 percent, and women who reported making decisions jointly about household purchases increased from 27 percent to 47 percent.¹

In contrast, women in Tooro, a community in which stunting rates have stagnated in recent years, explained the ways cultural norms, especially the frequency of domestic violence, have continued to dictate decisions about childbearing and child rearing. “Some men don’t support their wives to buy food, such as porridge for the children … and the mother cannot manage alone,” said one mother from Tooro.

In general, gender empowerment is more of a secular trend—a response to many interacting forces in society—than a discrete outcome of public policy. Nevertheless, Uganda’s government and some donors have developed strategies and programs to improve empowerment and gender equality. Most notably, the political representation of women was guaranteed in a quota system of reserved seats imbedded in the 1995 Constitution, and the number of reserved seats has gradually increased over the years in Uganda. The proportion of women in the Parliament has increased from 18 percent in 2000 to 34 percent in 2016.² 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.

Decentralization

Over the past generation, many low- and middle-income countries have undergone a process of decentralization, which distributes power from national to local governments. The theory behind decentralization is that local governments will empower local people to make demands of government and will be more responsive to those demands. In practice, however, decentralization has not always gone smoothly because the local governments have not always been equipped to perform their new duties. In many countries, local governments do not have the funds or the training to fully carry out their new responsibilities. The results of decentralization have therefore been mixed. In many instances, local governments focus more on the concerns of the local population, but they do not always have the resources at their disposal to provide high-quality services.

The story of decentralization in Uganda follows a similar pattern. Decentralization was enshrined as government policy in the 1995 Constitution.³ That same year, the Local Government Act decentralized the federal government and devolved its functions, powers, and services upon local governments. This legislation worked in tandem with the 1997 Decentralization Policy, which decentralized service delivery institutions and delegated their governance to local governments.

Respondents in our study agreed that decentralization has made governments more responsive and increased the quantity of key services including health and education. However, although the process of decentralization started with significant momentum and the rapid creation of local bodies, there was broad reported agreement that some of that momentum has been lost over time.⁴  

Overall, local authorities in Uganda remain under-resourced and under-staffed 20 years into decentralization.³ Therefore, district decentralization plans, although typically well-conceived, are rarely achieved because of inadequate commitment, capability, and collaboration.

Most of the funding available to local governments comes from grants made by the central governments, and restrictions on how to spend most of those grants undermine the autonomy of local authorities. In 2015, a new Public Finance Management Act required local governments to receive authorization to take out loans, further limiting their financial autonomy.

In addition, the problems of limited resources and staffing keep worsening because the number of districts continues to grow, from 33 in 1986 to 137 in June 2012.^{5, 6} Although the creation of more districts responds to the demand for government that is closer to the people, new districts often struggle with leaders who lack the experience to operate efficiently.⁶ According to a 2019 report, “Some district staff structures still operated as low as 13% percent [filled] for most new districts.”⁷ “District leadership is not strong,” summarized one key informant in Kasese District in Western Uganda. “For instance, not all departments know that nutrition is a cross-cutting issue that should be prioritized in the district work plan, other than talking about it.”⁴

Despite these challenges, there is no standing institution dedicated to implementing decentralization and making reforms based on barriers that arise to local governance. Furthermore, the Joint Annual Review of decentralization prescribed in the law was suspended in 2016 due to budget constraints. As a result, outcomes in key development areas vary widely from district to district, in part because each district faces different challenges and in part because the leaders of some districts lack experience and skill. The promise of decentralization remains, but it will not be fulfilled until local governments receive the support they need to achieve stability and fund their day-to-day operations.

Development assistance

Uganda has long been a major recipient of foreign assistance, especially because it worked closely with the International Monetary Fund, World Bank, and major bilateral donors to liberalize its economy in the 1990s.⁹ Between 2003 and 2012, the country received more than US$16 billion in official development assistance, ranking it as the 13th largest recipient worldwide. This history of support has helped Uganda achieve gains in poverty reduction, health, and education, but it also leaves the country vulnerable to unpredictable shifts in how much money is available. In 2020, for example, the United Kingdom, which had been the second-largest bilateral donor to Uganda, cut its disbursements by more than half.

To varying extents, the Ugandan government has relied on donor funding for large parts of its budget. At its highest point in 2006, official development assistance (which is managed by the Office of the Prime Minister) accounted for more than 40 percent of the budget, although the proportion is typically closer to 25 percent. The health sector is the largest recipient of donor funding. In 2017, the amount of donor funding for health was US$17 per person, more than twice as much as Ugandan government spending of US$7 per person.¹⁰ Some critics have argued that aid to health programs has enabled the government to under-fund health and move funds that would have been used to pay for the health system to other priorities, including military spending, that do not improve Ugandans’ well-being.¹¹

Donor-funded agencies, especially the Global Fund, the President’s Malaria Initiative, and the President’s Emergency Plan for AIDS Relief (PEPFAR) have been especially pivotal in improving rates of malaria and HIV in Uganda. Uganda’s progress in reducing HIV has been as impressive as its progress in reducing malaria and likely played a role in reducing the malnutrition burden.¹² Between 1990 and 2017, there was an 88 percent decline in deaths from HIV/AIDS.¹³ Similarly, the percentage of adults and children taking antiretroviral medication increased from 21 percent in 2010 to 50 percent in 2014.

The Global Fund has signed agreements with Uganda totaling more than US$2 billion.¹⁴ As of 2018, the President’s Malaria Initiative had disbursed approximately US$350 million in Uganda.¹⁵ Including 2022, PEPFAR’s planned disbursements in Uganda total US$5.6 billion.¹⁶ However, these programs tend to work vertically instead of integrating horizontally with Uganda’s health system, raising questions about sustainability.

Overall, the evidence suggests that although Uganda made strides toward tighter donor coordination around the turn of the millennium, donor activity has become more fragmented in recent years.¹⁷ In the late 1990s, in collaboration with donors, Uganda launched the Poverty Eradication Action Plan and the Health Sector Strategic Plan. These plans were intended to be funded in a coordinated way by the Poverty Action Fund and through general budget support according to a sector-wide strategic approach. The hope was that this shift away from individual project-based support would increase efficiency, effectiveness, and country ownership.

However, partly as the result of several corruption scandals that undermined donor confidence, these plans have not come to fruition.¹⁸ For example, in 1999–2000, donors provided approximately half of the funding for the Poverty Action Fund. By 2007–2008, they provided just 11 percent. In recent years, about half of the development assistance for health has come in the form of off-budget, project-based funds. The result of this return to project-based funding has increased duplication and fragmentation.¹⁹

In recent years, ODA has increasingly shifted from grants to concessional loans. Between 2019 and 2020, for example, grants decreased by 8 percent, but loans increased by 124 percent. This pattern was accelerated by the COVID-19 crisis, but it was evident long before the pandemic. Although loans provide Uganda with steady capital, the burden of paying them back over the years may be a drag on economic growth and development.²⁰

Without a doubt, development assistance in Uganda has contributed to the country’s improvements across many key development indicators. However, it is likely that the impact could be even greater if the Ugandan government and the donors were more aligned in terms of their goals and coordinated in terms of strategies for achieving those goals.