Why is Uganda an Exemplar?

Uganda’s stunting rate has declined steadily for the past 30 years. In 1988, 48 percent of children under five were stunted. By 2016, the rate had decreased to 29 percent. The pace of progress has also accelerated over time. Between 1988 and 2009, the stunting rate dropped by 10 percentage points (from 48 to 38 percent). In just the next seven years, from 2009 to 2016, it dropped by almost as much, decreasing by 9 percentage points (from 38 to 29 percent).

As with other Exemplar case studies, the most important takeaway from our research is that Uganda’s success is multisectoral—it is not due to a single intervention or progress in any one area but is a result of the combined impact of interventions and progress across many areas. Beginning in the 1990s, as Uganda began to stabilize after years of war and implemented effective policies, development indicators improved across the board.

The second most important takeaway from our research is unique to Uganda compared with other countries we have studied. In Uganda, the first stunting Exemplar with a high burden of malaria, we found that ownership of insecticide-treated bed nets—a proxy for the country’s rapid progress in controlling malaria—contributed more than any other factor to the increase in children’s height for age (HAZ) scores.¹ Overall, further research is needed on the causal relationship between malaria and stunting, but our analysis demonstrates that, at least in some cases, they are tightly linked.

In terms of its multisectoral progress, Uganda has achieved especially large gains in the areas of poverty reduction, health, nutrition, education, and water and sanitation:

• Poverty reduction—Between 2002 and 2016, Uganda’s extreme poverty rate (< US$1.90 per day)²
• Health—Between 2000 and 2016, the child mortality rate dropped by two-thirds³ and the maternal mortality ratio dropped by one-third.⁴ Between 2009 and 2014, the number of households with at least one bed net doubled.⁵
• Nutrition governance and political support—Uganda joined Scaling Up Nutrition (SUN) in 2011 and has increasingly incorporated nutrition into national policy while creating technical bodies for implementation.⁶
• Education—In 1990, the literacy rate among 15- to 24-year-olds was 70 percent.⁷ By 2018, it had increased to 90 percent, and young women were just as likely as young men to be able to read.
• Water and sanitation—Between 2000 and 2016, access to improved sanitation quintupled, access to basic drinking water doubled, and open defecation declined by more than half, although there is significant room for continued improvement across all of these indicators.⁸

Across these areas, the following common themes emerged to explain how Uganda succeeded:

• Women’s empowerment—Both qualitative research and quantitative proxies of empowerment suggest that women gained decision-making authority over time.
• Decentralization—Power has moved from the central government to local governments. This process has resulted in more responsive policies and programming throughout the country, but it remains incomplete. Gains will accelerate as local governments are adequately resourced to fulfill their responsibilities.
• Donor coordination—For decades, Uganda has received steady support from donor countries and organizations. Although the reliance on donors poses risks (because support could disappear), and despite evidence that donor support is not as coordinated as it could be, the ongoing contributions of donors have helped drive progress, especially in the health sector.

At 29 percent, Uganda’s stunting rate is still relatively high, and there is no guarantee that it will continue to decline as it has for the past three decades. After falling for many years, the poverty rate started to tick up again between 2013 and 2016,⁹ the most recent year for which we have data. Climate change may have contributed to the recent reversal in progress against poverty, and in any event, climate change poses a grave threat to an agricultural economy in the years to come. Moreover, with the COVID-19 pandemic still raging, the breadth and depth of the impact of a global pandemic on poverty and other development outcomes remains to be seen.

Given these challenges, Uganda will need to focus on what has worked in the past to continue reducing stunting rates. Sound policies across relevant ministries, departments, and agencies, along with political will and careful implementation, are the pathways to continued progress in nutrition and a brighter future for millions of young Ugandans.