February May 2015 - European External Action Service · Final Report Prepared by: ... MCH Maternal...

European Commission

This technical assistance is funded by The European Union

Technical assistance implemented by CARDNO Emerging Markets UK

FWC BENEFICIARIES 2013 – LOT 1 RURAL DEVELOPMENT AND FOOD SECURITY

EuropeAid/132633/C/SER/multi

Specific Contract 2014/355269/1

Identification Mission for Integrating Nutrition, Gender and Reproductive Health in the EU 11

th EDF

Programme in Northern Uganda

Final Report

Prepared by:

Paul BUKULUKI – Team Leader, Gender/Reproductive Health Consultant Judith KIMIYWE – Senior Nutrition Consultant

February – May 2015

This report is financed by the European Union through the European Commission and is presented by CARDNO Emerging Markets UK for the Government of Uganda and

the European Commission. It does not necessarily reflect the opinion of the Government of Uganda or the European Commission.

KEY DATA

Name of Project: Identification Mission for Integrating Nutrition, Gender and Reproductive Health in the EU 11th EDF Programme in Northern Uganda

Contractor: CARDNO EMERGING MARKETS (UK) LTD Address Oxford House, Oxford Road, Thame, Oxon, OX9 2AH, UK Phone +44 1844 216500 Fax +44 1844 261593

Web www.cardno.com/emergingmarkets

Contracting Authority: Delegation of the European Union to Uganda

Beneficiary: Government of Uganda

Start/End Date: 09.02.2015 – 09.06.2015

Primary Location: Kampala; secondary locations: Karamoja, Teso, Lango, Acholi and West Nile

DISTRIBUTION LIST ToR: “The final report will be submitted to the EU Delegation in 10 hard copies and electronic version.”

Recipient Copies Format

EU Delegation Uganda 1 Electronic copy

ACKNOWLEDGEMENTS The Mission wishes to acknowledge the full support of the staff of the Delegation of the European Union and the staff of the national stakeholder institutions engaged. Framework Contractors’ Project Director Signature:

http://www.cardno.com/emergingmarkets

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Identification Mission for Integrating Nutrition, Gender and Reproductive Health in the EU 11

th EDF

Programme in Northern Uganda Final Report – February – May 2015

Table of Contents

Abbreviations and Acronyms ........................................................................................... iv

Executive Summary ......................................................................................................... viii

1. Background and Methodology ................................................................................ 1

1.1 Introduction ................................................................................................................. 1 1.2 Objectives ................................................................................................................... 1 1.3 Requested Services.................................................................................................... 1 1.4 Methodology ............................................................................................................... 2

1.4.1 Study Design ............................................................................................................ 2 1.4.2 Sampling Procedures ............................................................................................... 2 1.4.3 Approach to Accomplishing the Service Requirements Set Out in the ToR ........... 3 1.4.4 Data Management and Analysis .............................................................................. 4 1.4.5 Ethical Considerations ............................................................................................. 4

2 Situational Analysis of Maternal and Child Nutrition, SRH, Population Growth and Gender Equality in Northern Uganda ............................................................... 5

2.1 The Situation as Regards Maternal and Child Nutrition ............................................... 5 2.1.1 Child Stunting ........................................................................................................... 5 2.1.2 Child Wasting ........................................................................................................... 6 2.1.3 Underweight in Children ........................................................................................... 6 2.1.4 Initiation of Breastfeeding ......................................................................................... 7 2.1.5 Median Duration of Breastfeeding ........................................................................... 7 2.1.6 Prevalence of Anaemia in Children and Women ..................................................... 8 2.1.7 Micronutrient Intake among Children and Mothers .................................................. 8

2.2 The Situation as Regards SRH and Population Growth .............................................. 9 2.2.1 Sexual and Reproductive Health ............................................................................. 9 2.2.1 Deliveries in Health Units ....................................................................................... 10 2.2.2 Post-Natal Attendance ........................................................................................... 10 2.2.3 Contraceptive Use .................................................................................................. 11 2.2.4 Population Growth .................................................................................................. 12 2.2.5 Fertility Levels and Preferences ............................................................................. 13 2.2.6 Age at First Birth ..................................................................................................... 13 2.2.7 Teenage Pregnancy ............................................................................................... 14 2.2.8 Desire to Limit Childbearing ................................................................................... 14 2.2.9 Desired Fertility Rates ............................................................................................ 14 2.2.10 Mortality .................................................................................................................. 15

2.3 The Situation as Regards Gender Equality ............................................................... 15 2.3.1 Education Attainment ............................................................................................. 15 2.3.2 School Attendance Ratios ...................................................................................... 15 2.3.3 Employment Status ................................................................................................ 16 2.3.4 Cash Earnings ........................................................................................................ 16 2.3.5 Ownership of Assets .............................................................................................. 17 2.3.6 Access to Media ..................................................................................................... 17 2.3.7 Women’s Participation in Household Decision Making ......................................... 17 2.3.8 Gender-Based Violence ......................................................................................... 18

Identification Mission for Integrating Nutrition, Gender and Reproductive Health in the EU 11th EDF Programme in Northern Uganda Final Report – February – May 2015

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3 Mapping of On-Going Nutrition, SRH, Gender Equality Programmes and Projects ................................................................................................................... 20

3.1 Emerging Issues/ Mapping of Service Organisations and Implementing Partners ..... 20

4 Causes and Effects of Maternal and Child Malnutrition, SRH Problems, High Population Growth and Gender Inequality............................................................ 21

4.1 Causes and Effects of Maternal and Child Malnutrition ............................................. 21 4.2. Causes and Effects of SRH Problems and High Population Growth ......................... 33 4.3. Causes and Effects of Gender Inequality .................................................................. 36 4.4. The interrelations between Maternal and Child Nutrition, SRH, High Population

Growth and Gender Equality ..................................................................................... 40

5 Roles and Responsibilities of Stakeholders and their Institutional Capacity in the Areas of Nutrition, Gender and SRH ............................................................... 42

5.1 Roles and Responsibilities of Stakeholders .............................................................. 42 5.2 Institutional Capacity Assessment ............................................................................ 44 5.3 Case Studies Related to Policy, Programming and Service Delivery ........................ 52

6 Best Entry Points for Future Interventions ........................................................... 55

6.1 Addressing Maternal and Child Malnutrition .............................................................. 55 6.2 Addressing SRH and Population Problems ............................................................... 58 6.3 Addressing Gender Inequality ................................................................................... 60 6.4 Best Practices that Provide Opportunities for the Integration of Nutrition, SRH

and Gender by Local Governments .......................................................................... 62 List of Tables

Table 1: Districts visited per sub-region and selection criteria ............................................... 3 Table 2: Percentage of children under 5 affected by under-nutrition ...................................... 6 Table 3: Initiation of breastfeeding ........................................................................................ 7 Table 4: Median Duration of Breastfeeding ........................................................................... 8 Table 5: Population Trends ................................................................................................. 12 Table 6: Total fertility by region ........................................................................................... 13 Table 7: Median age at first birth ......................................................................................... 13 Table 8: Teenage pregnancy by background characteristics ............................................... 14 Table 9: Percentage of married women aged 15-49 who want no more children, by number of living children ..................................................................................................... 14 Table 10: Total desired fertility rates and total fertility rates ................................................. 14 Table 11: Neonatal, post-neonatal, infant, child and under-5 mortality rates ....................... 15 Table 12: Percentage distribution of women and men aged 15-49 by highest level of schooling completed ........................................................................................................... 15 Table 13: Net attendance ratios .......................................................................................... 16 Table 14: Percentage distribution of women and men aged 15-49 by employment status ... 16 Table 15: Control over women’s cash earnings and relative magnitude of women’s cash earnings .............................................................................................................................. 17 Table 16: Percentage distribution of women and men aged 15-49 by ownership of housing and land ................................................................................................................. 17 Table 17: Exposure to mass media ..................................................................................... 17 Table 18: Women’s participation in decision making ........................................................... 18 Table 19: Percentage of all women and men aged 15-49 who agree that a husband is justified in hitting or beating his wife for specific reasons ..................................................... 18 Table 20: Percentage of ever-married women and men aged 15-49 that have ever experienced emotional, physical or sexual violence committed by their partner .................. 19


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Table 21: Percentage distribution of women and men aged 15-49 who have ever experienced physical or sexual violence by their help-seeking behaviour ........................... 19 Table 22: Percentage of women aged 15-49 who were cut, and attitudes to FGM .............. 19 Table 23: Prevalence of diseases in children under 5 ......................................................... 22 Table 24: Golden Indicators for Rural Water Supply (June 2014) ........................................ 29 Table 25: Human resources for health ................................................................................ 42 Table 26: Policy and legal frameworks ................................................................................ 44 Table 27: Coordination Structures for Nutrition, Reproductive Health and Gender Programming at National and Local Government Levels ..................................................... 46

List of Figures Figure 1: ANC Visits, 1st and 4th ............................................................................................ 9 Figure 2: Deliveries in health units ...................................................................................... 10 Figure 3: Post-Natal Care ................................................................................................... 11 Figure 4: Contraceptive use ................................................................................................ 12 Annexes

Annex 1: Mapping Matrix Annex 2: Institutional Capacity Assessment Annex 3: Annotated Bibliography


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Abbreviations and Acronyms

AARR Annual Average Reduction Rate ACF Action Against Hunger (Action Contre la Faim) ACT Artemisinin Based Combination Therapies ADRA Adventist Development and Relief Agency AIDS Acquired Immuno-Deficiency Syndrome AHSPR Annual Health Sector Performance Report ALREP Agricultural Livelihoods Recovery Programme ANC Ante-Natal Care AVSI International Service Volunteers’ Association CBO Community-Based Organisation CDFU Communication for Development Foundation Uganda CMAM Community Management of Acute Malnutrition COMPETE Competitiveness and Trade Expansion CSF Civil Society Fund CSO Civil Society Organisation CUAMM Collegio Universitario Aspiranti Medici Missionari (Italian NGO) DCD Directorate of Community Development DEMIS District Education Management Information System DfID Department for International Development DHIS2 District Health Information Software 2 ECFM Early Child and Forced Marriage EDF European Development Fund EMIS Education Management Information System EMTCT Elimination of Mother-to-Child Transmission EOC Emergency Obstetric Care ESSAPR Education and Sports Sector Annual Performance Report EU European Union EUD Delegation of the European Union FANTA Food and Nutrition Technical Assistance FAO Food and Agricultural Organisation FEWS NET Famine Early Warnings Systems Network FGD Focus Group Discussion FGM Female Genital Mutilation FIND Foundation for Innovative New Diagnostics FNS Food and Nutrition Stakeholders GBV Gender-Based Violence GMP Growth Monitoring Programme GoU Government of Uganda GPI Gender Parity Index GREAT Gender Roles, Equality and Transformation HDPs Health Development Partners HIV Human Immunodeficiency Virus HMIS Health Management Information System HPAC Health Policy Advisory Committee HSSIP Health Sector Strategic and Investment Plan HRHIS Human Resource for Health Information System ICA Institutional Capacity Assessment IDDS Individual Dietary Diversity Score IEC Information, Education and Communication IPC Integrated Food Security Phase Classification IUD Intrauterine Device


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IYCF Infant and Young Child Feeding KALIP Karamoja Livelihoods Programme KII Key Informant Interview KIWEPI Kitgum Women’s Peace Initiative LMIS Logistics Management Information System LOGICS Local Government Information Communication System LWF Lutheran World Federation MAAIF Ministry of Agriculture, Animal Industry and Fisheries MCH Maternal and Child Health MDD Minimum Dietary Diversity MDAs Ministries Departments and Agencies M&E Monitoring and Evaluation MIYCN Maternal, Infant and Young Child Nutrition MIS Management Information System MoES Ministry of Education and Sport MoFPED Ministry of Finance, Planning and Economic Development MoGLSD Ministry of Gender, Labour and Social Development MoH Ministry of Health MUAC Mid-Upper Arm Circumference NAADS National Agricultural Advisory Services NAPW National Action Plan on Women NDP National Development Plan NGO Non-Governmental Organisation NIMES National Integrated Monitoring and Evaluation Strategy NORAD Norwegian Agency for Development Cooperation NSPPI National Strategic Programme Plan of Interventions NUHITES Northern Uganda Health Integration to Enhance Services NUSAF Northern Uganda Social Action Fund OPM Office of the Prime Minister OVC Orphans and Vulnerable Children PAISCY Presidential Initiative on AIDS Communication Strategy for Youth PEPFAR President’s Emergency Plan for AIDS Relief PLHA People Living with HIV/AIDS PNC Post-Natal Care PNFP Private Not-For-Profit PRDP Peace, Recovery and Development Programme QA Quality Assurance REACH Renewed Efforts against Child Hunger RICE Rural Initiatives for Community Empowerment RMNCH Reproductive Maternal Newborn and Child Health RRH Regional Referral Hospital SACCO Savings and Credit Cooperative Organisation SBCC Social Behavioural Change Communication SDIP Social Development Sector Strategic Investment Plan SIDA Swedish International Development Agency SMS Short Message Service SNV Netherlands Development Organisation SRH Sexual and Reproductive Health SRMNCH Sexual, Reproductive, Maternal, Neonatal and Child Health STDs Sexually Transmitted Diseases SUN Scaling Up Nutrition SWOT Strengths, Weaknesses, Opportunities Threats TFR Total Fertility Rate TWG Technical Working Group


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UBOS Uganda Bureau of Statistics UCA Uganda Census of Agriculture UDHS Uganda Demographic Health Survey UN United Nations UNAP Uganda Nutrition Action Plan UNF Uganda Nutrition Fellowship UNFPA United Nations Population Fund UNICEF United Nations Children’s Fund UNJPGE United Nations Joint Programme on Gender Equality UNMHCP Uganda National Minimum Healthcare Package USAID United States Agency for International Development USSD Unstructured Supplementary Services Data UWONET Uganda Women’s Network VHT Village Health Team VSLA Village Savings and Loan Association WASH Water, Sanitation and Hygiene WFP World Food Programme WHO World Health Organisation


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Executive Summary

Background and objectives: The Delegation of the European Union (EUD) to Uganda commissioned this assignment with the overall objective of contributing to the identification and formulation of a high-quality programme for its interventions in northern Uganda under the 11th European Development Fund (EDF). The specific objectives of this assignment included:

1) Analysis of the situation as regards nutrition, gender and sexual and reproductive health (SRH) in northern Uganda, taking into account the political, social, economic, environmental and cultural aspects of these issues;

2) Identification of best entry points and a joint approach for tackling the three issues while avoiding overlap with other programmes; and

3) Provision of clear and concrete recommendations on how to best integrate these areas into the 11th EDF programme for northern Uganda and ensure their linkage to other components of the programme (livelihoods, security, land, good governance and economic and social development).

The focus of the assessment was on the areas of maternal and child nutrition, gender inequality, SRH and population growth in 4 specific sub-regions of northern Uganda, namely Karamoja, Lango, Acholi and West Nile. Through the assessment potential entry points for the future 11th EDF programme in northern Uganda were identified.

Approach and methods: In executing the assignment, a participatory and mixed-methods approach (largely qualitative methods for the collection and analysis of primary data supplemented by review of existing quantitative databases and other data from secondary sources) was adopted in consultation with various stakeholders at national, local government and community level. The methods of data collection included a comprehensive review of relevant policies, national and sector-specific development plans, published articles, studies and grey material from implementing partners. It also involved a review of the Health Management Information System (HMIS) and the Uganda Bureau of Statistics (UBOS) databases to track the performance of sub-regions as regards indicators relevant to nutrition, SRH and gender. Key Informant Interviews (KIIs) and group interviews were held with stakeholders at national and local government level while at community level, Focus Group Discussions (FGDs) were held with young and adult women and men.

In addition, the assignment involved mapping of relevant programmes and service providers and an institutional assessment of relevant agencies working in the three thematic areas. Qualitative data was analysed thematically, guided by the objectives and request for services, while quantitative data from databases and other secondary sources was analysed using frequencies, cross-tabulations and where applicable, trend analysis. This analysis informed: i) the identification of potential best entry points; and ii) a joint approach to tackling the three issues and providing recommendations on how to best integrate these areas into the 11th EDF programme for northern Uganda.

While the prevalence of stunting, wasting and underweight in children is still relatively high in Uganda, improvements have been registered. Further improvements have been seen with regard to the intake of micronutrients by children and mothers; however, exclusive breastfeeding remains a serious challenge with a high proportion of women exclusively breastfeeding for fewer months than recommended. Sub-regional variations also exist, with Karamoja sub-region scoring lowest on most of the indicators related to maternal and child nutrition.


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Sexual and reproductive health (SRH) problems within the sub-regions of interest are also diverse and complex. Ante-natal care (ANC) attendance, post-natal attendance, the number of deliveries assisted by skilled health workers and contraceptive use are all still low. This has largely resulted from limited access to and utilisation of SRH services.

In addition, the population of Acholi, Karamoja, Lango and West Nile sub-regions is growing. This could be explained by the relatively high Total Fertility Rate (TFR) and the early initiation of girls into sex and marriage, among other factors. Gender disparities in education attainment, school attendance, employment, decision making, ownership and access to resources exist in the sub-regions of interest. Gender disparity is mainly in favour of the male sex. Gender-based violence (GBV) is still a common practice within the sub-regions of interest with women and girls being more affected. Service organisations in the sub-regions of interest were mainly implementing SRH programmes. Gender was mainly understood as a cross-cutting issue and there were few standalone programmes targeting gender equality.

Also, few agencies were focusing on nutrition-specific and nutrition-sensitive programming, with most giving priority to food security and sustainable agriculture without the use of a nutrition lens. The ideal roles of the institutions assessed are clearly defined and known, but discrepancies exist between ideal and actual roles, especially at the level of implementation. The gaps are more associated with funding gaps and challenges, low staffing levels against the norm, low (and in some cases lack of) support supervision from the centre (Ministry level) to local governments and from higher local governments to lower local governments, inadequate dissemination of policies, guidelines and standards (especially at local government and facility level where the majority of programme implementation takes place) and weak coordination and monitoring and evaluation (M&E) arrangements.

The best entry points for addressing maternal and child malnutrition are:

1) Support to the strengthening of effective coordination of nutrition policy and programming interventions at all levels, with increased emphasis on the Nutrition Secretariat and district and sub-county nutrition coordination committees;

2) Contribution to efforts to promote a multi-sectoral approach to driving the agenda for integration of nutrition issues into national, sector and district development plans. This will facilitate the process of enhancing local government capacity to strengthen nutrition-sensitive programming at facility and community level;

3) Support to the roll-out of the recently developed Communication and Advocacy Strategy for nutrition with a major focus on the development and dissemination of Social Behavioural Change Communication (SBCC) strategies, especially through interpersonal and interactive communication strategies;

4) Strengthening of M&E systems for nutrition through supporting the roll-out of HMIS tools that have integrated a higher number of nutrition indicators in their data capture tools at facility and community level. There is also need to support efforts aimed at mainstreaming nutrition sensitive data in other MIS such as the MIS for the agricultural sector, MIS for the education sector.

5) Capacity building to ensure effective delivery in all strategic areas and by all staffs involved in the delivery of nutrition-related interventions;

6) Support to increasing the number of well-equipped nutrition centres (both in-patient and out-patient therapeutic centres) at local government level in all health centres, but especially at levels III and IV;


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7) Support to community-based initiatives for health and other initiatives in other sectors such as water, hygiene and sanitation, agriculture/veterinary extension services, social protection, financial services and markets as part of the efforts to integrate nutrition in other sectors

8) Support supervision is critical to the mentoring, standardisation and quality assurance (QA) of nutrition services delivered at local government and community level. There is therefore need to address gaps in support supervision from central to district level and from districts to communities.

The best entry points for addressing SRH and population problems are:

1) Guidelines for the formulation of Sexual, Reproductive, Maternal, Neonatal and Child Health (SRMNCH) policies exist but have not been effectively disseminated among stakeholders, especially at the level of local government and among Civil Society Organisations (CSOs) and community-based organisations. There is need to support the dissemination of these policies, laws and guidelines and ensure the orientation of health workers in the public and private sectors, as well as other stakeholders, to their use (especially at higher and lower local government level);

2) The maternal mortality ratio has either stagnated or sometimes worsened in Uganda and particularly (among others) in Karamoja and West Nile sub-regions. There is therefore need to focus on the creation of demand for maternal healthcare services, with particular focus on the promotion of ANC and delivery under skilled care;

3) There is need for the EUD to strengthen human resources for health, particularly in northern Uganda and especially in districts which have difficulty attracting and retaining doctors and midwives. This is because shortages of human resources for health, and especially of critical staff, pose a major challenge to SRMNCH;

4) In all sub-regions, the capacity of health workers to conduct outreach activities is limited due to lack of logistics. There is need to strengthen support in terms of training, equipment and transport to facilitate integrated clinical outreach camps that target hard-to-reach areas with limited access to health facilities;

5) Adolescent SRH emerged as a very important issue during consultations at all levels, especially in relation to early marriage, high rates of teenage pregnancy, early childbearing and its associated consequences. There is need for the EU to build on lessons learnt from on-going adolescent SRH interventions to support the following:

Promote the integration of adolescent-friendly SRH services into routine health services;

Support the implementation of interpersonal communication channels, especially peer-to-peer education, using interactive sessions, tools and games;

Promote a two-way approach to adolescent SRH through: i) interventions that focus on young people using young people; and ii) interventions that address the environment around young people in order to create a support system and network for adopting and sustaining behavioural change;

Empower boys and girls with life skills (abilities for adaptive and positive behaviour that enable individuals to deal effectively with the demands and challenges of everyday life);


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Improve communication skills among caregivers to enable them to support adolescents;

Train service providers in adolescent-friendly SRH services;

Build on lessons learnt from the implementation of the national SRH hotline in order to contribute to its effective implementation and thereby continue to provide counselling, on-the-spot information and referral services;

6) While there have been improvements in terms of physical access to health facilities and services, the functionality of health institutions remains limited, especially as regards SRMNCH. In many facilities, basic infrastructure such as electricity, water, communication, means of referral and adequate staff accommodation and security (especially at night) remain obstacles to the successful running of 24-hour quality services, including emergency obstetric care (EOC), especially in remote and rural areas. There is therefore need to support the strengthening of staffing, staff training and equipment that has a direct impact on maternal, newborn and reproductive health services, especially in remote and rural areas;

7) There is particular need to address the limitations of transport and communication that are affecting transportation for skilled attendance and EOC;

8) Capacity building through mentoring, refresher courses and staff training in SRH (especially EOC) in the short and long term is crucial to improving maternal and reproductive health outcomes. There is thus need for the EUD to prioritise improved training, particularly of midwives, who are critical in offering maternal, newborn and adolescent SRH services;

9) Support efforts to strengthen mentoring and support supervision in the sub-regions of interest in order to contribute to better SRMNCH indicators;

10) Support the establishment of mechanisms for the capturing of community data from non-Government implementers;

11) Invest in capacity strengthening for social mobilisation and SBCC for SRMNCH (especially at community level) through focusing on geo-context SBCC, which emphasises the adaptation and dissemination of standardised SBCC messages to specific communities that takes into account unique contexts and audiences;

12) Support on-going efforts to promote dialogue with cultural and religious leaders to formulate and implement pronouncements, policy statements and interventions to address the drivers of maternal health conditions, GBV, family planning, teenage pregnancy and HIV/AIDS in northern Uganda and other regions.

The best entry points for addressing gender inequality are:

1) Strengthen efforts to eliminate gender-related barriers to access to justice through supporting activities that increase the financing of access to justice for survivors of various forms of GBV;

2) Support efforts by Government and CSOs toward translating gender mainstreaming into a reality, particularly at local government and community level;


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3) Prioritise support to community-based awareness-raising interventions that build community-level capacity to change harmful gender-based norms, beliefs and practices;

4) Build the capacity of the Justice, Law and Order Sector through equipping them with the tools they need to better respond to gender-related barriers to access to justice, particularly among women and children;

5) Support efforts that advocate for improved staffing levels among units at national and local government level that have the mandate for promoting gender equality;

6) Support actions geared toward the economic empowerment of women through building on initiatives that aim to empower women involved in the private sector and informal small-scale enterprises to participate and benefit from economic development. There is also need to review the operational modalities of Savings and Credit Cooperatives (SACCOs) to ensure that they promote the participation and empowerment of women;

7) Address factors that affect the retention of girls in upper primary and secondary schools. This should take into account both institutional factors and family- and community-related factors (including masculinity and gender norms) that negatively affect the retention of girls in school. At institutional level, there is need to improve the learning environment by installing proper sanitation; ensuring good relationships between learners and teachers; and strengthening school feeding programmes (particularly in areas such as Karamoja that experience prolonged droughts) in order to attract girls to school and make sure they stay. At community level, efforts to work with community leaders to promote positive attitudes among parents and the community toward the education of girls should continue; engagement should be sought with parents and guardians through community mobilisation and sensitisation to reduce the level of dependence on children as agents for household survival (which limits the amount of time available to spend on schoolwork); and the distance travelled by women (and particularly girls) to fetch water should be reduced through increased coverage of safe water sources;

8) Male engagement in the transformation of harmful gender norms that affect women’s access to and control over resources and their equality in gender roles and decision making should be supported. This should build on lessons learnt from projects supported by UN Women globally and locally in Uganda to strengthen focus on male engagement at all levels;

9) Despite legislation outlawing female genital mutilation (FGM) being in place, evidence from Karamoja and other areas in Eastern Uganda (particularly among the Sebei) shows that the practice has not been eliminated. There is therefore a need to build on lessons learnt from the United Nations Population Fund (UNFPA) and its implementing partners to promote SBCC aimed at changing gender norms, attitudes and practices related to FGM. In addition there is need for the EU to support cross-border collaboration, particularly in Uganda and Kenya, to harmonise positions and strategies for the elimination of FGM.

Best practices that provide opportunities for the integration of nutrition, SRH and gender by local governments:

1) Integrate gender equality and SRH issues into both SACCOs and Village Savings and Loan Associations (VSLAs). These groups can be used to empower women


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economically and can also be upgraded to include teaching and counselling forums on matters of nutrition, SRH and gender in order to integrate all these in a more cost-effective way;

2) Promote interventions that integrate gender into food security by promoting and using high-value foods which can grow in this region combined with SBCC addressing harmful masculinity and gender norms that prohibit the consumption of nutritious foods by women and girls. This should facilitate gender- and nutrition-sensitive programming in the targeted sub-regions;

3) Provide messages and counselling on SRH, including family planning, to mothers when they bring their babies for growth monitoring and immunisation by integrating Maternal, Infant and Young Child Nutrition (MIYCN) and family planning into the services provided. The Reproductive Health Division of the Ministry of Health (MoH) includes a nutrition focal person and is already working on guidelines for the integration of reproductive health and nutrition;

4) Support the inclusion of messages on nutrition, SRH and gender in youth economic empowerment programming as a way of providing viable solutions to both economic and social issues that cause poverty among communities;

5) Promote extracurricular activities to generate appreciation of food production and utilisation through school demonstration plots. This will go a long way toward establishing good eating habits and can be integrated into the dissemination of messages on SRH and gender;

6) Build on existing efforts of the consortium formed by Renewed Efforts Against Child Hunger (REACH) under the Office of the Prime Minister (OPM) and Development Partners (DPs) to coordinate the integration of nutrition-sensitive programming into SRH and gender initiatives;

7) Support local government and health facilities to develop and implement integrated outreach for nutrition, SRH and gender;

8) Build on existing efforts to develop and operationalise guidelines for the integration of SRH, nutrition and gender;

9) There is need for the EUD to build on the lessons and best practices of the UNFPA and the collaborative project implemented by the Ministry of Gender, Labour and Social Development (MoGLSD) and the Uganda AIDS Commission that encouraged cultural and religious leaders to engage in dialogue, make pronouncements and develop and implement policy statements to address the drivers of maternal health conditions, GBV, family planning, teenage pregnancy and HIV/AIDS in northern Uganda;

10) Ensure a well-coordinated and gender-mainstreamed multi-sectoral response to SRH, GBV and nutrition at all levels through building capacity within the MoGLSD and its district and sub-county line departments to spearhead the integration of gender planning and budgeting into nutrition, food security and SRH interventions;

11) Build the capacity to conduct gender- and human rights-based analysis in integrated planning and programming, implementation and M&E of SRH, GBV and nutrition services, especially at local government level, in northern Uganda;


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12) Strengthen community systems (including Health Unit Management Committees, Parish Development Committees and Village Health Teams) to ensure ownership and sustainability through community-led programming, integrated planning, implementation and M&E of SRH, nutrition and GBV programmes at community level;

13) Strengthen coordination of supply chain management systems through enhanced information management for integrated programmes geared toward the promotion of SRH, nutrition and gender equality, especially at local government and facility level;

14) Strengthen mechanisms for the capturing of community data from non-Government implementers, particularly non-biomedical interventions, that affect SRH, gender and nutrition;

There is need for the EUD to support research into and collect evidence of social norms and harmful practices related to GBV, teenage pregnancy, early child and forced marriage (ECFM) and FGM and the impact of these issues on SRH. There is also need to build evidence for effective programming and best practices in relation to the prevention of and responses to GBV, FGM, ECFM and other harmful cultural practices that have implications for SRH in respect to: i) health-seeking behaviour; ii) the negotiation of safe sex and iii) the freedom to delay marriage and decide when and how frequently to have children that can be well fed in accordance with infant and young child feeding (IYCF) guidelines.


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1. Background and Methodology

This report provides a synthesis of findings from an identification mission for the integration of nutrition, sexual and reproductive health and gender in the 11th European Development Fund (EDF) programme in northern Uganda.

1.1 Introduction

It is widely recognised that stunting and under-nutrition pose a major global challenge. Uganda has a well-defined national policy framework for nutrition. In 2011, the Government of Uganda (GoU) joined the Scaling Up Nutrition (SUN) Movement, following which it developed a Uganda Nutrition Action Plan (UNAP) for 2011-2016, the goal of which is to focus public resources and national efforts on bringing about sharp improvements in nutrition among young children and women of childbearing age (15-49) by scaling up proven and cost-effective nutrition interventions. The UNAP provides strategies and interventions to comprehensively address malnutrition in Uganda, with special focus on children and women, using a multi-sectoral approach.

While Uganda has made significant progress in advancing gender equality and the empowerment of women in political, economic and social spheres, gender inequality still prevails in the country and is often accepted as the norm by both men and women. The gender priority interventions of the GoU are tackled through a multi-sector approach consisting of four thematic areas: livelihoods, rights, governance and macro-economic management. At the same time the GoU is determined to reduce the population growth rate as evidenced by the National Development Plan 2010/11-2014/15 and the 2010-2015 Health Sector Strategic Investment Plan (HSSIP), by promoting adherence among couples to a manageable family size. Uganda has published its first Costed Implementation Plan for Scaling up Family Planning in Uganda 2015-2020 in which the Government commits to dramatically reducing unmet needs for family planning by 2020.

1.2 Objectives

The overall objective of the assignment was to assist the Delegation of the European Union to Uganda (EUD) to successfully identify and formulate a high-quality programme for its interventions in northern Uganda under the 11th European Development Fund.

Specific Objectives included:

1) Analysis of the situation as regards nutrition, gender and sexual and reproductive health (SRH) in northern Uganda, taking into account the political, social, economic, environmental and cultural aspects of these issues;

2) Identification of best entry points and a joint approach for tackling the three issues while avoiding overlap with other programmes;

3) Provision of clear and concrete recommendations on how to best integrate these areas into the 11th EDF programme for northern Uganda and ensure their linkage to other components of the programme (livelihoods, security, land, good governance and economic and social development).

1.3 Requested Services

The Consultants were required to carry out an assessment focusing on the areas of maternal and child nutrition, gender inequality, SRH and population growth in 4 specific sub-regions of northern Uganda, namely Karamoja, Lango, Acholi and West Nile. In doing so the



Consultants identified potential entry points for the future 11th EDF programme in northern Uganda (see the detailed Terms of Reference (ToR) provided in Annex 4).

1.4 Methodology

1.4.1 Study Design

The Cardno team adopted a mixed-method, multi-sited, cross-sectional design using both qualitative (and participatory) and quantitative approaches. The assessment was conducted at sub-regional, local government and national level. At national level, data was collected from relevant stakeholders including Government officials from the Ministry of Health (MoH), the Ministry of Agriculture, Animal Industry and Fisheries (MAAIF), the Ministry of Gender, Labour and Social Development (MoGLSD) and the Office of the Prime Minister (OPM). In addition, consultations were held with development partners (DPs) including the United Nations Children’s Fund (UNICEF), the United Nations World Food Programme (WFP), UN Women, the United Nations Food and Agricultural Organisation (FAO), the United Nations Population Fund (UNFPA) and the EUD. Consultations were also held with officials from the private sector and civil society organisations such as FHI 360, World Vision, Save the Children (Uganda), Care International (Uganda) and Pathfinder International (Uganda), among others. At sub-regional level, data will be collected from local government officials, selected civil society organisations (CSOs) and community-based organisations (CBOs) as well as community members at parish and village level.

The qualitative approach enabled the collection of in-depth information and provided an understanding of the context, meanings and experiences of stakeholders in the northern regions in the areas of gender, nutrition and SRH. Quantitative data on indicators relevant to maternal and child nutrition, gender and SRH were extracted from existing databases (including those of the Health Management Information System (HMIS) and the Uganda Bureau of Statistics (UBOS)) and most notably, the recently concluded Population Census and the Uganda Demographic Health Surveys (UDHS).

The document review targeted relevant national policies and plans such as the National Development Plan (NDP) for 2010/11-2014/15, the draft second NDP for 2015/16-2019/20 (NDP II), the Health Sector Strategic Investment Plan (HSSIP), the Uganda Nutrition Action Plan 2011-2016 (UNAP), the Family Planning Costed Implementation Plan 2015-2020, the Reproductive Maternal, Newborn and Child Health Sharpened Plan for Uganda, the National Gender Policy, the Peace, Recovery and Development Plan, the Karamoja Integrated Disarmament and Development Programme, the First Costed Implementation Plan for Scaling up Family Planning in Uganda 2015-2020 and the New National Strategic Plan for HIV/AIDS 2015-2020, among others.

1.4.2 Sampling Procedures

The study used purposive sampling techniques given that it was largely a qualitative and participatory assessment. The assessment applied a multi-stage cluster-sampling approach to the selection of sub-regions, districts, sub-counties and communities for data collection. First, all 4 targeted sub-regions in northern Uganda (Karamoja, Lango, Acholi and West Nile) were selected for field visits. The second stage involved the selection of two districts from each region based on the following criteria: population variations, rural areas, poverty head count, border dynamics and level of coverage of interventions. From each district, two sub-counties were selected based on purposive criteria in order to include those with a relatively higher and lower concentration of projects. Two communities/parishes were selected from each sub-county for community-level interviews and focus group discussions (FGDs) in consultation with the sub-county authorities.



Table 1: Districts visited per sub-region and selection criteria

District by region

Sub-counties visited in each district by region

Selection criteria

Acholi

Gulu Bungatira

Koro

High population (443,733)*

Poverty head count relatively low compared to other districts in the sub-region (68.86)**

High concentration of interventions

Kitgum Labongo-Amida

Kitgum Matidi

Poverty head count comparatively high (74.3)**

Comparatively low concentration of interventions

Among districts that were highly affected by the LRA conflict

Lango

Lira Barr

Lira sub-county



Old district, may have more structures and systems of governance

Otuke Ogor

Adwari

Low population (105,617)*

Comparatively high poverty head count (62.15)**

Low concentration of interventions

New district, may have less well defined and functional systems

Karamoja

Moroto Tapac, Nadugenti

Border district

Poverty head count low compared to the other districts in the sub-region (86.9)**


Old district

Kotido Panyangara

Kotido sub-county

High poverty head count (95)**


West Nile

Arua Aroi,

Logiri


Border district more prone to receiving refugees and migrant workers


Nebbi Nyaravur, Parombo

Low population (385,220)*

Comparatively high poverty head count (65.05)**


Source: *UBOS 2014: Provisional results of the population census 2014

**UBOS 2012: District Statistical Abstracts

1.4.3 Approach to Accomplishing the Service Requirements Set Out in the ToR

Service requirement 1: This involved a desk review of literature from relevant policy documents and studies such as laws, policies, strategic plans, action plans and databases (HMIS and UBOS among others). Other secondary data sources included research reports and academic journals.

Service requirement 2: To meet service requirement 2, service provider mapping using key informant interviews (KIIs) at national, district and sub-county level was carried out. This aimed to document the level of geographical coverage, the resources allocated (level of funding and co-funding), the scheduling of interventions, the target populations of specific interventions, the number of staff implementing programmes, the extent of alignment with the NDP and sector-specific development plans and the identification of the main gaps in programming and service delivery among the different programmes focusing on maternal and child malnutrition, gender inequality, SRH and population growth.

Service requirement 3: To meet service requirement 3, the team used a combination of methods: KIIs at district, sub-county and community level, FGDs with community members



and the review of various documents including thematic area-specific surveys and special studies previously conducted by local governments and partners, among others.

FGDs were conducted with community members including young women and men (18-35 years) and adult women and men (> 35 years). In each of the four sub-regions, four focus group discussions: 2 for men (young men, adult men) and 2 for women (young women, adult women) were conducted. The aim of these FGDs was to map community perceptions of the causes and effects of maternal and child under-nutrition, gender inequality, SRH problems and high population growth.

Service requirement 4: To address this service requirement, an Institutional Capacity Assessment (ICA) was conducted focusing on the mandate (the ideal role) of public and private stakeholders in addressing maternal and child malnutrition, gender inequality, SRH and population growth problems vis-à-vis what is being done on the ground (their actual role). The institutional assessment of stakeholders focused on technical aspects such as capacity gaps, policy, planning, programming, implementation, coordination, monitoring and evaluation related to the thematic areas. A Strengths, Weaknesses, Opportunities and Threats (SWOT) analysis was used to aid this process, the results of which were used to inform analysis of the causes and effects of identified issues and possible means of improving policy and programming for the three thematic areas. In addition to the ICA, case studies were selected for comprehensive and in-depth analysis.

Service requirement 5: Based on the mapping, review and analysis, the team developed the best entry points for future interventions. Emphasis was placed on interventions that integrate activities across all three areas. The team held intra-team debriefings to discuss the entry points for future interventions that emerged from the document review, KIIs at national and local government level and FGDs at community level. After completing the data analysis process the team synthesised the emerging evidence on the best entry points for future interventions. The team identified interventions that integrate the three thematic areas and best entry points for future programmes that demonstrate the interrelation between the three thematic areas.

1.4.4 Data Management and Analysis

Data was analysed using both thematic and content analysis. The thematic areas of the assessment provided themes and sub-themes under which data was organised for intensive study and interpretation guided by the objectives of the assignment.

Time series analysis: The study team reported specific indicators on nutrition, gender and SRH that concerned a specific period of time.

Gap Analysis: The study team examined gaps in interventions by service providers. Gap analysis focused on funding, thematic and geographical coverage of the interventions and was also used to identify and prioritise key issues and recommend interventions and priority actions for future programming.

1.4.5 Ethical Considerations

The team made every effort to ensure that the baseline assessment followed scientifically acceptable ethical procedures during the planning and fieldwork phase. In each sub-region, the lead and associate consultants worked with the sub-regional teams to seek research authorisation from national research committees and/or councils. Each participant in the



study was requested to provide his/her oral informed consent. The process of securing participants’ informed consent involved clarifying the aim of the study, informing of their discretion to participate and withdraw at any time should they desire to do so, and assuring confidentiality. Interviews were conducted in a confidential setting to ensure privacy and non-interference by other people.

2 Situational Analysis of Maternal and Child Nutrition, SRH, Population Growth and Gender Equality in Northern Uganda

2.1 The Situation as Regards Maternal and Child Nutrition

2.1.1 Child Stunting

Approximately 27% of children under 5 in Karamoja, North1 (includes Acholi and Lango sub - regions) and West Nile sub-regions were stunted in 2011 and 12.5% of children under 5 were severely stunted (UDHS, 2011). This showed a reduction in prevalence compared to data from the 2006 UDHS, which showed that 41.2% of children under 5 were stunted and 17.9% to be severely stunted. Currently at national level there has been a reduction in absolute number of stunted children, the current Average Annual Reduction Rate (AARR) is at 1.47%. This could be as a result of the strategy adopted by the Uganda Nutrition Action Plan to address poor nutrition. It advocates for scaling up of multi sectoral efforts to establish a strong nutrition foundation. It is thus of utmost importance that the EUD draws lessons from the UNAP in its 11th EDF programme in Northern Uganda. Sub-regional variations existed; Karamoja and West Nile had the highest proportion of children under 5 who were stunted (Karamoja 36.7%, North 19.6% and West Nile 31.0% (see Table 2)). The significant difference between Karamoja and North sub-regions could be explained by differences in the extent of dietary diversity and variations in care and feeding practices of infants and young children. Karamoja sub region has a uni-modal rainfall pattern which is adequate for crop production, however crop production is less reliable as there is a high risk of production failure due to floods, water logging. This is coupled with the severe droughts which begin in November to the end of March. This is more common in the North Eastern Highland Apiculture and Potato; and Central Sorghum and Livestock zones. The main food crops grown and consumed within all livelihood zones (these include: North Eastern Highland Apiculture and Potato; Western Mixed Crop Farming; South Eastern Cattle Maize; Mountain and Foot Hills Maize and Cattle; and Central Sorghum and Livestock) of the sub region are maize and sorghum (FEWS NET, 2013). Other sub regions of Lango, Acholi and West Nile have a bi-modal rainfall pattern. Crop production in these regions is more reliable. Mixed cropping is common within these regions. A variety of crops including cassava, sweet potatoes, sorghum, maize, rice, irish potatoes, beans, ground nuts among others are grown and consumed.

Also it is a common practice within Karamoja sub-region to purchase food from markets where food types and varieties are limited, making it hard for people to access a diversity of foods (Integrated Food Security Phase Classification (IPC), 2013).

The prevalence of stunting was more common among children of given characteristics. Stunting was more common in children aged 24-35 months and lowest in children aged 6-8 months. Boys were more likely to be stunted than girls. This could be a result of how boys and girls are socialised (supported by norms about masculinity and femininity) and probably power relations that could accord privileges to girls (Sen et al., 2007). There is also research

1 North refers to the two sub-regions of Acholi and Lango



evidence that suggests that boys are often more affected by health inequalities than girls (Wamani et al., 2007). There is thus need for further research on this issue.

Stunting was more common among children who were born very small than in children who were of average or large size at birth. Children in rural areas were more likely to be stunted than those in urban areas. Children born to mothers with a secondary or higher education and children born to households in the highest wealth quintile were least likely to be stunted (UDHS, 2011).

2.1.2 Child Wasting

Approximately 4.7% of children under 5 in Karamoja, North and West Nile sub-regions were wasted in 2011 and 0.8% of children under 5 in these sub-regions were severely wasted. The proportion of children under 5 who experienced wasting and severe wasting in 2011 was lower than that reported by the 2006 UDHS (when 7.5% were wasted and 2.2% were severely wasted).

In Uganda, Karamoja sub-region had the highest proportion of children under 5 who were wasted (7.9%) – see Table 1). Wasting in Karamoja sub-region tends to follow seasonal trends (Karamoja has a mono-modal rainfall pattern which commences in April and ends in September. Intense drought is usually from November to the end of March. The pattern however is not reliable and in many years the rains are sparse and fail altogether (Mubiru, 2010)).

It also varies according to livelihood zone, with the pastoral zone having the highest prevalence (Action Against Hunger (ACF) and UNICEF, 2012).

Wasting was highest among children aged 0-8 months and lowest among children aged 24-59 months. A higher proportion of babies that were very small at birth were acutely wasted than those who were larger or of average size (UDHS, 2011).

2.1.3 Underweight in Children

20.2% of children under 5 were underweight and 5.7% were severely underweight in Karamoja, North and West Nile sub-regions in 2011. This is lower than the prevalence reported in the 2006 UDHS, when 22.4% of children under 5 were underweight and 7.2% were severely underweight.

Cases of underweight and severe underweight were commonest in Karamoja sub-region. Underweight children differed according to their background. Boys were slightly more likely to be underweight than girls (such a difference could again result from how boys and girls are socialised and the emergent power relations that could favour girls (Sen et al., 2007).

Babies reported to be very small at birth and those born to mothers who were thin (with a BMI of less than 18.5) were more likely to be underweight (UDHS, 2011).

Table 2: Percentage of children under 5 affected by under-nutrition

Stunting Wasting Weight

%

Severely stunted

% Stunted

% Severely wasted

% Wasted

% Severely

underweight

% Underweight

% Overweight

Karamoja 19.6 36.7 0.3 7.9 11.9 33.0 0.2

North 8.4 19.6 0.7 2.0 3.9 13.4 0.7

West Nile 14.0 31.0 1.2 6.2 4.6 21.9 0.7

Average 12.5 27.0 0.8 4.7 5.7 20.2 0.6

Source: UDHS, 2011



2.1.4 Initiation of Breastfeeding

The proportion of infants who have ever been breastfed improved slightly (by 1.3%) between 2006 and 2011, with marginal variations within the sub-regions of Karamoja, North and West Nile. In 2011, 40.7% of infants started breastfeeding within one hour of birth and 85.2% within a day. At country level the West Nile sub-region had the lowest proportion of infants breastfed within one hour of birth (27%). The Uganda Demographic and Health Survey 2011 reports that the initiation of breastfeeding within the first hour is more common among female babies, babies assisted at delivery by a health professional or born at a health facility, and those born in urban areas. The likelihood that a child will be breastfed within one hour of birth is slightly higher among children whose mothers have secondary or higher education and/or are in the highest wealth quintile. The national proportion of infants who receive pre-lacteal food fell to 31.4% in 2011 from 43.3% in 2006, with a substantial reduction observed in Karamoja sub-region (from 46.2% in 2006 to 19.2% in 2011). This could be due to the high and increasing proportion of pregnant women who are seeking ANC services from a skilled provider (between 2006 and 2011 the proportion rose from 92% to 96.6% according to the UDHS), but could also be explained by an increase in the number of women delivering within health units (see section 2.2.1). Furthermore, the Government of Uganda (GoU) has developed and disseminated IYCF policy guidelines calling for improved information and communication on the importance of avoiding the pre-lacteal feeding of newborn babies.

The practice of pre-lacteal feeding was more common in children whose delivery was not assisted, children born outside a health facility and children in urban areas. This feeding practice also decreases among mothers with higher levels of education and wealth.

Table 3: Initiation of breastfeeding

Percentage

ever breastfed

Percentage who started breastfeeding within 1

hour of birth

Percentage who started breastfeeding within 1

day of birth

Percentage who receive pre-lacteal

food

2006 2011 2006 2011 2006 2011 2006 2011

Karamoja 97.4 99.9 56.6 70.4 80.4 94.1 46.2 19.2

North 97.7 98.9 42.2 38.4 79.5 80.8 37.2 38.4

West Nile 98.6 98.8 48.9 27.1 79 86.8 46.5 36.5

Average 97.8 99.1 45.6 40.7 79.5 85.2 40.4 34.1

Source: UDHS, 2006 and 2011

2.1.5 Median Duration of Breastfeeding

The median duration of all types of breastfeeding in Karamoja, North and West Nile sub-regions fell from 23 months to 22 months between 2006 and 2011. However, no change was seen to the median duration of exclusive or predominant breastfeeding. The median duration of exclusive breastfeeding was 4 months and the median duration of predominant breastfeeding was 5 months in both 2006 and 2011. Between these years the median duration of exclusive breastfeeding rose slightly in Karamoja and North sub-regions; however in West Nile the median length of exclusive breastfeeding declined. The median duration of breastfeeding is longer among children in rural areas, women with no education breastfeed longer, and also those in the lowest wealth quintile breastfeed longer (UDHS, 2006 and 2011).



Table 4: Median Duration of Breastfeeding

Any breastfeeding Exclusive breastfeeding Predominant – breastfeeding

2006 2011 2006 2011 2006 2011

Karamoja 24.1 23.0 4.0 4.4 4.9 4.7

North 22.3 21.4 3.2 3.8 4.8 5.5

West Nile 22.8 21.5 4.6 3.3 5.3 4.8

Average 23.1 21.9 3.9 3.8 5 5


2.1.6 Prevalence of Anaemia in Children and Women

The prevalence of anaemia among children aged 6-59 months declined from 77.9% in 2006 to 51.8% in 2011. Sub-regional variations exist, with the prevalence declining most sharply in North (from 80.2% to 34%) and Karamoja regions (from 82.2% to 69.5%). The success of three programmes in particular (for de-worming, vitamin A supplementation and the use of insecticide-treated nets) appears to have reduced the prevalence of anaemia in children under 5 (the USAID-funded Strengthening Partnerships, Results and Innovation in Nutrition Globally (SPRING) project, 2014). In North and Karamoja sub-regions the use of all types of insecticide net increased between 2006 and 2011 (41.5% to 75% in North sub-region and 13.5% to 68.4% in Karamoja). Similarly the proportion of children aged 6-59 months that underwent de-worming increased in North and Karamoja sub-regions between 2006 and 2011 (39.9% to 48.2% in North and 44.3% to 64.5% in Karamoja). Lastly the proportion of children that had received vitamin A supplementation also increased in North and Karamoja sub-regions between 2006 and 2011 (48.1% to 59.4% in North sub-region and 46.8% to 73.7% in Karamoja).

The UDHS 2011 reports that 25.9% of children aged 6-59 months had mild anaemia, 25.3% had moderate anaemia and 0.6% of children were severely anaemic. The prevalence was highest among children aged 9-11 months, those in rural areas, those whose parents had no education and those whose parents were within the lowest wealth quintile (UDHS, 2011).

The prevalence of anaemia of all types in women aged 15-49 declined between 2006 and 2011 from 56.1% to 25.1%. The prevalence of mild anaemia declined from 40.3% in 2006 to 22% in 2011, the prevalence of moderate anaemia declined from 14.9% in 2006 to 4.6% in 2011 and the prevalence of severe anaemia declined from 0.8% in 2006 to 0.2% in 2011. A sharp decrease in anaemia was recorded in North sub-region from 64% in 2006 to 13.1% in 2011. Women in Karamoja had the highest prevalence of anaemia (43.3%). The prevalence of anaemia is higher among older women (aged 40-49), those with 6 or more children, pregnant women, those who smoke, those in rural areas, those who have no education and those in the lowest wealth quintile (UDHS, 2006 and 2011).

2.1.7 Micronutrient Intake among Children and Mothers

The UDHS (2011) reported that 64.6% of children aged 6-23 months living with their mother had consumed food rich in Vitamin A in Karamoja, North and West Nile sub-regions. Regional variations existed, with West Nile sub-region having the highest proportion of children consuming food rich in Vitamin A (West Nile 71.6%, Karamoja 68.1% and North 58.6%). 28.6% of children aged 6-23 months living with their mother had also consumed food rich in iron. Consumption levels were lowest in Karamoja sub-region (Karamoja 9.8%, North 25.9% and West Nile 44.5%). The UDHS (2011) also reported that 60.5% of children aged 6-59 months had been given Vitamin A supplements in Karamoja, North and West Nile sub-regions. This is higher than the proportion reported in the 2006 UDHS, when 41% of children had been given Vitamin A



Source: HMIS, 2015

supplements in these sub-regions. Vitamin A supplementation does not show a clear pattern among children of different ages, genders or wealth and there appears to be no relation to the mother’s age at birth or to urban vs. rural residence. 11.7% of children aged 6-59 months were given iron supplements and 51% had received de-worming medication. Karamoja sub-region had the highest proportion of children aged 6-59 months that had received iron supplements and de-worming medication (UDHS, 2011).

There was a significant increase in the proportion of women aged 15-49 who received post-partum doses of Vitamin A from 33.4% in 2006 to 58.5% in 2011 in Karamoja, North and West Nile sub-regions. The pattern was similar for all sub-regions. The percentage of women aged 15-49 who took de-worming medication during pregnancy almost doubled from 27.6% in 2006 to 53% in 2011 (UDHS, 2006 and 2011).

2.2 The Situation as Regards SRH and Population Growth

The major sources of data were the UDHS 2011 and the Health Management Information System (HMIS) (2011-2014). The rationale behind the use of these two sources was that even the most recent UDHS is a few years old and the team wanted to present some recent trends. Also, one source is population-based while the other is more programmatic.

2.2.1 Sexual and Reproductive Health

Timing of ANC visits

The Ministry of Health (MoH) recommends that a pregnant woman should attend at least 4 ante-natal care (ANC) visits. In all sub-regions and for all years reported on there was a sharp fall in the number of women attending the fourth visit as compared to those that had attended the first visit. Karamoja sub-region has the least number of women attending ANC at both the first and fourth visit. However, there has been improvement in fourth-visit attendance in all sub-regions (see Figure 1). Urban women are more likely to attend at least 4 ANC visits than rural women (UDHS, 2011).

Figure 1: ANC Visits, 1st and 4th



Source: HMIS, 2015

A high percentage of women aged 15-49 reported seeking ANC services from a skilled provider (Karamoja 96.6%, North 98.7% and West Nile 97.6%). Women aged 20-34 are more likely to receive ANC from a skilled provider than older mothers aged 35-39. There are minor differences in the use of ANC services from a skilled provider among urban and rural dwellers. Use of ANC services from a skilled provider increases with the mother’s level of education, and also among women in the highest wealth quintile (UDHS, 2011).

2.2.1 Deliveries in Health Units

The number of women delivering at health facilities is increasing among all sub-regions. There are however sub-regional variations, with West Nile sub-region having the highest proportion of women delivering in health facilities. On the other hand Karamoja sub-region has the lowest proportion of women delivering in health facilities (see Figure 2).

There are a large number of reasons why women fail to give birth in health facilities. The UDHS (2011) reports that the majority of women who fail to access health facilities do so because of financial difficulties, although a number of women also reported that the facility was too far away. Other reasons reported were not wanting to go alone to the health facility and having to get permission to go for treatment.

Figure 2: Deliveries in health units

2.2.2 Post-Natal Attendance

The pattern of post-natal care is similar to that of deliveries in health units. The number of women receiving post-natal care is increasing within all sub-regions, with West Nile sub-region having the highest number (see Figure 3).



Source: HMIS, 2015

Figure 3: Post-Natal Care

UDHS data indicate that 68.2% of women aged 15-49 receive no post-natal care. There are sub-regional variations, with Karamoja having the highest number of women who receive no post-natal care (Karamoja 73.2%, North 72.2% and West Nile 59.5%). Women who receive post-natal care tend to be characterised by background, with mothers from higher wealth quintiles and those in urban areas attending post-natal care more often than those in the lowest wealth quintile and those in rural areas (UDHS, 2011).

2.2.3 Contraceptive Use

According to the UDHS (2011), 76.3% of currently married women aged 15-49 in Karamoja, North and West Nile sub-regions were not using any contraceptive method. Non-usage was highest in Karamoja and West Nile sub-regions (Karamoja 92.2%, West Nile 85.4%). Data from the HMIS presents a similar pattern with Karamoja sub-region having the lowest usage of contraceptives (see Figure 4). In Lango sub-region contraceptive use rose sharply in 2013 with 710,726 male condom users in Lira district (HMIS, 2014).



Source: HMIS, 2015

Figure 4: Contraceptive Use

The UDHS (2011) reports that there are variations in the use of contraception among sub-groups and that there is a wide gap in the use of all methods of contraception between urban and rural areas. Use is more common among urban dwellers and also increases with education and level of household wealth, meaning the probability of use is higher among the more educated and wealthier. It is also true that the majority of women do not begin to use contraception until they have had at least one child.

The unmet need for family planning among married women aged 15-49 is relatively high (38%). The unmet need is similar in North and West Nile sub-regions, with Karamoja having a lower unmet need (Karamoja 20.5%, North 42.5% and West Nile 42.9%).

2.2.4 Population Growth

Population trends

The total population of the four sub-regions of Acholi, Karamoja, Lango and West Nile is estimated to be about 7.2 million people. Between the years 2002 and 2014 the population increased by about 2.08 million people. The gender composition of the population shows that there are slightly more females than males. Census results for the years 1991, 2002 and 2014 indicate that West Nile sub-region has the highest population while Karamoja sub-region has over the years had the lowest population. With regard to the population structure, the 2014 provisional census results report projects that 56.7% of Uganda’s population will be under 18 by the end of 2015. Only 4.2% of the population will be aged 60 and above (UBOS, 2014).

Table 5: Population Trends

Census year Population Size

Male Female Total

1991

Acholi sub-region 695,600

Karamoja sub-region 370,400

Lango sub-region 955,500

West Nile sub-region 1,130,500

Total 3,152,000



Census year Population Size

Male Female Total

2002

Acholi sub-region 1,084,000

Karamoja sub-region 721,500

Lango sub-region 1,425,200

West Nile sub-region 1,918,200

Total 5,148,900

2014

Acholi sub-region 732,269 779,345 1,511,614

Karamoja sub-region 479,852 509,577 989,429

Lango sub-region 1,007,005 1,067,613 2,074,618

West Nile sub-region 1,272,300 1,388,700 2,661,000

Total 3,491,426 3,745,235 7,236,661

Source: Census reports 1991, 2002 and 2014

2.2.5 Fertility Levels and Preferences

The Total Fertility Rate (TFR) for Karamoja, North and West Nile has remained relatively high over the years. There has however been a slight decrease in total fertility within these sub-regions. The fertility rates for Karamoja, North and West Nile sub-regions for the years 2006 and 2011 have remained higher than the national average (see Table 5).There exist significant differences in fertility levels among people from different backgrounds and a sharp difference between fertility among women in rural areas (6.8 children per woman) and urban areas (3.8 children per woman). There are also substantial variations in fertility among women with no education and those that have completed more than secondary education (6.9 children and 4.8 children respectively). Also, the TFR differs sharply among women in different wealth quintiles, with a rate of 7.9 children among women in the lowest wealth quintile compared to 4.0 among women in the highest wealth quintile (UDHS, 2011).

Table 6: Total fertility by region

Total Fertility Rate

2006 2011

Karamoja 7.2 6.4

North 7.5 6.3

West Nile 7.2 6.8

National TFR 6.7 6.2


2.2.6 Age at First Birth

The age at which a woman has her first birth is critical since it has a strong influence on the number of births that she could have in her lifetime, which in turn affects the size, composition and future growth of a population (Mathew and Hamilton, 2009). The age at which women start childbearing within Karamoja, North and West Nile sub-regions remained stagnant between 2006 and 2011. Women in urban areas, women with secondary or higher education and women in the highest wealth quintile have their first child at a later age than other women (UDHS, 2011).

Table 7: Median age at first birth

Women aged 20-49

2006 2011

Karamoja - 19.2

North 18.9 17.9

West Nile 19.2 19.5




2.2.7 Teenage Pregnancy

Teenage pregnancy has remained a major health and social concern in Uganda despite decreasing levels of fertility among teenagers (178/1,000 in 2000/01, 152/1,000 in 2006 and 138/1,000 in 2011). 27% of women aged 15-19 had begun childbearing within the sub-regions of Karamoja, North and West Nile in 2011. 9% of these were pregnant with their first child and 17.2% had had a live birth. There was a 2.6% reduction in the number of teenagers who had begun childbearing between 2006 and 2011. Teenage pregnancies vary according to background characteristics, with teenagers from rural areas, those with no education and those from the poorest households tending to start parenting earlier (UDHS, 2011).

Table 8: Teenage pregnancy by background characteristics

% of women aged 15-19 who:

Have had a live birth Are pregnant with first child Have begun childbearing

2006 2011 2006 2011 2006 2011

Karamoja 8.0 11.5 9.6 18.2 17.6 29.7

North 25.8 17.5 8.1 8.2 34.0 25.6

West Nile 18.1 19.7 3.7 6.6 21.8 26.4

Average 22 17.2 7.1 9.4 29.2 26.6


2.2.8 Desire to Limit Childbearing

Generally, the desire to limit childbearing grows as women bear more children and prevalence is highest among women who have had 6 or more children. The pattern in Karamoja sub-region is notably different as more than half (57%) of women with 6 or more children still wanted to bear more children.

Table 9: Percentage of married women aged 15-49 who want no more children, by number of living children

Number of living children

0 1 2 3 4 5 6+

Karamoja - 1.7 12.5 21.2 33.9 35.8 43.1

North - 2.9 6.8 20.4 56.8 57.3 82.2

West Nile - 1.8 12.9 24.4 36.8 62.7 74.8

Source: UDHS, 2011

2.2.9 Desired Fertility Rates

There is a significant discrepancy between total desired fertility rates and actual total fertility rates for the sub-regions of Karamoja, North and West Nile. Overall, women have more children than they would like. The discrepancy is highest in North sub-region (with women having 2 more children than they ideally wanted to have) and is lowest within Karamoja sub-region. The gap between desired and observed fertility is wider among women who live in rural areas than those in urban areas (UDHS, 2011).

Table 10: Total desired fertility rates and total fertility rates

Total desired fertility rates

Total fertility rates

Karamoja 5.8 6.4

North 4.3 6.3

West Nile 5.1 6.8

Source: UDHS, 2011



2.2.10 Mortality

There has been a decline in almost all levels of childhood mortality apart from neonatal mortality in the sub-regions of Karamoja, North and West Nile between 2006 and 2011. That notwithstanding, childhood mortality in these sub-regions remains high (see Table 11).. Children born to mothers who i) have no education; ii) are in the lowest or second-lowest wealth quintile; iii) are unusually young or old; iv) have short intervals between births; and/or v) have had more than 3 births have a lower probability of survival (UDHS, 2011).

Table 11: Neonatal, post-neonatal, infant, child and under-5 mortality rates

Neonatal

mortality (per 1,000 live births)

Post-neonatal mortality (per

1,000 live births)

Infant mortality (per 1,000 live

births)

Child mortality (per 1,000

children surviving up to 12 months)

Under-5 mortality (per 1,000 live births)

2006 2011 2006 2011 2006 2011 2006 2011 2006 2011

Karamoja 26 29 79 59 105 87 78 72 174 153

North 33 31 73 35 106 66 80 42 177 105

West Nile 25 38 73 50 98 88 96 41 185 125


Adult mortality in Uganda is slightly higher among men than among women (6.5 and 5.3 deaths per 1,000 people respectively in 2011). 20% of women and 25% of men are likely to die between the ages of 15 and 50. These probabilities have decreased for both women and men since 2000-01, with the most significant decrease occurring between 2006 and 2011. Maternal mortality accounts for 18% of all deaths among women aged 15-49. The maternal mortality ratio decreased over the years from 524 deaths per 100,000 births in 2000/01 to 418 deaths per 100,000 births in 2006, before slightly rising to 438 deaths per 100,000 births in 2011 (UDHS, 2000/01, 2006 and 2011).

2.3 The Situation as Regards Gender Equality

2.3.1 Education Attainment

The proportion of women in Karamoja, North and West Nile sub-regions who have never received any formal education is significantly higher than the proportion of men. About 25% of women and 6% of men have never had any formal education. In Karamoja sub-region the proportion of both women and men that never had any formal education is much higher than in the rest of the sub-regions. Data on the median number of completed years of education indicates that on average, boys spend about 3 more years in school than girls. It is important to note that in Karamoja sub-region male children spend 6 more years in school than their female counterparts.

Table 12: Percentage distribution of women and men aged 15-49 by highest level of schooling completed

No education Median years completed

Female Male Female Male

Karamoja 57.9 29.5 0.0 6.0

North 15.7 0.0 4.0 5.8

West Nile 19.3 3.7 3.6 6.0

Average 24.9 5.5 3.1 5.9

Source: UDHS, 2011

2.3.2 School Attendance Ratios

Gender differences in school attendance are more significant at pre-primary and secondary levels in Karamoja, North and West Nile sub-regions. In Karamoja, at both levels, girls attend school more than boys, while the pattern is different within North and West Nile sub-regions



(where boys attend school more than girls). At primary level, the gender gap is minimal. It should however be noted that slightly fewer girls attend school than boys in all sub-regions.

Table 13: Net attendance ratios

Pre-primary

Male Female Gender Parity Index (GPI)

Karamoja 4.4 7.4 1.66

North 11.8 10.4 0.88

West Nile 5.4 4.2 0.79

Primary

Karamoja 53.9 49.3 0.91

North 80.1 77.9 0.95

West Nile 81.2 76.7 0.98

Secondary

Karamoja 7.2 7.5 1.05

North 5.8 3.7 0.64

West Nile 11.5 7.6 0.66

Source: UDHS, 2011

2.3.3 Employment Status

More men (89.8%) than women (65.1%) were employed during the reporting period of 2011. In Karamoja sub-region only a slight difference exists between the employment status of the sexes with just 3.4% more men being employed than women. Sharp differences however exist in North and West Nile sub-regions as the proportion of employed men was much higher than that of women. In North sub-region the difference is 37% and in West Nile 18.9%. With regard to the proportion of men and women who are not in employment, 1% more women reported that they were unemployed.

Table 14: Percentage distribution of women and men aged 15-49 by employment status

Currently employed Not currently employed

Women Men Women Men

Karamoja 85.3 88.7 6.8 4.1

North 53.0 90.0 10.3 8.0

West Nile 71.1 90.0 4.2 5.6

Average 65.1 89.8 7.6 6.6

Source: UDHS, 2011

With regard to type of occupation, men are more represented in professional/managerial work, skilled agriculture, forestry and fisheries, plant and machine operation and assembly work. Women are mostly involved in clerical work, sales and services, crafts and trade and elementary work.

2.3.4 Cash Earnings

More than half (62.6%) of women with cash earnings reported that they made independent decisions on the use of their earnings. A quite significant proportion of women however reported that their husbands decided on how their cash earnings should be used (9%). Women’s control over their cash earnings was significantly lower in North sub-region. Most women do not make independent decisions as to their earnings; decisions are either made jointly with husbands or it is the husband who makes the decision. Gender disparities in cash earnings exist, with almost two thirds (63.7%) of women reporting that their husbands earn more than they do (UDHS, 2011).



Table 15: Control over women’s cash earnings and relative magnitude of women’s cash earnings

Person who decides how the wife’s

cash earnings are used: Wife’s cash earnings compared

to husband’s cash earnings:

Mainly

wife

Wife and husband

jointly

Mainly husband

Other More Less About

the same

Husband has no

earnings

Don’t know/no

data

Karamoja 68.6 22.7 7.4 0.9 13.3 44.2 15.9 8.1 18.5

North 36.7 47.0 13.9 0.6 15.1 72.6 9.9 0.5 1.9

West Nile 66.8 24.1 7.9 0.0 10.2 79.9 5.1 0.8 4.0

Average 62.6 27.3 8.8 0.5 12.3 63.7 10.4 3.8 9.7

Source: UDHS, 2011

2.3.5 Ownership of Assets

Lone ownership of a house is more common among men than women, with 50.3% of men and 12.4% of women reporting that they own a house. The pattern of ownership of houses in Karamoja sub-region is however different, with slightly more women reporting ownership (29.5% of women compared to 29% of men). Gender disparities in home ownership are the most significant in North sub-region, with 53.2% more men owning houses than their female counterparts. The pattern of lone ownership of land is similar, as more men also own land (39.1% of men compared to 6.7% of women). In Karamoja and West Nile sub-regions, more than half of women reported that they did not own land. Table 16: Percentage distribution of women and men aged 15-49 by ownership of housing and land

Percentage who own a house Percentage who own land

Alone Jointly Alone and

Jointly

% who do not

own a house Alone Jointly

Alone and jointly

% who do not own land

Women Men Women Men Women Men Women Men Women Men Women Men Women Men Women Men

Karamoja 29.5 29.0 27.2 30.4 6.8 20.2 36.5 20.4 11.7 49.9 21.8 13.0 8.2 6.2 58.3 30.9

North 9.2 62.4 51.6 14.1 6.2 1.6 32.9 21.9 8.0 35.7 48.2 31.6 4.8 1.2 39.0 31.6

West Nile 7.3 41.0 37.7 21.1 2.9 10.6 52.0 27.3 7.4 39.7 29.9 17.6 6.0 6.1 56.6 35.6

Average 12.4 50.3 42.4 18.8 5.2 7.3 39.8 24.1 6.7 39.1 37.2 24.1 5.8 3.6 48.4 32.9

Source: UDHS, 2011

2.3.6 Access to Media

Exposure to mass media is higher among men (3.6%) than women (1.5%), though it should be noted that the proportion of men and women exposed to mass media is in all cases extremely low. The gender gap in exposure to mass media is widest in Karamoja sub-region where only 0.6% of women have access to mass media compared to 5.1% of men.

Table 17: Exposure to mass media

Access TV, radio and print media at least once a week (%)

Access none of the 3 media at least once a week (%)

Women Men Women Men

Karamoja 0.6 5.1 69.3 23.6

North 1.8 2.2 16.3 17.1

West Nile 1.6 5.2 20.4 18.9

Average 1.5 3.6 27.7 18.6

Source: UDHS, 2011

2.3.7 Women’s Participation in Household Decision Making

Over half (57.8%) of women reported having participated in decisions related to their own healthcare, major household purchases and visits to their family and friends. However a



significant proportion of women (7.1%) reported that they do not participate in any of these three decisions. Non-participation in decision making was highest in West Nile sub-region.

Table 18: Women’s participation in decision making

Specific decisions

Woman’s own

healthcare

Making major household purchases

Visits to family or friends

% who participate in all three decisions

% who participate in none of the

decisions

Karamoja 81.6 78.4 80.7 69.2 7.3

North 85.5 79.4 77.0 61.9 4.5

West Nile 71.6 66.8 67.1 44.6 10.8

Average 80.2 75.1 74.6 57.8 7.1

Source: UDHS, 2011

2.3.8 Gender-Based Violence

Attitudes toward wife beating

About 50% of women agree that a husband is justified in hitting or beating his wife for at least one of the following reasons: burning food, arguing with him, leaving the home without telling him, child neglect and/or refusal to have sexual intercourse with him. The most widely accepted reason for wife beating is child neglect. A significant proportion (45.2%) of men were also of a similar view that it is justifiable to hit or beat their wives for at least one of the above-mentioned reasons. To these men the most widely accepted reason for wife beating is the woman arguing with the man. It should however be noted that the proportion of women who agree that husbands are justified in hitting their wives is bigger than that of men who are of the same opinion.

Table 19: Percentage of all women and men aged 15-49 who agree that a husband is justified in hitting or beating his wife for specific reasons

Women Men

Husband is justified in hitting or beating his wife if she:

Husband is justified in hitting or beating his wife if she:

Bu

rns

th

e f

oo

d

Arg

ues w

ith

him

Go

es o

ut

wit

ho

ut

tellin

g h

im

Neg

lec

ts

the c

hil

dre

n

Refu

ses t

o

ha

ve s

exu

al

inte

rco

urs

e

wit

h h

im

Perc

en

tag

e

wh

o a

gre

e

wit

h a

t le

as

t

on

e s

pe

cif

ied

reas

on

Bu

rns

the f

oo

d

Arg

ues w

ith

h

im

Go

es o

ut

wit

ho

ut

tellin

g h

im

Neg

lec

ts

the c

hil

dre

n

Refu

ses t

o

ha

ve s

exu

al

inte

rco

urs

e

wit

h h

im

Perc

en

tag

e

wh

o a

gre

e

wit

h a

t le

as

t o

ne s

pe

cif

ied

reas

on

Karamoja 4.4 14.0 20.8 38.3 17.1 43.9 10.0 33.4 8.4 28.0 1.7 42.7

North 11.9 32.4 18.8 29.2 18.2 42.1 3.2 46.9 29.7 33.8 20.7 59.3

West Nile 33.7 45.9 40.0 52.9 25.3 66.0 7.5 15.9 15.6 19.5 7.3 25.1

Average 17.6 33.3 26.1 38.7 20.3 50.3 6.8 34.3 21.8 28.1 13.3 45.2

Source: UDHS, 2011

Spousal violence

Many women who were (or had been) married reported having experienced emotional and physical violence (45.1% and 50.9% respectively) at the hands of their partner. A significant proportion of women (24.6%) also reported experiencing sexual violence. Spousal violence among ever-married women was most common in North sub-region. Ever-married men reported lower incidences of physical and sexual violence compared to the incidence among ever-married women, with only 1.3% of ever-married men experiencing sexual violence.



Table 20: Percentage of ever-married women and men aged 15-49 that have ever experienced emotional, physical or sexual violence committed by their partner

Women Men

Emotional violence

Physical violence

Sexual violence

Emotional violence

Physical violence

Sexual Violence

Karamoja 35.3 38.0 15.0 52.4 33.3 0.0

North 50.2 56.4 26.4 37.8 20.3 1.0

West Nile 43.2 49.8 26.8 33.4 20.5 2.3

Average 45.1 50.9 24.6 38.9 22.8 1.3

Source: UDHS, 2011

Seeking help to stop violence

There are no significant differences among women and men who sought help with stopping physical or sexual violence, with 50% of women and 50.8% of men seeking help. The pattern is however different in the case of women and men who do not seek help and do not tell others about the violence. A bigger proportion of women decided to neither seek help nor tell anyone about their experience of physical or sexual violence (34.7% of women compared to 19.7% of men). Over half of men and women who had experienced physical or sexual violence in the sub-region of Karamoja never sought help or told anyone about their experience.

Table 21: Percentage distribution of women and men aged 15-49 who have ever experienced physical or sexual violence by their help-seeking behaviour

Women Men

Sought help

to stop violence

Never sought

help but told

someone

Never sought help or

told anyone

Missing/ don’t know

Sought help

to stop violence

Never sought

help but told

someone

Never sought help or

told anyone

Missing/ don’t know

Karamoja 22.2 18.2 58.6 1.0 20.0 22.2 57.2 0.6

North 57.1 13.2 29.7 0.0 67.0 28.0 4.7 0.2

West Nile 50.6 12.5 32.6 4.3 42.4 15.4 20.0 22.2

Average 50 13.6 34.7 1.6 50.8 23.5 19.7 5.9

Source: UDHS, 2011

Female genital mutilation

FGM was mostly reported in Karamoja sub-region (4.8%), while in other sub-regions the prevalence was very low (0.5% in North sub-region and 0.2% in West Nile sub-region).

Respondents’ opinions were sought as to whether the practice of FGM should be continued or stopped. A high percentage of women (75.8%) were of the view that it should be stopped. Such attitudes were strongest in Karamoja sub-region where FGM was more common.

Table 22: Percentage of women aged 15-49 who were cut, and attitudes to FGM

Attitudes to FGM

% of women cut Should continue Should be stopped

Don’t know/ depends

Total

Karamoja 4.8 10.9 80.1 9.0 100

North 0.5 16.9 73.1 10.0 100

West Nile 0.2 13.3 78.5 8.2 100

Average 1.2 14.7 75.8 9.5

Source: UDHS, 2011



3 Mapping of On-Going Nutrition, SRH, Gender Equality Programmes and Projects

3.1 Emerging Issues/ Mapping of Service Organisations and Implementing Partners

Most agencies, irrespective of their size and scope of activities, were making an effort to align their interventions with the national and sector planning frameworks. However, this was affected (particularly at local government level) by limited access to and use of policies, guidelines and standard operating procedures (SOPs). A number of innovations were identified, especially among international non-Governmental organisations (NGOs) and UN agencies working with CBOs. Examples include the transport voucher scheme organised by the Italian NGO CUAMM for maternal and child health and Community Action for Health (CAFH)’s community based growth monitoring for infants and children. However, these innovations were not systematically documented (i.e. no evidence could be built of their effectiveness) and they did not have clear roadmaps for replication and scale-up to other areas.

Most commonly seen were partnerships between national-level civil society organisations (CSOs) or between international CSOs and CBOs/district local governments. It would thus seem that it is becoming popular and a ‘norm’ to work in partnerships at both higher and lower local government levels. However, these partnerships are not always structured and in some cases are ad-hoc in nature, limiting their effectiveness in meeting goals and targets. Most partnerships also seemed to lack systematic capacity building and organisational development strategies over the short and long term.

While NGOs and CSOs at national level generally exhibited most aspects of organisational development (including strategic plans, human resources and financial manuals), CBOs operating at community level did not. There is thus a need for strategies to build the capacity of CBOs in organisational development processes.

Analysis of the thematic areas covered shows that few agencies were focusing on nutrition-specific and nutrition-sensitive programming. For most the focus was on food security, livelihoods and sustainable agriculture without the use of a nutrition lens. This affected the level of involvement of agencies in both nutrition-specific and nutrition-sensitive projects.

There were regional variations in the concentration of health and development programmes related to SRH, maternal and child health, nutrition and gender equality. Compared to other sub-regions such as Acholi and Lango, West Nile had fewer implementing partners working in these thematic areas.

In terms of coverage of interventions, there were also variations within sub-regions. Some districts (such as Otuke in Lango sub-region and Nebbi in West Nile) had relatively fewer partners and programmes involved in SRH, nutrition and gender equality. It was also noted that in almost all sub-regions it was rare to find partners covering the whole district, with most partners and their programmes covering less than half of the sub-counties and facilities in a district. Similarly, most partners did not offer a comprehensive package of SRH, nutrition and gender equality but instead focused on 2-3 components of the minimum package of services recommended.

The duration of most projects/programmes was 2-3 years with only a few programmes lasting 4 or 5 years. This has implications for the scale-up and sustainability of interventions. Some partners noted that the inception phase of a project could take up almost 75% of the



first year, thus leaving very little time for effective implementation, integration and capacity building for the sustainability of interventions.

Funding levels for most agencies were low and there were uncertainties as to the renewal of funding for existing programmes and services. However, funding also varied according to sector and thematic area, with health in general (including SRH) receiving more funding than gender and nutrition. In most cases gender was conceived as a cross-cutting issue and thus attracted smaller budgets. At the level of local government, it was noted that even when funding is allocated to gender-related activities, it can be difficult to secure the release of funds for their implementation.

Among the majority of agencies and partners, integrated programming was conceived and perceived as a promising practice. However, capacity challenges remain to the effective organisation and delivery of an integrated package of services as well as to the undertaking of integrated planning, implementation and M&E of interventions.

Most of the agencies mapped indicated human resource/staffing gaps in terms of numbers, capacities and skills of staff to offer services according to the SOPs and guidelines for SRH, nutrition and gender equality.

It was also noted that despite efforts toward institutional strengthening at local government level and among implementing partners, gaps remain (especially in relation to procurement and supply chain management) that need to be considered when designing capacity building interventions.

At local government level coordination has improved, but is still not being done effectively due to limited capacity and particularly, funding gaps that affect the organisation of regular meetings and the subsequent follow-up of identified action areas. In such circumstances, coordination agendas are largely driven by partners (who have funds) rather than being systematically planned and managed by local government line departments.

A detailed mapping matrix is provided in Annex 1.

4 Causes and Effects of Maternal and Child Malnutrition, SRH Problems, High Population Growth and Gender Inequality

4.1 Causes and Effects of Maternal and Child Malnutrition

The causes and effects of maternal and child malnutrition are classified according to the United Nations Children’s Fund (UNICEF) Conceptual Framework, which underlines the immediate, underlying and basic causes.

Immediate causes

a) Lack of special dietary considerations for mothers and children

Across all sub-regions, children tend not to be fed on any food other than that eaten by other family members (predominantly cassava and beans in Arua, sorghum in Karamoja and millet, cassava and beans in Lango and Acholi). Few mothers can afford to feed their children on milk. In some sub-counties (such as Nyaravur in Nebbi district) that are served by water bodies, parents have the opportunity to feed their children on fish (primarily silverfish) in addition to other foodstuffs such as beans and greens. Despite the wide range of available nutritious foods in Lango, Acholi and West Nile, focus group discussions indicated that families tend to eat limited varieties of food. This affects the extent to which



they adhere to a balanced diet. The availability of, cassava, sorghum, millet, rice, yams, pumpkin, groundnuts, sesame, sweet potatoes, beans, fish, animal products (meat and milk), yellow bananas, mangoes, oranges, avocadoes, paw-paws and vegetables if appropriately prepared and consumed in balanced manner would assure mothers and children of a balance diet.

Children eat foods that the rest of the family eats. It would be proper if children were given things like fish and greens. You find that they only take breakfast and supper… (FGD Adult Men, Aroi Sub-County, Arua).

As is the case with children, consultations through FGDs and key informant interviews (KIIs) indicated that there are no special dietary considerations for pregnant women, which undermines their nutritional status.

Food for most mothers is not easily available because some men do not cooperate with their wives to provide food; therefore in these households, women find it very hard to provide the necessary food for their children and themselves (FGD Young Men, Arua).

Pregnant women lack nutritious food; they eat cassava, sweet potatoes, beans and posho. There are families that even lack this type of food. Some women cannot afford this type of food because it is expensive, while some women do not take such food as important (FGD Young Men, Barr Sub-County, Lira).

b) Diseases

Diseases such as diarrhoea, malaria pose an immediate threat to nutrition outcomes among pregnant women and children. 39% of children under age 5 were reported to have had fever in the sub regions of Karamoja, North and West Nile. Sub regional variations exist with Karamoja sub region recording the highest prevalence (Karamoja 40.9%, North 38.5% and West Nile 37.6%). The prevalence of fever increases as the children’s age increases. It is highest among children 12-23 months. Thereafter, the proportion of children reporting fever decreases. There is significant difference in the prevalence of fever between children in urban and rural areas. Three in ten urban children under age 5 were reported to have had fever compared with more than four in ten rural children. 21.5% of children under 5 were reported to have had diarrhoea within the sub regions of Karamoja, North and West Nile. Sub regional variations existed with North (Lango and Acholi) having the highest prevalence of diarrhoea. The occurrence of diarrhoea varies by age of the child. Young children ages 6-23 months are more prone to diarrhoea than children in the other age groups; those age 6-11 months have the highest prevalence of diarrhoea among the age cohorts. Diarrhoea is more common among children who live in households with a non-improved toilet facility or a shared toilet facility compared with children who live in households with improved, not shared facilities. Rural children are only slightly more likely than urban children to get sick with diarrhoea (UDHS, 2011). Table 23: Prevalence of diseases in children under 5

Disease Prevalence rate

Fever Diarrhoea

Karamoja 40.9 20.3

North 38.5 23.8

West Nile 37.6 18.7

Average 38.6 21.5

Source: UDHS, 2011



Underlying causes

a) Food insecurity

One of the various underlying causes of maternal and child malnutrition is food insecurity, which is attributable to ecological and climatic factors as well as to the poor post-harvest handling of food. These factors are elaborated below:

i) Ecological and climatic factors

The ecological and climatic conditions of the different sub-regions under consideration have variable levels of impact on food production, food security and nutrition. Of the four sub-regions, Karamoja is the hardest hit by the harsh climatic conditions which in part account for persistent hunger and malnutrition in the region. Karamoja and the area of Lango sub-region that borders Karamoja usually produce food during one rainy season per year and otherwise suffer long droughts. Karamoja sub-region receives considerable rainfall in the wet season, but practices for the harvesting and conservation of rainwater for use in the long dry season to feed animals and irrigate/water crops are sub-optimal.

In all four sub-regions, trees are being cut at an alarming rate to provide fuel and building materials and are not being replaced. This has tremendous effects on the climate (especially in Karamoja, where the situation is worsened by the fact that charcoal burning and firewood gathering and selling currently support a significant portion of the region’s rural economy). In the medium and long term, this affects food production and availability and subsequently causes nutrient deficiencies.

Ecologically, maternal, infant and young child nutrition (MIYCN) was said to be largely dependent on the harvest. If the harvest is good, mothers and children can secure porridge for breakfast, lunch and supper, while poor harvests result in poor feeding practices.

The intensity and effect of harsh climatic conditions is reflected in the views of community members that participated in the study:

Feeding children is a big challenge during the dry season. There is no food and no money to buy food. Children are suffering. What I see is many children are really malnourished. They are constantly sickly, they are always at the health facility (FGD Adult Men, Kotido Sub-County, Kotido).

What I have seen as a challenge here is that the food we plant is affected by bad weather – too much sunshine. So when you plant, you get poor yields. Secondly, due to high population, a farm is divided into small parts, hence low production (FGD Adult Men, Aroi Sub-County, Arua).

There is not enough food in this dry season, we only have beans, there are no variety of foods. We do not have greens, vegetables because it is the dry season. This limits our ability to care for children (FGD Adult women, Ogor Sub-County, Otuke).

...food is increasingly becoming scarce in the village. There is a challenge in getting food right now in the village…This is because people had a poor harvest of food last season because the soil is exhausted. At the moment there is severe drought which has resulted in scarcity of green vegetables and food (FGD Young Men, Barr Sub-County, Lira).

The differences in climatic and ecological conditions across the four regions account for differences in nutrition practices. In Karamoja, persistent hunger and famine affect nutrition



significantly and leave women with limited options (and at times, no options at all) for feeding their children. Consultations with community members during FGDs and KIIs drew attention to the practice whereby mothers, due to limited options, feed their children on draff (spent grain) from local breweries. It was reported that it is not uncommon for households to go without food for days while subsisting on draff (which is locally available and sometimes free). Others depend on leaves from trees that grow in the wild as food. As such, charcoal burning and the overwhelming demand for firewood for sale are threatening not only the ecosystem but also sources of food.

Once again in Karamoja, the climatic and ecological conditions have propagated a practice of growing a single food crop (sorghum), predominantly supplemented (minimally) by maize and beans. Diversification is limited; there is a common mindset that other crops do not thrive in the region and the production of other nutrient crops is thus not often attempted. The situation is however different in other sub-regions. In West Nile, Acholi and Lango for instance, a great variety of crops are grown in the region including: cassava, sweet potatoes, banana, sorghum, maize, finger millet, rice, Irish potatoes, groundnuts, sesame, field peas, pigeon peas, cowpeas, soybeans and beans.

These sub-regions have relatively greener belts which support the production of a variety of crops. A wide range of livestock is also reared that includes cattle, goats, sheep, pigs, chicken, turkeys and ducks, all of which offer great potential for food and nutrition security. The observed challenges to nutrition in these areas are more often linked to limited knowledge of desirable or recommended feeding practices than to the non-availability of food (food insecurity).

It is such differences that account in part for different nutrition practices and status across regions. For example, the following cases mark a significant difference between West Nile and Acholi on one hand and Karamoja on the other:

In this community, families and children have about two meals a day, despite the poverty levels. There is breakfast in the morning; a few homes have lunch, then supper. If you consider the health of children in this community, very few are malnourished (FGD Adult Men, Aroi Sub-County, Arua).

Here in Amida during the dry season like this we like giving them beans, silverfish, pigeon peas and posho since we don’t have greens or vegetables (FGD Adult Women, Amida Sub-County, Kitgum).

In Kitgum (Acholi sub-region), nodding disease was reported to affect the nutritional status of children as the seizures deny them the opportunity to eat. Caregivers are also denied the opportunity to farm as they must care for their sick children. In other instances, mothers are bypassed by the rainy season; however the supplementary feeds provided by the health facilities are insufficient (Bukuluki et al., 2014).

ii) Poor post-harvest handling of food

Poor post-harvest handling of food was specifically cited to be a perennial problem across all sub-regions. For example, in addition to having only one productive season and producing predominantly one food crop (sorghum, which is minimally complemented with maize and beans), what little produce is harvested is poorly handled. Even when farmers have a good harvest it is often short-lived due to poor post-harvest practices. In Karamoja, it was noted in FGDs and KIIs that some families hold ceremonies during which the same sorghum meant for food and food security is used to make local brew, while the rest is used to prepare food for the celebrants.



Other sub-regions such as Acholi and West Nile reported under-utilisation of land and the prevailing use of rudimentary farming technology such as hand hoes. Use of ox-ploughs is limited. This significantly affects food production, food security and consequently the nutrition of women and children in particular.

Specifically in Karamoja, the population is also very much affected by dependency on the food relief that for a long time was supported by the WFP due to the emergency situation. It thus follows that interventions addressing malnutrition in Karamoja should appreciate the necessity to address socio-behavioural aspects as well as climate adaptation strategies (due to the long drought).

iii) Limited access to extension services

Agricultural extension services are a less developed service generally in Uganda and particularly in the sub regions of Acholi, Lango, West Nile and Karamoja. Under public service structures, districts and sub counties under the Directorate of Production are supposed to have technical staff to render agricultural extension services to the farmers. In northern Uganda, West Nile and Karamoja sub-regions like in the rest of Uganda, extension services have predominantly been a domain of NAADS (National Agricultural Advisory Services) programme. As much as the local government structures define that there should be extension service workers at the district and sub county levels, this human resource structure was overshadowed by a parallel structure of NAADS extension workers. NAADS has however been phased out since 2013/14 and replaced by Operation Wealth Creation. The phasing out of NAADS meant automatic reduction of extension services. Currently, there is a glaring human resource gap in regard to extension services. It is also imperative noting that even during the era of NAADS, farmers’ access to extension services was not obvious. NAADS programme in its design targeted progressive farmers and not any farmers. This exclusionary extension service delivery approach implied that in these three sub regions with few progressive farmers, access to extension services remained far from a dream come true. In Uganda, including in the four Northern sub regions, the major reforms of agricultural extension were planned under National Agricultural Advisory Services (NAADS). Lung’ahi & Opira (2013) attest to such reforms as: further decentralisation of extension responsibilities, from the district to the sub-county level; contracting extension services from a range of providers; involving farmers in programme planning, evaluation, and decisions about extension providers; establishing cost sharing between national and local governments and farmers; and the creation of more effective operational links between farmers, markets, extension workers, and agricultural researchers. With the phasing out of NAADS, all these reforms and benefits are no more. Provision of extension services in Acholi, Lango, Karamoja and West Nile sub regions just as in other sub regions has been marred with various gaps. The services hardly reach the farmers that ought to benefit from them. Besides extension workers being hardly accessible and sometimes non-existent, where they ever exist, their demands are an overweight to poor farmers. Often, they complain of lack of transport and other forms of facilitation to enable them conduct farm fieldwork across communities. In the circumstance, if they are to visit the farmer, the latter is expected to facilitate their travel to his or her farm. In practice, farmers with ability to pay for extension services (even when the services should be free) access the services. Practically, farmers and extension workers have a vivid disconnect. This means that farmers have no chance of improving their food production practices including getting to know the improved seed varieties, disease and pest resistant varieties, the right planting seasons and market opportunities. This in part continues to account for poor crop/food production yields, food insecurity and malnutrition.

http://www.agriculturesnetwork.org/persons/253438





Lung’ahi & Opira (2013) explicitly illustrate the transformations that agricultural extension in Uganda at large has undergone. These include; increasingly being “seen in terms of commercial or farming for market with emphasis on “modernization” of agriculture as opposed to family farming, which produces most of the food consumed in Uganda”, continued ignoring of subsistence farmers in favour of commercial farmers. Putting this reality into perspective, majority of the farmers in all the regions under consideration remain excluded from accessing agricultural extension services because they largely practice subsistence farming. Adong, Mwaura & Okoboi (2012) share a perspective that whereas NAADS offered a promise in terms of extension services, it is worth noting that the farmer groups (the primary institutions through which government supported agricultural households’ production and marketing activities in Uganda under the NAADS program did not attract many members. The trio citing the Uganda Census of Agriculture (UCA) observe that only 16% of about 3.9 million Agricultural households belonged to farmer groups nationally though Northern Uganda led other regions in membership to Farmers’ Groups. With the phasing out of NAADS, the farmers’ groups are a defunct structure. iv) Market barriers

Northern Uganda, Karamoja and West Nile are faced with multifaceted market barriers. For instance, the two decade war has meant long term effects and impact on levels of productivity in Northern Uganda. Opira (2013) observes that despite great access to fertile agricultural land by many formerly displaced persons, majority face input constraints (seeds, tools and knowledge) which limit their ability to increase productivity, and in turn undermines their basic survival and nutrition. Opira further recounts that difficultly in accessing markets not only continues to hamper achievement of sustainable livelihoods in Northern Uganda but poses a national threat considering that the north (Karamoja, West Nile, Acholi and Lango sub regions) represent over 30% of Uganda’s total land surface. As large pieces of land remain unused or underutilised, threats to livelihood sustainability, economic potential and nutrition become more glaring. Cognisant of market barriers, some measures have been invented. An example is the refurbishing in 2011 of Gulu Warehouse—a producers’ warehouse by WFP through its “purchase for progress” initiative. According to Opira (2013), this ware house was refurbished and equipped so as to give farmers and traders an opportunity to add value to their produce and penetrate bigger markets. The warehouse was installed with high capacity machinery for grain processing, cleaning, grading and storage for farmers and traders in the region. The facility has since been handed over and thus managed by the Coronet Group. However, whereas this intervention is very commendable in as far as enabling farmers and producers accessing markets, caution ought to be taken that the same measure has the potential to render the farmers food insecure. In Uganda, it is common that unregulated markets can be counterproductive. This warehouse facility is a symbol of demand for agricultural production which is very good. But at the same time, unless sale of food stuffs is regulated, the quest for money can lead the farmers to sell the little produce and thereby rendering themselves food insecure. Observing that the facility is reported to be underutilised considering its capacity of to handle 6000 metric tons (Ibid), the excess demand can motivate excess supply of even household food. It is essentially necessary that the demand and supply sides of the trade are regulated. Some farmers though versed with the best practices have difficulties in affording some of agricultural inputs, the primary equipment needed for proper post-harvest care. Other market barriers include the phenomenon of middlemen who buy grain (maize, beans, rice, groundnuts, sesame and sorghum) from stockists and farmers located in rural villages and





transport it to Kampala or other destinations like Juba in Southern Sudan. These play a significant role in maintaining low the prices for most farm produce since the middle men mind less about ensuring quality (Opira, 2013) but also take advantage of the farmers who by themselves may not be able to circumvent the market dynamics. This sustains the farmers in a cycle of inability to afford farm inputs needed to maximize their production potential, guarantee food security and nutrition in the regions. On a further note, farmers’ and producers’ warehouse similar to the one in Gulu are unheard of elsewhere in Acholi sub region and in the rest of the region. Yet, Gulu warehouse is licensed to handle only maize and beans, leading to its underutilization. The other grain crops grown within the region such as rice, groundnuts, sesame and sorghum are excluded.. Market information is also very important in facilitating producers know where they can market their produce as well as helping the food insecure know where to seek food support. Incidentally, market information is hardly available to both suppliers and those demanding food. It is not uncommon for example that Acholi or Lango sub region can have bumper food harvests while Karamoja faces food scarcity but without any mechanism to access the food suppliers and the buyers with needed information. This significantly sustains food insecurity in some regions. The situation is exacerbated by a mindset that Kampala and of recent South Sudan are the market destination for every foodstuffs produced in Uganda. Another dimension of market barriers lies in lack of effective demand for food stuffs. Given the local/household economy of particularly Karamoja but also some parts of Acholi, Lango and West Nile sub regions, many fall short of effective demand for food stuffs on the market within and outside the respective regions. The situation is worsened by the fact that in Uganda, “the behavior of food prices depends heavily on tradability of the commodity” (Haggblade and Dewina, 2010). Staple foods (the grain crops) grown in the regions under study are highly demanded within the country, in the East African region and in South Sudan. As much as this denotes existing potential to increase intra-regional trade (USAID and COMPETE Program, 2010), it contributes to food insecurity following the sale of a greater proportion of the produce.

b) Poor breastfeeding practices

Encouragingly, mothers reported receiving information on breastfeeding from health facilities as observed below;

Here, pregnant women are advised to start giving breast milk to their babies immediately after delivery, within one hour (FGD Young Women, Aroi Sub-County, Arua).

Mothers are advised to give babies breast milk immediately after delivering their babies. This is because breast milk helps protect children against certain diseases that might attack them as they grow up. The babies are given colostrums. Initially, mothers thought that colostrums contained spoilt milk and they would squeeze it out because it was thick and yellowish, but nowadays mothers give children colostrums (FGD Young Women, Adwari Sub-County, Otuke).

That first breast milk has no disadvantage. It is very good. I was also advised to give my baby that milk (FGD Young Women, Aroi Sub-County, Arua).

We are told to breastfeed exclusively for 6 months. And for supplementary feeds, they are only meant for children older than 6 months (FGD Young Women, Kotido Sub-County, Kotido).



The above notwithstanding, food insecurity was found to significantly affect women’s dietary intake and in turn, breastfeeding practices. Mothers often find it hard to appropriately feed themselves, which in turn makes them less likely to have enough breast milk to feed their children. This was most commonly mentioned in FGDs in Kotido and Moroto:

Most children in this community are malnourished due to poor breastfeeding because mothers don’t feed well (FGD Young Men, Nadunget Sub-County, Moroto).

We try to follow the infant feeding instructions but during breast milk crisis moments due to poor feeding by the mother, we look for cow’s milk and feed the infants including those below 6 months, but not food (FGD Young Women, Kotido Sub-County, Kotido).

It was noted that the complementary feeding of infants and children over 6 months of age is a challenge (WFP/UNICEF, 2014). The views of community members obtained during FGDs substantiate the observation that the introduction of complementary feeding is untimely, inadequate and in some cases altogether lacking.

c) Inadequate care

As one of the underlying causes, inadequate care is partly associated with lack of nutrition awareness and early weaning of children.

i) Lack of nutrition awareness

Across all sub-regions nutrition awareness among mothers and other caregivers of infants and children was low, especially with respect to particular types of food and their nutrient content.

There is lack of knowledge among our women in feeding children. They just give very young children pieces of cold cassava in the morning, they do not know balanced diet. But under out-patient therapeutic care, they are being trained (KII, Lira District Staff).

Food is available and we can get it for cooking but people are stuck on the same kind of food but here there are so many kinds of food really. The Acholi think that the only good food is meat, eggs and rice (FGD Young Women, Amida Sub-County, Kitgum).

So eating the same food is still very common and people don’t know how to balance food, making our children grow without proper food values (FGD Young Women, Amida Sub-County, Kitgum).

Low levels of nutrition awareness are in part explained by low levels of literacy, especially among mothers and caregivers. In Karamoja, MIYCN is deeply affected by what is described as the predominant “zero years of formal education” among most women aged 15-49 (WFP/ UNICEF, 2014). Poor knowledge of good nutritional practices contributes to poor feeding practices, which in turn result in malnutrition.

ii) Early weaning of children

Many children are weaned too early. This happens most frequently among mothers who conceive within six months of a delivery and believe that the pregnancy/unborn child will affect the health of the breastfeeding baby. Some mothers who conceive within six months of delivery do not use family planning methods, while others simply have no control over conception as such power is reserved for the man. Whether due to early conception or other factors, early weaning denies the baby the opportunity to be exclusively breastfed and limits



their potential to receive optimal complementary feeding and continued breastfeeding for the first two years of life. This partly accounts for stunting rates and even severe malnutrition in some cases. In Kotido, cases of early weaning were reported during both FGDs and KIIs.

Some children are weaned when they still need to be breastfed but because their mothers cannot produce breast milk due to poor feeding, there is no option (FGD Young Women, Kotido Sub-County, Kotido).

What causes all that is hunger, pregnant women do not feed well, and children born are not well fed. During food shortages, everyone looks up to supplementary feeding at the health facility (FGD Young Women, Kotido Sub-County, Kotido).

d) Inadequate access to safe water, sanitation and hygiene

This was reported to be among the underlying causes of malnutrition. Scarcity of safe water was found to affect all four of the studied sub-regions. Boreholes (which are considered to be the safest source of water by community members) are still few and participants in the study did not report water from boreholes having been boiled or treated (most likely since it is perceived to be safe). Wells, springs and seasonal rivers are commonly relied on since they are reliable in terms of constant water supply; however, they are also unsafe and are very rarely treated.

According to the Uganda Water and Environment Sector Performance Report (2014), there are variations in water coverage across districts within the sub-regions. Districts in Karamoja (with the exception of Abim and Moroto) are still grappling with low water coverage/access and in Moroto, water sources are available but their functionality is low. A number of districts in West Nile (including Adjumani, Yumbe and Moyo) have the same problem. The difference between water access/coverage and functionality of the water source/point is clearly noted. Whilst in some communities efforts have been made to provide water sources/facilities and thus increase access, some of the water sources are not very well maintained. Thus, they break down or their water yield tremendously falls. Both water access and functionality of water sources impact on maternal and child nutrition. These two sub regions of Karamoja and West Nile are hard hit by harsh climatic conditions and it is only of late that borehole coverage is considerably increasing. The two sub regions of Acholi and Lango score much better than Karamoja and West Nile though their water coverage cannot be said to have reached a satisfactory level to impact adequately on maternal and child nutrition. The comparative better water coverage in Acholi and Lango is in part explained by the post-conflict recovery programmes that were spearheaded by both government and a vibrant civil society. At the time, Karamoja and West Nile did not attract attention for intervention. The table that follows provides a view of water access and functionality of water sources;

Table 24: Golden Indicators for Rural Water Supply (June 2014)

District Access Functionality2

Karamoja sub-region

Abim 89 81

Amudat 32 98

Kaabong 25 93

Kotido 46 75

Moroto 80 41

Napak 49 73

Nakapiripiriti 47 88

West Nile sub-region

Adjumani 43 88

Arua 72 86

2 Functionality denotes condition of the available and accessed water sources in terms quantity and quality of

water yield. For example, boreholes that have broken down have zero functionality.



District Access Functionality2

Koboko 62 95

Maracha 86 84

Nebbi 74 70

Zombo 91 82

Yumbe 35 97

Moyo 35 84

Lango sub-region

Agago 70 71

Alebtong 92 75

Amolatar 75 80

Apac 71 79

Kole 75 65

Dokolo 88 83

Lira 90 82

Otuke 92 81

Oyam 62 81

Acholi sub-region

Amuru 86 73

Gulu 94 85

Kitgum 88 60

Lamwo 92 83

Nwoya 95 76

Pader 72 83

Source: Uganda Water and Environment Sector Performance Report (2014)

As regards sanitation and hygiene, Karamoja sub-region scores the worst in terms of latrine coverage and there is open dumping of human waste. The UDHS (2011) clearly observes that in Karamoja sub-region, the disposal of children’s stools into the toilet/latrine stood at 18.4% compared to 49.7% in Northern region (Lango and Acholi) and 66.6% in West Nile. These figures are corroborated by the observation of the Uganda IPC Working Group (2014) that over 90% of households in Amudat and Napak and over 80% of households in Moroto and Nakapiripirit use the open bush for defecation (a trend partly explained by low latrine coverage). Further inquiry into the matter revealed that households and communities are sceptical about digging pit latrines because they fear that the loose soil will fall in.

Overall, evidence from both the field and available literature acknowledges and laments the lack of water and sanitation as one of the significant underlying factors hindering proper food utilisation, particularly in Karamoja but also (to varying levels) in the other regions.

e) Few and inadequately facilitated therapeutic centres

In-patient therapeutic centres are largely located at Regional Referral Hospitals (RRHs), which lack good-quality assessment equipment such as scales, height measurement and Mid-Upper Arm Circumference (MUAC) tapes. In short, most sub-regions are characterised by limited access to therapeutic services amid a high prevalence of malnutrition. There is a general lack of health services needed to offer prevention of malnutrition through good healthcare. The absence of needed preventive healthcare in the context of malnutrition on one hand and the shortage of in-patient therapeutic centres make the situation rather less bearable.

In all regions, therapeutic feeding is supported by DPs but generally remains inadequate. Given the current severity of malnutrition in a context of scarce preventative interventions, in-patient and out-patient therapeutic care is sorely needed but the level of need far exceeds the availability of such care.

In Lira district, Lira Regional Hospital and the Pentecostal Assemblies of God Health Centre IV run in-patient therapeutic centres, but these sometimes run out of supplementary food and nutrition assessment materials. In addition, UNICEF has supported the opening of other



nutrition centres in Lango sub-region (e.g. in Alebtong Health Centre IV, Orum Health Centre IV, Kole-Aboke Health Centre IV, Anyeke Health Centre IV and Apac District Hospital), staff from all of which were trained in Lira with UNICEF support. This was followed by the official opening of these centres in October 2014 by a team from UNICEF and the MoH. it was however reported that all these nutrition centres lack a consistent supply of therapeutic food.

In Otuke district, there is only one therapeutic centre (Orum Health Centre IV). This provides out-patient therapeutic care. Some staff from this facility were trained in nutrition by the Northern Uganda Health Integration to Enhance Services (NUHITES) project in conjunction with the MoH and UNICEF. In other health facilities staff have also been trained, but they only carry out nutrition screening and referral (and do not administer care).

Basic Causes

a) Socio-cultural factors

These include the varying myths, beliefs, gender roles and nutritional practices that exist across the sub-regions. For instance, in Acholi and West Nile, cultural myths that discourage women from eating certain types of food such as liver, eggs, and gizzard were identified. It was also found that gender and culture combine to affect nutrition at household level. For example, in all four regions food, nutrition and child health issues are perceived to be the responsibility of women and when men get involved, they are seen merely to be helping. This undermines the quantity and adequacy of food. This phenomenon of minimal male involvement to the detriment of MIYCN was found to be affecting all four sub-regions:

…the men are not supportive so women find it hard to get food. If they are to favour a few children by giving them good foods, some are left out (FGD Young Women, Aroi Sub-County, Arua).

Some children feed well within this community but there are families with no balanced diets. If it is women who are the breadwinners in a home, they may not provide as desired; hence children end up being unhealthy (FGD Young Women, Aroi Sub-County, Arua).

In Karamoja, men traditionally focus on cattle rearing and relegate responsibilities for food and nutrition to women. Many pregnant women in particular become trapped in cultural dictations of gender roles and receive less support from their husbands in their endeavour to feed their households. In addition, women predominantly have to earn income through burning charcoal and gathering firewood; activities which consume a lot of time under the scorching sun and can involve trekking long distances (sometimes up to 10km). As such women tend to go a long time without eating and often do not eat until they make sales, after which they buy food and return home in the evening to prepare the day’s meal.

Pregnant women are not taken care of in this community. They are forced to do heavy work in order to survive. Their husbands also have their work – looking after their animals while women look for firewood, food which is got after selling charcoal and firewood... their health is poor. They go for charcoal burning, go to town to sell. They do not find time to bath, they don’t get food for lunch but only get dinner... (FGD Adult Men, Tapac Sub-County, Moroto).

Some mothers were also reported to be engaging in counterproductive behaviour. Some resort to drinking and neglect their children:

Mothers go to town to drink, come back drunk, don’t feed and don’t bathe children, so they become malnourished (FGD Young Men, Nadunget Sub-County, Moroto).



b) Policy, institutional and structural factors

Other causes of malnutrition are institutional and policy-related. At district and sub-county level there is limited or no nutrition-sensitive programming. In addition, roll-out of the Uganda Nutrition Action Plan (UNAP) to local governments has been slow and the Plan has not yet been rolled out to some sub-counties despite nearing its end. Knowledge of UNAP is scanty at sub-county and facility level and districts have not developed district-specific Nutrition Action Plans to which they could commit.

The identification mission also discovered that there were limited initiatives and funding for SBCC aimed at the promotion of proper nutrition practices. Traces of such initiatives were very hard to come by. Dysfunctional structures for the coordination and promotion of nutrition and food security were another institutional factor affecting nutrition across regions. For instance, all districts visited reported having District and Sub-County Nutrition Coordination Committees but these were found not to be functioning.

c) Limited community-based/community-led nutrition initiatives

Community-based and community-led nutrition promotion interventions are lacking. Nutrition is currently handled at a curative rather than preventative level and is more facility-based than community-led.

Across all four sub-regions, there were hardly any identified functional community-based or community-led nutrition promotion initiatives or structures. Village Health Teams (VHTs) and local leadership are not adequately utilised and are not facilitated to engage in nutrition activities, despite their potential to substantially contribute not only to nutritional assessment, awareness, sensitisation and referral but also to bridging the gap between communities and health facilities.

d) Weak linkages between communities and health facilities

Across all regions, linkages between communities and health facilities are weak. Nutritional assessment at community level and referrals to health facilities are small-scale, yet health workers are unable to afford the regular integrated outreach activities which would help them to approach malnutrition from a preventative perspective. It follows that health workers wait for health facilities to deal with the problem from a curative perspective. Worse, facilities are inadequate (or are even altogether lacking) in terms of in-patient and out-patient therapeutic care centres. The absence of linkages between communities and health facilities is exacerbated by the long distances that most community members must travel to reach health facilities.

In all regions, the role of VHTs and other local structures such as local, religious and opinion leaders is yet to be harnessed in promoting nutrition and preventing malnutrition (including bridging the gap between communities and health facilities).

e) Low staffing levels of nutritionists at local government and facility level

Gaps in human resource capacity counter the effective delivery of nutritional assessment and malnutrition management by health facilities. Due to heavy staff workloads, nutritional assessment is considered a secondary activity and priority is given to other health conditions which are seen as inevitable, acute and urgent. Midwives for example have no time to monitor weight and height when they also have to see to ANC, maternity clinics and family planning.



f) Inadequately trained personnel in nutrition assessment

Overall, there are few personnel among health facilities and communities who have been specifically trained in nutrition assessment. This hampers both response to malnutrition and the prevention thereof. While emphasis is being placed on integrating nutrition into other healthcare packages, not all health workers have received training in nutrition.

We are not integrating it. Staffs that are trained are few. All health workers at all health units should be competent to assess nutrition for every client regardless of the kind of illness/case presented (District staff, Otuke).

There are marked variations in the significance of the factors explained above. The principal causes and effects of malnutrition cut across the immediate, underlying and basic factors. For instance, food insecurity (an underlying factor) stands out among other factors since it underpins poor feeding practices (including early weaning of children) and affects people’s participation in food production. Among the immediate factors, nutrition illiteracy stands out while weak linkages between health facilities and communities coupled with nutrition human resource constraints, are more pronounced than any other basic causes. These are core causes that require comparatively more urgent attention than other factors.

4.2. Causes and Effects of SRH Problems and High Population Growth

Physical/ecological factors

Poor terrain, poor condition of access roads and the long distance to and from health facilities are all factors that discourage people from seeking sexual and reproductive health (SRH) services.

Here, the roads are not good. The only good road is the main road here. During the rainy seasons, roads are impassable making it hard to reach the health centres (FGD Young Women, Aroi Sub-County, Arua).

Our health centres are very far; some people stay in far places and fail to reach hospital on time especially during emergencies. Our challenge is the distance to hospitals; some people lose interest (FGD Young Women, Aroi Sub-County, Arua).

…the nearest health facility is Moroto Regional Hospital which is 10km away. Otherwise, Tapac Health Centre III is about 36km from here. So to go to the health facility, you really must be sick… (FGD Adult Men, Tapac Sub-County, Moroto)

Socio-cultural, religious and gender-related factors

Different regions hold different cultural beliefs and myths. It was however found across all regions that some men and women want large numbers of children. In Karamoja for example among the Tepeth of Moroto, one quoted reason (in an FGD with adult men) behind the increasing intolerance of FGM is the fact that women who have survived FGM normally find it difficult to produce more than 7 (seven) children yet men want more than this number. Some men equated each girl born to 60 cows as dowry at the time of marriage, while boys were perceived as a pillar in the home to help the men with masculine roles and security.

There are also widespread myths and beliefs about family planning such as excessive bleeding, cancer in the case of intrauterine devices (IUDs), weight gain/loss, reduced libido and so on. Such cultural beliefs stand strongly in the way of the uptake of family planning services:



...women say it’s men who are still a problem. They discourage women to enrol. It is even worse for long-term and permanent methods. Men take it that women who enrol are cheating (KII, Moroto District).

There is also local community perception and attitudes that affect men’s participation in family planning. For example, involvement of men is limited because of fear of what the community would say and hence men shy away (FGD Young Men, Bungatira Sub-County, Gulu).

In case you produce only two children, what do you do if diseases kill them? So you produce many so that diseases kill some and leave others (FGD Adult Men, Kotido Sub-County, Kotido).

With respect to ANC, some women believe that they can deliver babies without visiting the health facility. In many cases they have always done it, and will thus continue to do it.

Across all sub-regions, the discussion of sex and sexuality among adults and children is a taboo. In Karamoja sub-region it was noted that the increase in population growth is in part attributed to recent changes from a pastoralist existence to a more settled one. In the past, men used to leave their homes for long periods of time (up to a year or two), which allowed for the natural spacing of children. However, now that life is more settled the men live with their wives and therefore reproduction is fast.

In Karamoja, it was noted that in order for any interventions to take off, the engagement of elders is fundamental. However, respondents reported only minimal engagement of elders in SRH services.

Gender also impacts on SRH, particularly among women. In all regions women traditionally have limited or no say or control over how many children a couple should have.

Leadership challenges at all levels to the promotion of SRH, including family planning

Across all regions, leaders at different levels have not fully participated or engaged in family planning campaigns for population control. This is different from ANC where at least some leaders were reported to be actively involved in encouraging pregnant women to complete the required 4 ANC visits and also to take their children for immunisation.

Male involvement challenges

Male involvement remains a daunting challenge. Men are reportedly hesitant to escort their wives to ANC for fear of being tested for HIV. In Lira district for example, the District Health Office cited mothers’ enrolment or uptake of family planning to be as low as 24%. This was largely blamed on minimal male involvement in MCH, which isolates mothers and women.

Some women would go to the health centre but are discouraged by their men who do not accompany them, yet it is a requirement that men accompany their women to the health centre (FGD Young Women, Aroi Sub-County, Arua).

As a pregnant woman, if you do not come for ante-natal care with your husband, you may not be worked on. If your husband is not around, you cannot go to the health centre (FGD Adult Men, Aroi Sub-County, Arua).



Policy-related and institutional factors

These include:

Lack of youth-friendly services: Across all regions, district, facility and community members lamented the lack of youth-friendly services and youth corners in health facilities and schools. The general and open environment that does not guarantee adolescent privacy intimidates and discourages young people from seeking SRH services. It is worth pointing out that there are no well-defined linkages between schools and health facilities. Such linkages should be explored and developed through school health and SRH policies.

Limited awareness of policies and guidelines, especially at local government, facility and community level: It is a common practice that stakeholders at different levels speak generically about SRH. Specific understanding of the guiding policies and guidelines is sparse and becomes sparser as one goes down to community level, where understanding of SRH is very limited. Policies are not disseminated adequately and are not translated into local languages.

Short-term projects and donor dependence: Ministries and districts are heavily reliant on partners and this affects the implementation and sustainability of SRH programmes. It was found that districts and sub-counties that were receiving assistance through interventions by the United Nations Population Fund (UNFPA), Marie Stopes, Straight Talk, the Red Cross and Reproductive Health Uganda were doing comparatively better than counterpart districts that received no such support. Otuke district for example could not point to a single SRH programme running in the district except for a few resource-challenged activities in health facilities.

Limited support supervision: Supervision of Ministry support to local governments and of support by higher local governments to lower local governments was reported to be lacking, with both district and Ministry teams complaining about resource-related challenges. Limited supervision of support is noted to affect both the quality and effectiveness of service delivery as well as the motivation of frontline staff to deliver SRH services. Limited supervision of support also undermines the potential for frontline cadres to share their experiences with supervisors.

Limited outreach: Due to limited staff and resources and inadequate facilitation, integrated community outreach is irregularly conducted. This takes place in a context of long distances to health facilities which discourage community members from seeking health facility services in sub-regions.

Inadequate utilisation of and investment in SBCC: In the sub-regions, SBCC initiatives are inadequate. In Lira district for example, staff at the office of the District Health Officer commented that lower-level health facilities often lack sufficient information, education and communication (IEC) materials for health education and community outreach. In Karamoja in particular, low levels of awareness are a key barrier to the use of SRH services.

....uptake is also affected by low awareness; e.g. condom top rings are used as earrings or finger rings (FGD Young Men, Moroto).

Low staffing levels in critical SRH cadres, especially among doctors and midwives but also anaesthetists and theatre assistants: This was found to not only affect the delivery of quality services but also to breed a loss of confidence in SRH systems and services.



Inadequate equipment in health facilities, particularly operating theatres: In addition to low staffing, health centre equipment is often inadequate and sometimes unavailable; e.g. in Lira, it was reported that some Health Centre IVs have dysfunctional theatres. In other sub-regions, long-term and permanent family planning supplies were said to be irregular. The human resources needed to administer long-term family planning methods are inadequate, especially at Health Centres II and III.

Poor management of family planning side-effects: Family planning is heavily associated with side-effects as reported by study participants. Side-effects encompass the negative consequences or physiological changes that women encounter as a result of using a particular method that otherwise would not be faced. Some reported experiencing weight gain or loss, excessive menstrual bleeding, low libido, general malaise and loss of appetite, among others. Most women seek family planning without the knowledge of their husbands (who are usually against it) but find themselves unable to hide the side effects from them. Moreover, husbands are not usually supportive as they refer the women back to wherever they sought the method – and to make matters worse, it was reported that health facilities are not adequately equipped to manage the side effects. This discourages uptake of family planning services.

The problem with family planning is the side-effects on women such as weight loss, so other women fear… (FGD Adult Men, Aroi Sub-County, Arua).

For me this is a life experience. My wife used family planning but she disturbed me a lot. She over-bled until we went to the health centre for stoppage of the method (FGD Adult Men, Kotido Sub-County).

Limited supply of standard kits for all health facilities: Health facilities at lower levels expressed concern about the GoU “push” system, whereby health supplies are delivered to facilities irrespective of need and numbers served. This leaves health facilities with inadequate or no supply of priority items on the one hand and excess availability of lower-priority supplies on the other. For example, Parambo Health Centre III in Nebbi delivers about 107 mothers per month but receives only 50 kits every 2 months.

4.3. Causes and Effects of Gender Inequality

Socio-cultural factors

Socio-cultural factors are critical in causing and perpetuating gender inequality. Negative attitudes to gender equality reflected in unequal gender roles, power relations and access to and control over resources were specified as key hindrances to gender equality. By and large, gender inequality is embedded in Uganda’s culture. In many cultures across the four sub-regions, men command a lot of power and unchallenged authority which affects women and children. Typically, there are socio-culturally defined gender imbalances and skewed relations between men and women.

The socio-cultural factors behind gender inequality are grouped according to the following sub-themes; land ownership, decision making, gender-based violence (GBV), participation of women in the economic sector and the education of boys at the expense of girls. These are discussed below.

Women’s participation in the economic sector

Study findings reveal that women are largely denied an equal opportunity to participate in economic activities that could elevate their socio-economic status in society. This was very



typical in Lango, Acholi and West Nile. Where women engage in economic activities, many do not have control over the returns from such activities but instead have to cede it to their husbands. The following observation is illustrative:

The men do not want women to go and engage in business, they want women to remain at home and cook, care for the children only this limits women’s opportunities to raise income (FGD Adult Women, Ogor Sub-County, Otuke).

Contrastingly, in Karamoja sub-region women were found to be very actively engaged in the economy. However, this sub-region is a particularly acute example of imbalanced gender roles. Women in Karamoja are responsible for household income generation while men limit themselves to cattle rearing. The dual responsibility of women for income generation and food provision has considerable impact on maternal and child health and nutrition in that women leave their children unattended when they go out to collect firewood, burn charcoal or sell charcoal and firewood to raise money for household survival. In this case, women’s economic engagement in Karamoja is more of a cost than a benefit.

Land ownership and control over productive resources

Men’s excessive control over land resources and women’s lack of control over the same permeates gender relations across all four of the studied regions. In all sub-regions, women culturally and traditionally lack control over land use, despite being largely (and sometimes entirely) responsible for food production and household nutrition. This disempowers them all the more, as was heard from different study participants:

Concerning land, here it is men who own land and make decisions. They say it is their fathers’ land and women are only married into that home. In case a woman loses her husband, his relatives are free to take over the land of the deceased and the woman has no say (FGD Young Women, Aroi Sub-County, Arua).

In Acholi, they say that women have no right to ownership of land (FGD Young Women, Bungatira Sub-County, Gulu).

Some of us buy food from the market because of lack of farmland, especially the girls who return home from marriages and do not have anywhere to cultivate… (FGD Young Women, Bungatira Sub-County, Gulu).

In Acholi and Lango sub-regions, land wrangles were cited as a significant cause of gender-based violence. Women are not culturally expected to own land.

Land wrangles can also prevent us from farming; culturally we are not allowed to own land so it makes it difficult for us do any work on the land (FGD Adult Women, Adima Sub-County, Kitgum).

Generally, the relegation of women to the status of land users (where such rights are accorded to them) puts these women in a very precarious position that robs them of even the lowest level of production autonomy.

Decision-making processes between men and women

Traditionally, the participation of women in decision making, including as regards their own reproductive health (such as how many children to bear in a lifetime and when to have sex with their partners) is very limited. Such decision-making powers are reserved for men.



Men have a say in everything e.g. men could decide on anything including unsafe or safe sex. The perspective of women is not considered. So even HIV-positive women continue becoming pregnant and producing children (KII at CUAMM, Moroto).

Decisions regarding the sale of agricultural produce (including of food) as well as control of the proceeds are made universally by men. This is irrespective of the heavy farm workloads endured by women in addition to their reproductive and community responsibilities, which leave these women without money and with very little time to take care of sick children or attend to proper hygiene and sanitation. FGDs in all four regions showed that most of the resources in the household are owned by men and even where women do own resources (such as chickens), men exercise extensive control over the cash earnings received from them.

Gender-based violence

This does not occur in a vacuum. It was for instance a common revelation that during and after harvest, domestic violence is common as men want to take control of the produce and the proceeds from the produce regardless of their contribution to production. In the worst cases, the proceeds from the sale of domestic produce are spent on alcohol by the man and his friends.

Some men can decide to sell a goat and drink all the money with friends. When you ask him, he responds ‘was it your goat?’ (FGD Adult Women, Moroto)

Some men sell land without informing the women and they do not want women to talk about it as they are the head of the house. When you talk about it then you are boxed straight or fought. Men say they have all the authority to plan and they don’t want to be ruled by wives. The women are not allowed to question men. The men sell land and even spend all the money on drinking (FGD Young Women, Lira Sub-County, Lira).

Men are perpetrators especially during this season that we have harvested and we have sold, some proceeds they spend on drinking (FGD Young Women, Bungatira Sub-County, Gulu).

There is always conflict over the sale of proceeds from agricultural produce which the man always does without the consent of the woman and if the woman agrees, the man misuses the money without bringing it home (FGD Young Women, Bungatira Sub-County, Gulu).

Some men want their wives to finance their alcoholic drinking and when the wives fail or refuse to do so, fighting erupts. Most men believe that once they have paid dowry, their wives belong to them, meaning they can do anything they want and the women should not complain. This fuels conflict.

In Karamoja sub-region nutritional challenges at household level combine with gender-biased roles and social behaviours to propagate and/or perpetuate GBV. Sometimes men spend the whole day drinking, only to return home and demand food which is often not readily available. Sometimes the women have failed to sell charcoal or firewood and have earned nothing; hence they are unable to afford food for the household but the drunk husband will not accept such reasoning. In other cases, both the woman and the man go drinking in different places and return home in the evening to find there is nothing to eat.

When men drink, they find women also drunk, they want food but there is no food available. Then it starts. Women regardless of their situation are expected to provide food. Men just demand (FGD Young Women, Moroto).



GBV is there in our community for instance due to too much drinking. Also when there is nothing to eat in the house, there is blame of one another. A man says the woman is not feeding him, that she is not doing enough while the woman insists the man should do something to contribute to the household food basket (FGD Adult Women, Moroto).

In some instances, it was reported that men often take pride in confining women within their homes and denying them the opportunity to step beyond the domestic sphere. For other men, polygamy is very satisfying and is therefore practised. All these however result in GBV:

Some of our cultures are so rigid that women are left to be domesticated to the home and not be so involved in the public domain. The worst one is polygamy where we have these men who marry so many women and this is a main cause of domestic violence (FGD Young Women, Amida Sub-County, Kitgum).

Unequal access to education among boys and girls

Gender inequality is also reflected in unequal access to education and its effects. According to the WFP/ UNICEF (2014) report, female-headed households constitute a third (32%) of all households in Karamoja sub-region with Napak scoring highest (42%). Dishearteningly, the report acknowledges that a number of these female heads of household are either disabled or chronically ill (10%). In addition, and in contrast to their male counterparts (68%), most female heads of household have never been to school (81%). This affects their knowledge of nutrition and related behaviour and practices, as well as their attitudes toward and practices related to SRH. Generally, most female-headed households are food-insecure, with limited access to land and poor food consumption. WFP/UNICEF (2014) emphasises that nutrition and food security interventions need to be gender-aware so as to prioritise female-headed households. This situation also occurs in other sub-regions (such as Nebbi).

In our community here in Barr, there are people who produced many children and paying school fees becomes hard for them, so they prefer to give away girls in marriage so that the boys use their dowry for their education. This is because when a girl attains education she will be married off and boys will remain home and take care of the home (FGD Young Men, Barr Sub-County, Lira).

In order to confront and change these socio-cultural barriers to gender equity and equality it is necessary that interventions be conducted through a variety of lenses in accordance with the inter-connectivity of these factors.

Limited commitment from leadership to changing unequal gender relations

There is limited commitment by district and community leadership to meaningfully challenge the status quo. At community level, local leaders are trapped in a paradoxical situation whereby they are asked to challenge the cultural norms that maintain the male dominance to which they belong. At local government level these leaders are involved in hardly any community outreach, thus limiting avenues to the engagement of communities in the drive to change unequal gender roles. It was however reported that this subject is occasionally discussed at community meetings presided over by local leaders (e.g. through the National Agricultural Advisory Services (NAADS) and Northern Uganda Social Action Fund (NUSAF).

Little has been done to help people understand the concept of gender in practical terms. Many still see it as a concept that challenges male power and dominance and it is not interpreted in terms of improved relations between men and women.



Policy and institutional challenges

Across all levels (national, higher and lower local government), gender is perceived and approached as a cross-cutting issue, which is promising since it provides all sectors and departments with the opportunity to include gender issues in their plans. Unfortunately, departments rarely take this opportunity and in practice, responsibility for gender is relegated to the Ministry of Gender, Labour and Social Development (MoGLSD) at national level and to the Department of Community Development at local level, both of which are underfunded.

While the laws, policies and guidelines that impact on gender are numerous and articulate, limited enforcement and implementation of these policies and guidelines is a concern among stakeholders. Contradictions have also been observed in some laws. For example, Police Form 3 has been revised to allow midwives to examine and provide evidence in court but the Evidence Act states that only a Police surgeon may do this. This affects access to justice for survivors of GBV.

Low capacity among local governments to implement gender equality programmes

The Directorate of Community Development (DCD) consistently faces the challenge of underfunding. It remains marginalised and thus ill-equipped to implement gender-related programmes. The financial/budgetary marginalisation of the parent Ministry is also felt at local government level. Underfunding confines an ideally community-based department to its office since staff cannot participate in community outreach, training or sensitisation due to lack of facilities (motorcycles, other vehicles and finance).

Low staffing levels, especially at district level, combine with low funding to rob the DCD of the capacity to live up to its mandate. Some of the districts visited reported staffing levels of below 50%, while others reported levels of about 70%.

In some districts (such as Kotido) it was reported that the district has formed gender working groups, but the group members do not meet regularly due to logistical challenges. The fact that such groups are present, but not functioning contributes to the lamented status quo.

4.4. The interrelations between Maternal and Child Nutrition, SRH, High Population Growth and Gender Equality

Food production is predominantly, though not absolutely, the responsibility of women. Men are only minimally involved in some activities (e.g. land opening and planting) while women take on weeding and harvesting. Minimal male involvement in food production in regions such as Karamoja, Lango and West Nile not only predisposes households to limited food (and thus, food insecurity and malnutrition) but also paves the way for GBV, especially when men exercise their perceived authority and control over farm produce (including food).

The large family sizes associated with limited or absent utilisation of modern contraceptives, minimal male involvement in family planning and cultural barriers to its uptake exert further nutritional pressure on already overstretched families. Moreover, nutritional challenges precipitate GBV. The findings presented in the Community Connector Situational Analysis Report (2012) indicate that poor spacing of children and large family sizes mean that women are constantly preoccupied with either pregnancy or nursing. This not only undermines their capacity to meet the nutritional demands of the household but also affects their reproductive health.

Women’s gender roles including production, reproduction and community participation, rob them of the time they need to attend to their SRH needs. Besides having limited time to eat,



they are also deterred from attending adequately to the nutritional needs of infants and children. Whenever farm produce cannot support household feeding, women are further challenged since their roles cannot assure them income to meet nutritional needs through the market, especially where they lack male support.

Gender inequality has been documented as both a cause and an effect of malnutrition while at the same time, gender and nutrition programming offers opportunities for synergy (FAO, 2012). For example, nutrition offers entry points for designing programmes that are sensitive to gender issues through nutrition education, school-based and youth programmes and agricultural extension (Ibid). In addition, the designing of food security interventions through a nutrition and gender lens offers opportunities to address power relations and improve the distribution of tasks and chores between men and women. For example, women’s economic empowerment reduces women’s dependency on men and opens doors for men’s respect for and recognition of women’s contribution. Simultaneously, women’s participation in decision-making processes also improves.

Evidence from the field, especially in Lango, Acholi and West Nile sub-regions, shows that women with little or no control over economic resources are likely to be more dependent on their spouses and their participation in decision making is limited. Contrary to what emerged from other sub-regions, findings in Karamoja suggest that women’s economic empowerment alone does not necessarily improve gender equality and relations. Indeed, in Karamoja it can exacerbate women’s burden since in addition to economic engagement they continue to shoulder all the other socially ascribed gender responsibilities. This is similar to other studies that caution against overstretching women and girls who are already overburdened with household and reproductive tasks (such as childcare, food preparation, water and firewood collection, etc.) with additional tasks (FAO, 2012; Mucha, 2012).

The above implies that while the engagement of women in economic empowerment projects may not be harmful per se, it is less likely to impact overall gender relations, nutrition and SRH if it is not combined with other interventions that address harmful norms as regards masculinity and gender. This underscores the need for multidimensional programmes that take into account the interrelationships between gender inequality, SRH and maternal and child malnutrition.

At an institutional level, it was noted that despite improvements in physical access to health facilities and services, the functionality of health institutions remains limited (see also the UNFPA Report 2014), especially as regards SRH and MIYCN services. In addition, the GoU has made conscious effort to build and upgrade health facilities as well as strengthening and streamlining the provision of healthcare commodities that support SRH, MIYCN and related gender issues. However, basic infrastructure such as electricity, water, communication, means of referral, adequate staff accommodation, and security (especially at night) remain obstacles to the provision of quality services, especially in remote and rural areas. Serious discrepancies also exist, with some newly built health facilities unable to function due to lack of staff and other resources (UNFPA, 2014). Current efforts to support staffing through the provision of training and equipment and ensuring the dissemination of guidelines and SOPs are still lacking, despite being essential to the achievement of positive impact on MCH and SRH services and the addressing of gender-related barriers to service access.

Available statistics on human resources for health (HRH) show the deficiencies in delivery of services that impact on nutrition, SRH and gender.

In 2013 the proportion of approved positions filled by appropriately trained health workers was 73% in the sub-regions of Karamoja, Lango, West Nile and Acholi, leaving a vacancy of 27% (see Table 20).



The 2014 HRH audit report notes that there are sufficient numbers of general administrative and clinical staff in Uganda (to 101% capacity). Nurses are staffed to 83% capacity and midwives to 76%. The report also notes that the following health cadres are severely short in number: pharmacists (8%), anaesthetists (30%), health administrators (33%) and cold chain technicians (40%). Overall, staffing is skewed in favour of specialised health institutions and larger health facilities. Compared to previous years staffing levels have increased, but the distribution of staff remains skewed against lower-level health facilities where most patients seek care. In addition, cadres that are critical to the scale-up of maternal and child survival interventions, especially doctors and midwives, are severely short in number (MoH, 2014).

Table 25: Human resources for health

Percentage of positions filled in all units

2008 2009 2010 2011 2012 2013

Karamoja 58.6 58.8 53.1 65.9 59.9 65.4

Lango 77.6 73.7 67.3 71.9 77.6 87.8

West Nile 52.1 55.3 60.4 52.3 68.1 69.6

Acholi 42 63 63.1 71.6 61.4 70.8

Average 57.6 62.7 60.9 65.4 66.8 73.4

Source: Human resource audit reports (MoH), 2009-2014

5 Roles and Responsibilities of Stakeholders and their Institutional Capacity in the Areas of Nutrition, Gender and SRH

5.1 Roles and Responsibilities of Stakeholders

The ideal roles of the institutions assessed at national and local government level are clearly known and defined. Across the 3 thematic areas of nutrition, gender and SRH, the Government of Uganda has the mandate to provide the following for the design and implementation of National Action Plans and programmes related to nutrition, SRH and gender:

Leadership and strategic policy direction;

An appropriate regulatory and enforcement framework;

Public services;

A favourable environment for the private sector and civil society;

Monitoring, accountability and oversight;

Guidelines, standards and technical assistance.

The GoU is also mandated to carry out multi-sectoral coordination for better nutrition, SRH and gender outcomes. This role is implemented through national Ministries and committees, local government departments and district and sub-county committees (all of which have clearly defined roles).

As a case in point, the Uganda Nutrition Action Plan (UNAP) prescribes the roles of the different structures. The Food and Nutrition Council (FNC), one of the 3 policy coordination entities, is mandated to provide policy direction, guidance and oversight as well as national coordination of the implementation/M&E of UNAP and other nutrition-related programmes in the country. The FNC i) coordinates joint planning and review with Ministries, departments, DPs, CSOs, the private sector and universities; ii) monitors and evaluates national nutrition response; iii) mobilises resources and support for nutrition response; iv) provides national standards and norms for nutrition; v) advocates for the development of nutrition structures and adequate resource allocation; vi) lobbies for the establishment of a consolidated



nutrition fund by development partners; and vii) facilitates cross-sector collaboration with higher-level committees (in the Cabinet and Parliament) and the Multi-Sectoral Technical Committee on Nutrition.

The Cabinet Sub-Committee (the second policy coordination entity) ideally meets biannually to review progress on key nutrition indicators in the country and provide policy direction while the Parliamentary Sub-Committee on Nutrition (the third policy coordination entity) depends on the guidance received from the FNC and Cabinet Sub-Committee to make the key policy and financial decisions.

The National Planning Authority is mandated to coordinate and harmonise nutrition-related issues with national development planning and M&E.

The UNAP also defines the roles of the Nutrition Development Partners’ Committee, Uganda Nutrition Coordination Forum Sectoral-Level Coordination Committees and District-Level Coordination Committees.

Local government is mandated to ensure the integrated planning and budgeting of nutrition, SRH and gender issues (including management of their implementation, regular monitoring, supervision and evaluation and providing technical guidance to stakeholders and service providers in the respective sectors).

Civil society plays a crucial role in i) advocating and sustaining political will for Government action; ii) ensuring the monitoring and accountability of both the public and private sectors; iii) service delivery; iv) scaling up nutrition, SRH and gender mainstreaming interventions at community level; and v) contributing to the process of information gathering for a stronger evidence base and SBCC, among other roles. As an example, the private sector plays a role in i) producing and marketing affordable SRH products, fortified foods and other nutrition-related products; ii) formulating public-private partnerships (PPPs), iii) social marketing; and iv) generating growth in food production, income and employment (SUN/UNICEF, 2011).

Notably however, whereas the ideal roles of the institutions assessed at national and local government level are clearly defined and known, discrepancies exist between their ideal and actual roles (particularly in the case of public institutions and structures). Gaps are primarily associated with funding, understaffing and low (and in some cases absent) supervision of i) support at central (Ministry) level to local governments; and ii) support from higher to lower levels of local government. Supervision of support continues to be an under-prioritised area in terms of logistics and human resources. As a result, the gaps in nutrition, SRH and gender interventions continue to resurface with each intervention and reporting cycle. For example, a review of sector-specific Annual Performance Reports over different years reveals the same recurrent gaps. This continues to challenge the availability, adequacy and quality of the SRH, nutrition and gender services provided.

Discrepancies between ideal and actual roles are also partly due to minimal dissemination and roll-out of policies, guidelines and Action Plans. For example, UNAP is almost at its end and districts still have not developed customised Nutrition Action Plans, let alone received dissemination of UNAP to all districts and sub-counties. Policies and guidelines have not been translated into local languages and as such, they are only useful at central level where stakeholders can understand them.

High population growth (estimated at 3.5% per year) similarly accounts for the gap between ideal and actual roles. The growing population puts massive pressure on existing resources, facilities and infrastructure and thus hampers the quality and adequacy of (among others) maternal and child nutrition services.



Below are some proposed solutions for addressing these gaps (for a comprehensive list of recommendations, please refer to Section 6 on best entry points):

There is need to tap into the community structures that have the potential to enhance facility-based nutrition, SRH and gender interventions. Community interventions can go a long way toward providing preventative services (community mobilisation for malnutrition prevention) and early response through timely assessment and referral;

Support supervision should be prioritised and strengthened;

Deliberate efforts should be made to address staffing gaps;

Development planning at all levels should consider the high population growth rate;

Country and sector plans should be disseminated at all levels, including community level.

5.2 Institutional Capacity Assessment

Functional Capacity One: Capacity to Formulate and Implement Policies and Legislations The government of Uganda has in place a good legal and institutional framework, guidelines and service standards to enable implementation of programmes under the three sectors of Nutrition, Gender and Reproductive Health. Uganda has committed itself to several international and regional agreements on Nutrition, Reproductive Health and Gender which provides a guiding framework for legislation, policies and programming at national level. Table 26 summarises the different international and regional accountability frameworks to which Uganda has committed itself. Table 26: Policy and legal frameworks

International and regional agreements

National policies and legislations

Nutrition

The World Food Summit (1996), International Conference on Nutrition (1992), Declaration on Millennium Development Goals ( 2000) and the follow-up summit in ( 2010 ), International Covenant on Economic, Social and Cultural Rights, Convention (1948) on Elimination of All Forms of Discrimination Against Women and International Health Partnerships and related initiatives, and Africa Regional Nutrition Strategy

Uganda Nutrition Action Plan (2011-2016); Agriculture Sector Development Strategy and Investment Plan 2010/11 – 2014/15; National Agriculture Policy (2001); Uganda Food and Nutrition Policy (2003)

Reproductive Health

Family Planning 2020 Pledge, United Nations General’s Global Health Strategy Pledge, Information and Accountability for Women and Children Pledge, Life Savings Commodities for Women and Children’s Health Pledge

National Population Policy (2008); the National Population Action Plan (2011-2015); Reproductive, Maternal, Newborn and Child Health Sharpened Plan for Uganda (2013); Uganda Family Planning Costed Implementation Plan (2015-2020); Reproductive Health Commodity Security Strategic Plan (2009/10 – 2013/14); Roadmap for Accelerating the Reduction of Maternal and Neonatal Mortality & Morbidity in Uganda 2007 – 2015, National Adolescent Health Policy for Uganda (2004); The Reproductive Health Policy (2003)



International and regional agreements

National policies and legislations

Gender

WCHR in Vienna, 1993; ICPD, 1994; the Beijing Declaration and Platform for action WSSD, 1995; The Convention on Elimination of All Forms of Discrimination Against Women (1979); the Common Wealth Plan of Action on Gender and development (2005-2010); the United Nations Declaration on Violence Against Women (1993); the Millennium Declaration (2000); the Protocol on the Rights of Women in Africa (2003) and the declaration by African Union Heads of State concerning gender equality (2004)

The Social Sector Development Sector Strategic Plan 2011/12 – 2015/16; Guidelines for establishment and Management of GBV shelters in Uganda, 2013; National Action Plan for Women, 2007; The Uganda Gender Policy (2007); Domestic Violence Act (2010); The prohibition of Female Genital Mutilation Act, 2010

In 2013 Uganda launched the Uganda Vision 2040 which provides long term development paths and strategies to operationalise Uganda‘s Vision statement which is “A transformed Ugandan Society from Peasant to a Modern and Prosperous Country within 30 years”. The Uganda Vision 2040 sets specific objectives and strategies to address Nutrition, Reproductive Health and Gender. It is articulated that the government shall trigger nutrition security through supporting agriculture. In regard to reproductive health and population growth, Uganda will focus on creating a more sustainable age structure by reducing the high fertility rate through increased access to quality reproductive health services, keeping all children of school going age in school with more emphasis on the girl child. In regard to gender the Vision spells out that over the next 30 years efforts shall be made to ensure gender responsive policies, programmes and actions. Furthermore gender mainstreaming shall be a core part of the planning process. Uganda is developing its second National Development Plan after the ending of its first development plan that run from 2011 to 2015. The National Development Plan puts in place the country’s medium term strategic direction, development priorities and implementation strategies in the three areas of Nutrition, Reproductive Health and Gender. The first development plan advocated for improvement in maternal and child nutrition through encouraging and supporting ante-natal care services through health and nutrition education, promoting dietary diversification, growth monitoring, and counselling, supporting infant and young child feeding (IYCF) in the context of HIV, and promoting and supporting exclusive breastfeeding for the first six months, timely introduction of adequate complementary feeding and continuous breastfeeding to at least 24 hours. It also advocated for better sexual and reproductive health through integrating population factors and variables at various levels of development planning, reducing unmet needs for family planning, mobilising resources for the effective implementation of the National Population Policy and Programme, developing a monitoring and evaluation system for the implementation of the National Population Policy among others. Furthermore it advocated for gender equality through promoting gender mainstreaming in development plans, programmes and projects, reducing gender-based violence and promoting women’s rights, and promoting the economic empowerment of women. It is expected that sector master plans and strategies, Local Government Development Plans and annual plans and or budgets should be aligned with development priorities as set in the Vision 2040 and National Development Plan. All operational and strategic actions of government, private sector, civil society and media should be directed towards achievement of the set development priorities.



The Uganda Nutrition Action Plan (UNAP), and the Reproductive Maternal Newborn and Child Health (RMNCH) Sharpened Plan put in place coordination arrangements to support implementation of nutrition and reproductive health activities at national and decentralised levels. In regard to gender the United Nations Joint Programme on Gender Equality (UNJPGE), a program that was developed to address significant gaps in response to gender equality in Uganda which included weak coordination, supported the establishment of coordination arrangements that would support policy and technical level coordination (see Table 27 for details). There is research evidence that points to the fact that national coordination arrangements in place especially those in Nutrition sector are in good communication, do collaborate and network. The Food and Nutrition Stakeholders (FNS) secretariat works closely with the Cabinet sub-committee on FNS and the Parliamentary Sub-Committee on Nutrition to offer policy guidance and coordination (FAO, 2013).. Table 27: Coordination Structures for Nutrition, Reproductive Health and Gender Programming at National and Local Government Levels

Nutrition Designated roles

National Level Coordination

Cabinet subcommittee, the FNC & Parliamentary subcommittee on nutrition

Policy coordination

Nutrition multi sectoral technical committee

Technical level coordination

Nutrition development partners committee

Promote and identify funding resources for nutrition agenda, policy guidance on alignment of nutrition programmes to MDGs, and nutrition commitments of the UN Development Agency Fund and other international organisations

Uganda nutrition coordination forum Review implementation of the UNAP and provide advise and advocacy for nutrition

Decentralised Level Coordination

Sectoral level coordination committees Joint planning and budgeting for nutrition activities, prepare monitoring reports, provide technical guidance

District nutrition coordination committees

Provide technical advice to district planning committees, and district council. It also monitors and evaluates nutritional activities

Reproductive health


The Inter Ministerial committee Ensure that commitments across sectors are realised for attainment of MDG 4 and 5

The Infant and Maternal Mortality reduction task force

Ensure that reproductive health concerns are included infant and maternal mortality programmes/strategies

The Health Policy Advisory Committee Ensure national policies and program are supportive of reproductive maternal, new born and child health (RMNCH) principles and responsive to the local health needs

MCH Technical Working Group and (sub) committees

Provide technical coordination for RMNCH plan


The District RMNCH stakeholders forum Technical guidance and performance monitoring

Health Unit Management Committees Strengthen lower level community linkages

Gender


Gender and Rights Sector Working Group at MOGLSD; Gender Responsive Budgeting Unit and the Technical Working Committee in MOFPED; Gender Statistics Committee at UBOS; Gender Task Force at JLOS

Policy coordination



Nutrition Designated roles

Technical Working Groups (The Gender Statistical Working Group at UBOS; Gender Working Group at MFPED; Gender Team at NPA; The Gender Resource Team in the MoLG; & The Gender Working Group in JLOS)

Strengthen gender mainstreaming in Ministries, Departments & Agencies (MDAs)


District Gender Coordination Committees

Technical guidance

Albeit the conducive normative and policy environment for implementation of Nutrition, Reproductive Health and Gender programmes, there still exist capacity gaps in this area that require attention. Domestication of international and regional accountability frameworks has not been satisfactorily done. Treaty monitoring bodies have raised grave concerns with the slow or no progress in regard to some aspects in the sectors of Nutrition, Reproductive Health and Gender. For example the committee on elimination of discrimination against women raised concerns on discriminatory laws, visibility of the convention, and violence against women among others. There are also bills that have for the last decade or so been under review but have never been turned into law yet they would greatly improve programming. These include; the Marriage and Divorce Bill and the Sexual Offences Bill. There is inadequate and in some cases no knowledge among stakeholders on the different treaties, laws, policies and guidelines that provide frameworks for implementation of Nutrition, Reproductive Health and Gender activities. In the four sub regions visited during the assessment it was common to find copies of some of the legal and policy frameworks shelved in the offices of the district department heads, however it was often commented that utilisation of these frameworks was low, and also interpretation of the content was poor which often misguides programme implementation. At the different sub counties offices visited, there wasn’t any office that was in possession of key policy and legal frameworks on gender, reproductive health and nutrition. In the different districts visited during the assessment, there were no context tailored versions of the Uganda Nutrition Action Plan (UNAP), Reproductive Maternal Newborn Child Health (RMNCH) Sharpened Plan, and the National Action Plan on Women (NAPW). Furthermore there were no translated versions (in local languages) of the different sector plans.

Even though the National Development Plan (2011-2015) demands that all operational strategic actions should be directed towards achievement of set development priorities, a big proportion of non state actors especially community based organisations do not align their programme objectives, targets and interventions to sector specific plans. This was also highlighted in the Uganda nutrition sector capacity assessment conducted by FAO (2013) where about 80% of food and nutrition actors across the country had not aligned their food and nutrition objectives, targets, indicators and interventions to the UNAP.

The district coordination structures charged with providing technical leadership in implementation of nutrition, gender and reproductive health activities (district nutrition coordination committee, district RMNCH stakeholder’s forum, and district gender coordination committee) are not in place in most districts visited. In districts where these committees have been put in place for example in Moroto which has a Gender working group, the committee has functional related challenges. The activities of the working group are funded by non state actors whose funds are project tied. This means that the ending of a



given project would translate into non funding for the working group activities. Also the district finance departments and councils never fund activities of the district coordination committees.

In the three sectors of Nutrition, Gender and Reproductive Health, a multi sectoral response towards addressing nutrition, gender and reproductive health needs has been adopted to deliver system wide changes. However the various multi sectoral interventions have been poorly resourced which has limited effectiveness of the set interventions. The different implementation structures of the Uganda’s national plans, policies and strategies in the areas of Nutrition, Gender and Reproductive health do not have the required technical and functional capacity to generate evidence and articulate priority issues (see also UNJPGE, 2014). The staffing levels in the departments of Agriculture, Community Based Services, and Health are low when compared the scope of the mandate they hold. This is partly due to the low and limited financing available for Nutrition, Reproductive Health and Gender activities. During field consultations it was found out that Nutrition, Reproductive Health (especially adolescent and youth friendly reproductive health services) and Gender were non funded priorities as it is common for budgeted money not to be released. Furthermore in the sub regions visited critical staffing positions within the community based services office, the district health office and the veterinary and agriculture office were vacant which affects implementation of plans, policies and strategies. This also impacts on the capacity of government departments to take on Gender, Nutrition and Reproductive Health programmes that were previously being implemented by non state actors (see also FAO, 2013). Functional Capacity Two: Knowledge capacity to access; generate; manage and exchange relevant knowledge and adopt it to local systems Considerable progress has been made by GOU through various sectors (MoH, MOE&S, MAAIF, OPM, MoGLSD and MoLG) to improve functional capacity to capture, collate and use data for improving programming. However, capacity in sector differs particularly between the national, district, sub-county and community level. The decentralized system of governance and sectoral development frameworks provide opportunities to collect, analyse and make use of the wealth of data that is generated at various levels in sectors. However, interviews with various stakeholders in the sub-regions indicated that most of the existing surveys provide only national and regional level information and may not be adequate for programming at district and lower levels. Review of documents and interviews with study participants show that the existing data management systems such as the Health Management Information System (HMIS), Logistics Management Information System (LMIS); Education Management Information System (EMIS); Local Government Information Communication System (LOGICS) are often not very comprehensive and in some sectors are seldom adequately standardised (UNFPA Country Programme Action Plan 2006 – 2010). It has been noted by some stakeholders that knowledge management and particularly Monitoring and Evaluation (M&E) is often “last in, first out” when budgets are tight. Although the M&E units has been established, “M&E activities still receive the least budgets and when projects are constrained with funds, it’s the M&E activities that are encroached on to bridge the gaps” (also see Asiimwe and Ojok3 2012:16). A key structure that needs to be targeted at the community level is the VHTs. A recently concluded survey by MOH and Pathfinder International the functionality of the M&E particularly at the lower local government and the community level is low. For example, districts do not have databases for the VHTs and lack evidence of monitoring, supervision,

3 Asiimwe, E and Ojok, H (2012) Strengthening country M&E system for AMREF Uganda project report



and coordination of the VHT programme, yet VHTs are the operational core at the community level (MOH and Pathfinder International, 20154). VHTs are also not adequately equipped with knowledge and skills in data collection, collation and use to inform programming at the community level. However, a review of documents and key informants with national level actors in sector revealed that in the last five years, most sectors have witnessed innovations in building capacity for more effective MIS. For example, the DHIS2 has been customized to provide weekly, monthly, quarterly reports, and annual financial year reports. The DHIS2 currently captures information on health service utilisation, the weekly epidemiological surveillance report-that includes RMNCH indicators, AIDS treatment, and the health unit population report. MOH plans to integrate information from mTrac, and HRHIS into DHIS2 in the coming months. By May 2012, DHIS2 had been rolled out to 61 Districts. The Ministry has made a commitment through the sharpened Plan for RMNCH to rigorously monitor the implementation of the plan to ensure that the priority actions for strengthening the M&E systems are implemented. The other important innovation in this area is mTrac20—mobile-phone based data reporting tool that was taken to scale by MOH in 2011, with funding from DfID and in collaboration with UNICEF, WHO and FIND (World Vision 20135). mTrac is an SMS, USSD and web-based data collection tool built on Rapid SMS, a free and open-source data collection and transmission platform initially created by UNICEF to address the inefficiencies of paper-based systems, including timeliness, completeness and accuracy of health service data (ibid). mTrac has two distinct contributions to the existing HMIS: enabling real-time disease surveillance –including weekly HMIS reports that report on maternal and perinatal deaths. Using this innovation, data is transmitted weekly from the health facilities and community health workers onto a web-based dash-board for action by MOH programme manager. The information is synthesized and presented in a format (tables and charts) that allows quick interpretation and immediate action. m-Trac also promotes community accountability through two key approaches anonymous SMS Hotline (tool-free) that community members can use to report on service delivery bottlenecks, mainly the on supply of medicines (ACTs) (Asiimwe C. et al, 2011)6. There is need for scaling such innovations in for increasing capacity to access, generate, manage and exchange relevant knowledge and adopt it to local systems. Similarly, there is renewed interest by MoH and its partners in benchmarking, quality Improvement and performance management using the scorecard tools. For example, the RMNCH scorecard allows sub-national benchmarking to address gaps in data reporting at the district and lower levels which is helpful in identifying low performing areas and developing action plans. It also provides an overall ranking of regions/districts and demonstrates how regions/ districts are doing in meeting the benchmark across the first 23 indicators. Although these innovations have shown to improve knowledge management and sharing, quite a number are in pilot stage and have not been rolled out to most of the districts in the regions targeted by the assessment. There is need to support rolling out of these interventions to improve knowledge management and sharing to inform programming at sub-national and community levels.

4 MOH and Pathfinder International (2015). National VHT Assessment in Uganda. Ministry of Health Uganda,

United Nations, Pathfinder International. 5 World Vision report on the “Progress on Taking Forward The United Nations Secretary-General’s Global Strategy For

Women’s and Children’s Health Uganda Country Case Study September 2012 6 Asiimwe C et al. (2011). Use of an Innovative, Affordable, and Open-Source Short Message Service– Based Tool to

Monitor Malaria in Remote Areas of Uganda, Am. J. Trop. Med. Hyg., 85(1), 2011, pp. 26–33



Functional Capacity Three: Partnering Capacity

The Government of Uganda (GOU) has generally adopted a multi-sectoral, multi-partner and multi-level approach to policy and programming in nutrition, reproductive health and promoting gender equality. For at the national and sector levels, the government works through structures on which there is representation and participation of non-governmental organizations (NGOs), private sector, United Nations agencies, and other development partners such as bilateral agencies. Through the various structures, government and partners have increased their commitment to improve nutritional, reproductive health and gender equality outcomes. These partnerships are in part driven by a strong domestic policy environment (e.g. the National Development Plan, Vision 2040, the National Gender Policy and sector specific Plans such as the Ugandan Nutrition Action Plan [UNAP] 2011-2016), RNMCH plan, National Strategic Plan for HIV and AIDS (2015-2020), HSSP III among others. For example, in the delivery of health services including reproductive, new born, maternal and child health services , the Public and Private sectors, other Ministries and Departments, HDPs, Civil Society Organizations (CSOs), and the community work in strategic partnerships (MoH/HSSP III, 2010). The private sector is considered as complementary to the public health sector in terms of increasing geographical access to health services (including nutrition, reproductive health and gender equality). Almost in all sectors including nutrition, reproductive health and gender, stakeholders (including government, CSOs, bilateral agencies, United Nations agencies work in partnership to support the implement, monitoring and evaluation of national, district and community level interventions nutrition, sexual and reproductive health and gender equality. One the key milestones has been the institutionalization of the practice of signing MoU between GoU and Health Development Partners (HDPs) which covers that spells out the obligations of each party and describes the structures and procedures to facilitate the functioning of the partnerships. There is an increasing representation and participation of CSOs at the national level. For example, CSOs are strongly represented on the Health Policy Advisory Committee (HPAC) and on Technical Working Groups for reproductive health, nutrition and gender. HPAC has met regularly and consistently and it is perceived by actors to be the most effective forum for consultation with stakeholders. Therefore support to these structures is essential for effective partnership at the national and district level to enhance capacity to provide nutrition and reproductive health services, and promote gender equality. Specifically for nutrition, the UNAP provides for the coordinating structures and partnership arrangements to strengthen, and support nutrition coordination structures at both national and local government levels. However, an assessment carried out by FAO (2013) revealed that coordinated networking, collaboration and partnerships for nutrition programmes at district, facility and sub-county levels are weak and not able to facilitate optimal nutrition programming and investment. At the community level, several structures for service delivery have been established and are increasingly taking on a substantial role in delivery of nutrition and reproductive health services. VHTs have been formed and many government and non-government organizations as well as development partners are investing in building their capacity to deliver health services. Recent studies have shown gaps in coordination of VHT activities. For example, districts do not have data bases on the number and location of functional VHTs and partners have taken up VHTs, provided training on their programmatic areas without the basic/core training required of VHTs using the Ministry of Health VHT training manual (Pathfinder International and MoH, 2015)



Functional Capacity Four: Capacity to Manage Implementation and Delivery of Nutrition, Reproductive Health and Gender Programmes

The three sectors of Nutrition, Reproductive Health, and Gender have National Plans of Action (Uganda Nutrition Action Plan, 2011 – 2016; The Reproductive Maternal, Newborn and Child Health Sharpened Plan for Uganda, 2013; and The National Action Plan for Women, 2007 respectively) in place to ensure implementation of the different sectoral policies. The plans provide a strategic direction for the different sectors, they also provide implementation, financing, and monitoring and evaluation frameworks that are adopted in the different sectors. The policies and sectoral plans provide delivery mechanisms/structures at national, local government and community level tasked with implementation of Nutrition, Reproductive Health and Gender interventions. A clear mechanism for linking these structures is also provided by the sectoral plans. The sectoral plans (the Reproductive Maternal, Newborn and Child Health Sharpened Plan for Uganda and the Uganda Nutrition Action Plan 2011 – 2016) adopt a multi-sectoral approach to addressing nutrition and reproductive health problems. Under this approach specific nutrition and reproductive health problems are addressed through collaboration within a multi-sectoral framework. Such a response requires action to engender political will, leadership and coordination, to develop and sustain new partnerships and ways of working, and strengthen the capacity of all sectors to make an effective contribution (Common Wealth Secretariat, 2003). In the four sub regions visited during the assessment development partners had established a referral system which provided a comprehensive institutional framework that connects various stakeholders with well defined responsibilities into a network of cooperation. The stakeholders established a clearly outlined referral pathway and procedures with clear and simple sequential steps. The National Action Plan on Women (2007) takes on a gender mainstreaming approach where any organisation or department takes into account gender equality concerns in all policy, programme, administrative and financial activities as well as organisational structures and procedures. . Although the different sectoral plans provide mechanisms and structures for implementing Nutrition, Reproductive Health and Gender programmes, there are capacity gaps that fail effective implementation of these programmes. These are highlighted in the following paragraphs. The various implementation structures at district and community level for example district nutrition committees, health management units, sector working groups are not fully constituted and neither are they functional. This is mostly because these structures do not have separate budgets to run their activities. Local government planning and budgeting for nutrition, reproductive health and gender is still poor. Financing for programmes in the three areas of nutrition, reproductive health and gender is heavily done by non government actors whose programmes are time and place bound. The local governments visited during the assessment did not have separate domesticated context oriented district sector plans drawn from the various master sector plans. As a result community based resources that would improve nutrition, reproductive health and gender have not been utilised.



There are staffing gaps in the community based services department, district health office, and agriculture and veterinary services department. Critical cadres for example agriculture extension workers in the agriculture and veterinary services department, midwives in the district health office are few and within some areas of operation (for example at sub county level) positions of these cadres are not filled. (A detailed Roles and Responsibilities of Stakeholders and their Institutional Capacity Assessment is provided in Annex 2.)

5.3 Case Studies Related to Policy, Programming and Service Delivery

The UNFPA-UNICEF Joint Programme on FGM: Accelerating Change

In order to accelerate the eradication of female genital mutilation (FGM) within a generation, the United Nations Population Fund (UNFPA) and Children’s Fund (UNICEF) developed and implemented the Joint Programme on Female Genital Mutilation and Cutting in 15 African countries. The Joint Programme adopts a culturally sensitive human rights-based approach that strategically leverages social dynamics in favour of eradication. The following steps have taken place in Uganda:

The FGM Act was enacted in 2010;

A culturally sensitive approach that is based on human rights and anchored in social change theory has been adopted;

Alternative rites have been introduced;

“Culture days” have been held to celebrate positive aspects of culture;

A Knowledge, Attitudes and Practices (KAP) survey has been conducted to facilitate the implementation of evidence-based interventions;

Gatekeepers have publicly renounced FGM;

Reformed gatekeepers have championed negotiations and built consensus;

An enabling environment has been created to facilitate FGM eradication.

The key lessons learnt from this programme are:

Shifts in social norms can occur when communities collectively realign around new concepts, practices and behaviour;

Information and dialogues on the SRH-related implications of FGM lead communities to ask questions, renegotiate loyalties and propel self-directed change;

Public declarations build a critical springboard for rapid and universal change and/or action;

Use of reformed community gatekeepers as champions propels change;

Projects should build on the positive aspects of culture to promote new values and develop new practices;

Using a social norm approach that includes accountability measures for sustained engagement can lead to the eradication of FGM.



The Gender Roles, Equality and Transformation (GREAT) Project

The goal of this project, which is being implemented in northern Uganda, is to develop an understanding of the processes through which social norms and attitudes to gender, SRH and violence are transmitted so as to facilitate the formation of gender-equitable behaviours that reduce GBV among adolescents. During the first year of the project formative research was conducted, consisting of an ethnographic study and a programme review, to identify opportunities to promote the formation of gender-equitable norms and attitudes among adolescents and the significant adults in their lives.

The research included innovative qualitative methods, such as the collection of life histories from young people at different stages of the life course (very young adolescents, older adolescents, newly married and newly parenting adolescents) and in-depth interviews with individuals nominated by young people as significant influencers in their lives. During year 2, intervention models such as radio dramas were developed based on a life-cycle perspective in order to catalyse discussion and change at scale, produce toolkits of scalable products to promote reflection and dialogue, facilitate a community action cycle for the mobilisation of key community leaders to promote and sustain change, and provide training for VHTs to improve the accessibility and quality of youth-friendly SRH services.

The project targets vulnerable groups, including newly married and parenting adolescents, very young adolescents and older adolescents, with age-specific and audience-segmented messages. Field consultations indicate that the project approach enables differentiated yet complementary interventions for specific age groups living in the same communities. This facilitates the transformation of attitudes and fosters healthier, more equitable behaviours. Through this ecological model, the project can focus on adolescents and on the creation of an enabling environment for the generation and sustaining of behavioural change.

Reproductive Health Voucher Scheme

This project aims to facilitate safe childbirth and provide treatment for sexually transmitted diseases (STDs) to Uganda’s poor. Retail outlets (e.g. pharmacies and drugstores) located near target populations sell vouchers for medical treatment at a nominal fee. Purchasers then receive care at participating medical facilities using coupons attached to each voucher. Participating medical facilities are selected and trained by the Voucher Management Unit, which reimburses medical facilities on a per-item basis following the collection of appropriate documentation after treatment.

There are two different types of voucher: 1) safe delivery and 2) treatment of STDs. Safe delivery vouchers entitle mothers to four pre-natal visits, assisted childbirth, one post-natal check-up visit and counselling in family planning. In the event of a complicated pregnancy, the vouchers also cover transport to a hospital and advanced treatments such as caesarean section and blood transfusions. Vendors sell STD vouchers in pairs to facilitate the treatment of couples rather than individuals. Each STD voucher pays for an average of three medical visits along with relevant laboratory tests and medication. All vouchers sold through this programme have multiple detachable coupons that each correspond to one medical visit. Using a voucher scheme increases women’s access to trained medical professionals during pregnancy and also provides subsidised STD treatment to poor Ugandans of both genders. The structure of this project also shifts responsibility for good performance to service providers; since vouchers are valid at a number of care sites, each facility competes for patients on the basis of service quality.



The Food and Nutrition Technical Assistance III Project (FANTA)

The third Food and Nutrition Technical Assistance (FANTA) project is a 5-year cooperative agreement between the United States Agency for International Development (USAID) and FHI 360. FANTA aims to improve the health and wellbeing of vulnerable groups through the provision of technical support in the areas of i) MCH and nutrition in development and emergency contexts; ii) HIV and other infectious diseases; iii) food security and livelihood strengthening; iv) linkages between agriculture and nutrition; and v) emergency assistance in nutrition crises. FANTA supports the Government of Uganda (GoU) by:

Collaborating with stakeholders to develop and implement a national nutrition advocacy strategy;

Strengthening the capacity of district/sub-county Nutrition Coordination Committees to plan, budget, advocate for and monitor nutrition activities;

Developing Nutrition Assessment, Counselling and Support training materials;

Training nutrition service providers;

Strengthening the implementation of nutrition services by the health system;

Managing and implementing the Uganda Nutrition Fellowship to develop skilled nutrition practitioners;

Developing nutrition programming to address Uganda’s social development goals and agricultural challenges and opportunities;

Collaborating with the Uganda Partnership for HIV-Free Survival to accelerate the adoption of the 2010 World Health Organisation (WHO) guidelines on the prevention of mother-to-child transmission of HIV and on HIV and infant feeding.

FANTA established the Uganda Nutrition Fellowship (UNF) in 2013 as an update of the successful nutrition internship programme that it pioneered in Uganda in 2010. Through the UNF, FANTA promotes the development of skills in leadership, teamwork, communication and nutrition-related technical topics through quarterly retreats, professional development workshops and opportunities to share experiences. To graduate from the programme, Uganda Nutrition Fellows must complete a project that addresses a challenge relevant to their host organisation. Through these activities, the UNF aims to develop skilled nutrition leaders while also providing host organisations with highly motivated and well-qualified young professionals to support their nutrition work.

Field consultations indicate that FANTA has the potential to contribute to enhanced coordination at national and local government level and has started creating inroads for the strengthening of community-based nutrition initiatives. Through supporting the development and implementation of the communication and advocacy strategy in partnership with the Office of the Prime Minister (OPM) and other stakeholders, FANTA is also contributing to the strengthening of SBCC, which is very important to the changing of attitudes and behaviours, including the masculinity and gender norms, that create barriers to the adoption of desirable nutrition behaviours.

Positive Changes in Gender Relations (The Karamoja Case)

On a positive note, the long-specialised and biased gender roles in Karamoja sub-region were reported to be changing for the better in some communities. Particularly, men’s attitudes are changing. As the cattle economy has dwindled in the region, men have started



to become involved in food production alongside women. This has the potential to increase food production and improve household nutrition.

In the past our roles were parallel but now we do some activities together. In the past, men only used to lie under trees herding their cattle, leaving childcare and food issues to women. But now men have started supporting women (FGD Adult Women, Tapac Sub-County, Moroto).

We feel better about these changes, now we understand ourselves better. Even going to the garden, we go together. Sometimes they even go earlier as we attend to children and we get them there. They also now go for charcoal burning and firewood. Sometimes when you go for firewood or charcoal, you come back late and tired and you find he has prepared some food for the children (FGD Adult Women, Tapac Sub-County, Moroto).

The above observations communicate that behavioural and attitudinal changes are possible once the right strategy is designed and the right channels utilised to reach the different target groups.

This change in gender relations, particularly in Karamoja, is attributed to the engagement of both men and women in group activities such as VSLAs (including those supported by the Adventist Development and Relief Agency (ADRA)), anti-violence clubs, and male action (anti-violence) groups supported by the UNFPA through District Community Development Offices. Male action groups are specifically composed of men as a means of reducing men’s violence against women. The groups sensitise against GBV and also handle some GBV cases. Cases beyond their capacity are referred to the police or the sub-county Community Development Offices. These initiatives have helped foster significant and positive attitudinal change and have improved relations between men and women.

6 Best Entry Points for Future Interventions

6.1 Addressing Maternal and Child Malnutrition

1) Support is needed to strengthen capacity of nutrition coordination structures at local government level (including the Sector Level Coordination Committees, and District Nutrition Coordination Committees). In particular, the EU could co-currently provide financial support while also advocating for establishment of a separate budget for activities of local government coordination structures. Having a separate budget would facilitate regular nutrition coordination engagements. In addition, support in terms of the provision of permanent secretariat staff and a full-time coordinator is needed for purposes of ensuring that meetings are held and that all relevant documentation and information is disseminated to all development partners. There is also need to establish mechanisms at local government level to regularly orient the coordination committees on policy and legal frameworks so that they are well understood and utilised;

2) The Uganda Nutrition Action Plan (UNAP) calls for a multi-sectoral approach to drive the agenda for integrating and implementing nutrition issues into national, sector- and district-level development plans. There is need to build on these efforts to strengthen nutrition-sensitive policy and programming at all levels, as well as to advocate for the integration of nutrition activities and services into district work plans and budgets and the release of funds to implement these activities. The normal practice is that various sectors basically aim/struggle to have their priorities accommodated in the District Plan. Little effort is made to secure an integrated planning process as the different sectors forward their respective (isolated) priorities to the district technical planning



committee and planning unit. There is no single integrated team that goes down to the lower levels and into communities to gather ideas in an integrated manner. In spite of this gap, much strength lies in the multi-sectoral district technical planning committee that can be harnessed and built upon to drive the nutrition agenda;

3) Given the interrelationship between water, sanitation and hygiene (WASH) nutrition and, food security, there is need to support interventions that focus on the integration of WASH, food security and nutrition in all sub-regions. There is also need to review nutrition guidelines to strengthen their integration with WASH and food security. This requires a multi-sectoral approach that harnesses the involvement of stakeholders at national and decentralised levels, especially in the MoH, MAAIF, MoES, the Ministry of Gender, Labour and Social Development (MoGLSD), the Ministry of Water and the Environment (MWE), the Ministry of Finance, Planning and Economic Development (MoFPED) and the Ministry of Local Government (MoLG);

4) There is a need for awareness creation via the implementation of a communication and advocacy strategy, including roll-out of the recently developed Communication Strategy for Nutrition with a major focus on the development and dissemination of social and behavioural change communication (SBCC) strategies, including in the area of interpersonal communication;

5) There is a need to strengthen monitoring and evaluation (M&E) systems for nutrition through supporting the roll-out of Health Management Information System (HMIS) tools that have integrated a higher number of nutrition indicators in their data capture tools at facility level. In the long term, given that the District Health Information System (DHIS) has limited indicators for nutrition, there is a need to establish a web portal to collect all data on nutrition to inform policy and targeted programming. A supplementary monitoring tool is needed to capture information on socio-economic status, food security and consumption, capacity building and availability of guidelines, job aids and information, education and communication (IEC) materials. In addition, since the HMIS is facility-based, there is a need to for mechanisms to effectively capture data outside the facility in partnership with community-based structures. There is also need to support efforts aimed at mainstreaming nutrition sensitive data in other MIS such as the MIS for the agricultural sector, MIS for the education sector to generate key data such as the minimum dietary diversity (MDD) of children (6-23 months) and the individual dietary diversity score (IDDS) of children 24-59 months and women of reproductive age.

6) There is need to support the capacity building of all staffs involved in the delivery of nutrition-related interventions (including health and non-health professionals) in all strategic areas and at all levels of service delivery in the various sectors (agriculture, WASH, education and social protection). Capacity building should also target community structures, especially Village Health Teams and other relevant structures;

7) Support is required to increase the number of well-equipped nutrition centres (both in-patient and out-patient therapeutic centres) at local government level in all Health Centres and other sectors. At community level there is need to strengthen the community management of acute malnutrition (CMAM) in order to offer opportunities to create awareness and provide basic nutrition counselling and SBCC to mothers and caregivers. There is need for community-based initiatives for health to integrate nutrition into all areas of service provision. Schools and youth programmes should maximise on opportunities to include positive health and nutrition practices that will address negative cultural practices. Within primary and secondary school curricula, nutrition should be integrated into the content of such subjects as basic and health science, social studies and English in primary schools and biology, home economics, agriculture, health science and extracurricular activities in secondary schools. To



achieve this, the EU in partnership with the National Curriculum Development Centre should consider supporting the development of guidelines for integration. There is also need to explore mechanisms to strengthen school-community linkage and how these can be used in the context of CMAM to enhance prevention, early identification and management of acute malnutrition. This can be conceptualised and implemented within the context of school health policies, the Sector HIV and AIDS Plan of the MoES, and the National Adolescent Health Policy;

8) Support supervision is critical to the mentoring, standardisation and quality assurance of nutrition services delivered at local government and community level. Supervision of support from the centre to districts and from districts to communities is currently not done regularly. There is therefore need to support efforts to increase support supervision, particularly at local government and community level;

9) The UNAP is expiring in 2016. There is need to provide technical support to the development of the new Nutrition Action Plan that should address the integration of nutrition with health and other services through a gender-sensitive lens;

10) There is need to build the capacity of district and local government officials, especially those from Production Departments, to integrate nutrition programming in food and livelihood programmes;

11) There is need to build on lessons learnt from the model used by the FHI 360 Community Connector programme in order to promote comprehensive nutrition-sensitive approaches. FHI 360 Community Connector programme provides a comprehensive and multi sectoral approach to poverty, food insecurity and under nutrition. The programme builds the capacity of local governments, farmers, private sector entities and community based organisations, as well as informal community groups and people living with or affected with HIV through;

Improving nutrition and hygiene in communities and households

Production of diverse and higher quality foods within households and communities

Generating demand by women and men for later timing and spacing of pregnancies

Increasing household assets and income

Introducing appropriate technologies that improve food productivity and post harvest handling and decrease women’s workload

Utilising risk management techniques to mitigate economic shocks

Integrating gender analyses and strategies to improve nutrition and livelihood

There is thus need for the EUD to employ a comprehensive approach in addressing under nutrition through integrating nutrition, agriculture and livelihood interventions at the community and household level.

12) There is need to reinforce the facility-based management of acute malnutrition with CMAM. This necessitates working with existing community structures such as VHTs, VSLAs, mothers’ support groups, etc. to build their capacity in the prevention, timely detection, case identification, nutritional assessment, management, counselling and referral of cases of acute malnutrition. Trained community-based structures can also help with dispensing therapeutic foods, thereby lessening the burden of facility-based staff. These structures could also support the promotion of nutritional interventions such as exclusive breastfeeding, household hygiene and feeding of children during



and after illness, WASH, growth monitoring and promotion, optimal complementary feeding practices and the prevention and correct treatment of diarrhoea, malaria and pneumonia. They can also be involved in patient monitoring following discharge from the therapeutic unit at the health facility to provide support for sustaining behavioural change;

13) The use of low-cost appropriate technologies that are being implemented by some programmes, e.g. the construction of good food storage structures and improved food preservation methods to ensure the availability of food during the long dry season, will not only reduce the workload of women but will also improve the quality of products, minimise food wastage and losses and improve nutrient retention. Oxfam, the Medical Assistance Programme and the MAAIF for instance are involved in implementing such programmes.

14) There is need for the EU and its partners to consider undertaking operational research to bridge the information gaps on dietary diversity and vitamin A deficiency among people of different age groups living in different livelihood zones in Karamoja and other sub regions that were targeted by the assessment.

6.2 Addressing SRH and Population Problems

1) There is need to support the dissemination and implementation of laws, policies, strategies and services for Sexual, Reproductive, Maternal, Neonatal and Child Health (SRMNCH) in Uganda. These policies exist but have not been effectively disseminated among stakeholders, especially at local government level and among civil society and community-based organisations (CSOs and CBOs);

2) There is need to focus on demand creation for maternal and child health (MCH) services, particularly in ante-natal care (ANC), safe delivery and post-natal care and especially in Karamoja and West Nile sub-regions. Uganda has recorded marked improvements in SRMNCH indicators, but the maternal mortality ratio has stagnated or in some cases worsened (also see the 2014 Uganda Country Brief by the United Nations Population Fund (UNFPA) on SRMNCH and Human Rights);

3) There is need for the Delegation of the European Union (EUD) to strengthen human resources for health (HRH), particularly among the northern regions and especially in Karamoja sub-region which experiences difficulty attracting and retaining doctors and midwives. This is because the availability of HRH, and especially that of critical staff, poses a major challenge to SRMNCH. Doctors and midwives are in short supply and national patient-staff ratios are poor. Morale is low, promotional career opportunities (especially for midwives) are limited and overall, the distribution of medical staff is skewed wildly in favour of urban and more economically buoyant sites compared to rural, poor and hard-to-reach areas (UNFPA, 2014). Notwithstanding the inroads in staffing that have been achieved via recent efforts by the Government of Uganda (GoU) to recruit and retain staff (with support from Health Development Partners) and have improved the situation in several regions, many facilities (particularly in northern sub-regions such as Karamoja) still lack staff critical to improving maternal, newborn and sexual and reproductive health;

4) There is need to strengthen support in terms of training, equipment and transport to facilitate integrated clinical and non-clinical outreach camps that can target hard-to-reach areas in which access to health facilities is limited. It was noted in almost all sub-regions that the capacity of health workers to conduct outreach activities is limited due to lack of logistical support;

5) Adolescent sexual and reproductive health (SRH) emerged as a very important issue during consultations at all levels especially in terms of early marriage, high rates of



teenage pregnancy, early childbearing and its associated consequences. Teenage pregnancy rates are high (135 per 1,000 teenagers). Access to SRMNCH services which could avert maternal morbidity and mortality in women, e.g. family planning and adolescent health services, are limited and abortion is currently criminalised. There is need for the EU to build on lessons learnt from on-going adolescent SRH interventions to support the following:

a) Promote the integration of adolescent-friendly SRH services into the routine health services provided at all levels in northern Uganda;

b) Support the implementation of interpersonal communication channels, especially peer-to-peer education, that move away from the lecture method toward more interactive sessions that use interactive tools and games;

c) Build on lessons learnt from the Gender Roles, Equality and Transformation (GREAT) project and the adolescent health projects funded by Plan International and the Communication for Development Foundation Uganda in order to promote a 2-way approach to adolescent SRH based on interventions that: i) focus on young people using young people; and ii) address the environment around young people to create a support network for SBCC and its sustainability;

d) Increase awareness levels of risky adolescent practices such as early marriage, teenage pregnancy and early childbearing;

e) Empower both boys and girls with life skills (abilities for adaptive and positive behaviour that enable individuals to deal effectively with the demands and challenges of everyday life) including assertiveness, decision making, problem solving, creative thinking, critical thinking, effective communication, interpersonal relationship skills, self-awareness, empathy, coping with emotions and coping with stress;

f) Improve communication skills among caregivers to enable them to support adolescents;

g) Train service providers (including health workers, teachers and VHTs) in the provision of adolescent-friendly SRH services;

h) Build on lessons learnt from the implementation of the national SRH hotline to contribute to its effective implementation and thus continue to provide counselling and referral services. Interactions with adolescents show that they find it more convenient to access on-the-spot information;

6) Overall, there is both a deficit in infrastructure and a shortage of equipment for the supply of SRMNCH services. Review of reports and consultation with stakeholders in northern Uganda indicate that there are insufficient supplies and commodities. It was also noted that there are limitations in transport and communication for referral. Physical access to services, especially transportation for skilled attendance and emergency obstetric care (EOC), was noted as a particular constraint (also see UNFPA et al., 2014). There is particular need to address the logistical limitations that affect transportation for skilled attendance and EOC (especially in Karamoja and in some sub-counties in West Nile and Acholi);

7) Capacity building through mentoring, refresher courses and staff training in SRH (especially EOC) in the short and long term is crucial to improving maternal and reproductive health outcomes. There is thus need for the EUD to prioritise improved training, particularly of midwives, who are critical in offering maternal, newborn and adolescent SRH services;



8) While the GoU is credited with having put in place a national coordination framework backed by the National Integrated Monitoring and Evaluation Strategy (NIMES) and Technical Working Groups (TWGs) and a National Quality Improvement Framework and Strategic Plan (see UNFPA 2014), consultations in the field revealed that M&E arrangements are weak and consist of only a few functional systems that are often fragmented and situated at programme and project level. Stakeholders also indicated that while the coordination of SRMNCH programmes has improved at national level and in some districts (UNFPA 2014), the quality and depth of peripheral supervision and mentoring, especially in northern Uganda (West Nile, Karamoja, Acholi and Lango) remains weak due to logistical challenges. There is thus need to support efforts to strengthen mentoring and support supervision in these regions in order to contribute to better SRMNCH indicators;

9) The EU should continue to support interventions that advocate for the establishment and strengthening of social accountability mechanisms to address the reproductive rights of women and girls in northern Uganda;

10) There is need to invest in the strengthening of capacity for social mobilisation and SBCC for SRH and reproductive rights, especially at community level. It is also important to strengthen efforts to build the capacity to set up sustainable community-based management structures for the social mobilisation of SRH in northern Uganda. This can also be enhanced via emphasis on geo-context SBCC (i.e. the adaption and dissemination of standardised messages for behavioural change communication to specific communities that consider unique contexts and audiences and focus on the most vulnerable groups as regards SRH, such as adolescents and young women);

11) There is need for the EUD to build on the lessons and best practices of the UNFPA and the collaborative project implemented by the MoGLSD and the Uganda AIDS Commission that encouraged cultural and religious leaders to engage in dialogue, make pronouncements and develop and implement policy statements to address the drivers of maternal health conditions, gender-based violence (GBV), family planning, teenage pregnancy and HIV/AIDS in northern Uganda. Through this initiative, 9 cultural institutions including in Acholi, Karamoja, Lango and Alur (West Nile) held community dialogues and developed action plans to address barriers to access to services, promote gender equality and ensure reproductive rights. The EUD should consider supporting the implementation and M&E of these innovations.

6.3 Addressing Gender Inequality

1) Strengthen efforts to eliminate gender-related barriers to access to justice through supporting activities that increase the financing of access to justice for survivors of various forms of GBV;

2) Support efforts by the GoU and CSOs toward translating gender mainstreaming into a reality, particularly at local government and community level. Specifically, promote the mainstreaming of gender through its integration into district development plans and the promotion of gender budgeting;

3) Prioritise support for community-based interventions that raise awareness and build community-level capacity to change harmful gender norms, beliefs and practices;

4) Build the capacity of the Justice, Law and Order sector through equipping them with the tools they need to better respond to gender-related barriers to access to justice, particularly among women and children. There is particular need to support advocacy activities to promote a human rights-based approach to policy and programming, most importantly through working with various duty bearers (including Parliament, the



Judiciary and local government) in order to build their capacity to respond to cases of violence and end impunity;

5) There is need to support efforts that advocate for the improved staffing of both national and local government units whose mandate includes the promotion of gender equality. Currently, most district departments have low staffing levels and staff are not adequately trained in gender equality policy or programming;

6) Support actions geared toward promoting women’s economic empowerment through building on international-level initiatives (such as UN Women’s “Women In Business”) whose aim is to empower women in the private sector and informal small-scale enterprises to participate in and benefit from economic development. This would particularly promote women’s engagement in economic leadership and decision making. There is for example need to work with the Private Sector Foundation and the Uganda Chamber of Commerce to promote the adoption of women’s empowerment principles among private sector actors and roll these out through community-level structures, particularly Village Savings and Loans Associations (VSLAs) and Savings and Credit Cooperatives (SACCOs). There is also need to review the operational modalities of SACCOs in order to ensure that they promote the participation and empowerment of women;

7) Build on lessons learnt from the implementation of the Youth Fund to increase women’s participation in and access to financial resources. In Arua district, the Youth Livelihoods Programme that started in 2013/14 has supported 115 youth groups so far. Of the 1,500 young people that have benefited, 730 are women and 870 are men. This is of course positive, but there is need to ensure that the recommended guidelines for 50/50 gender representation are followed;

8) Address factors that affect the retention of girls in school. These include both institutional factors and family/community-related factors through the following:

a) At institutional level, improve the learning environment by installing proper sanitation as well as ensuring good relationships between learners, teachers and the administration;

b) Strengthen school feeding programmes, particularly in areas such as Karamoja sub-region that experience long droughts, to attract girls to school and make sure they stay;

c) Continue efforts to work with community leaders (including cultural and religious leaders) to promote positive attitudes among parents and the community toward the education of girls and promote the education of girls as a human right;

d) Engage with parents and guardians via community mobilisation and sensitisation in order to reduce the level of dependence on children as agents for household survival (which limits the amount of time available to spend on schoolwork). There is also need to build on lessons learnt from the promotion of energy-saving and retention technologies to make more time for girls to participate in education;

e) Reduce the distances travelled by women, and particularly girls, to fetch water through increased coverage of safe water sources. This should include the operation and maintenance of water facilities as well as their ownership and sustainability;

f) Given that some parents and community members are discouraged from taking their children to school due to the perceived poor quality of education, there is need to support access to high-quality education for girls, including technical and vocational education and training (TVET). This should enable women and girls to enter high-priority and profitable fields, disciplines and sectors;



9) Support processes geared toward changing gender norms that take into account the life-cycle approach. This considers the unique needs and challenges faced by women, girls, men and boys at various stages of life and the resources needed to confront them. Such change would facilitate the removal of barriers that currently prevent women, girls and other vulnerable groups from accessing and using services, especially in the areas of education and health. Activities that work with rights holders to reduce their tolerance of impunity and empower them to claim their rights should also be supported;

10) Build on lessons learnt from the GREAT project in order to scale up interventions that i) recognise and address the heterogeneity of adolescents (very young adolescents, older adolescents and newly married/parenting adolescents) and their environment in transforming gender norms; ii) impact on SRH and GBV; and iii) make use of unique opportunities for transformation during each stage of adolescence;

11) Support male engagement in the transformation of harmful gender norms that affect women’s access to and control over resources and their equality in gender roles and decision making. This should build on lessons learnt from projects supported by UN Women both globally and locally in order to strengthen focus on male engagement at all levels. Evidence suggests that unless men are actively engaged in supporting better family health and wellbeing and the empowerment of women, progress will remain slow. Women will remain vulnerable to reproductive health threats, including GBV, and men themselves will remain trapped in the confining space of traditional masculine norms (Population Reference Bureau, 2009). As indicated by former UN Secretary General Kofi Annan: “Men should be actively involved in developing and implementing legislation and policies to foster gender equality and in providing role models to promote gender equality in the family, the workplace and in society at large”;

12) Strengthen partnerships between UN agencies, civil society (at national and local government level) and the GoU aimed at joint planning, coordination and M&E to identify and address issues of gender equality, women’s political participation and women’s economic empowerment;

13) Despite legislation outlawing female genital mutilation (FGM) being in place, evidence from Karamoja and other areas in Eastern Uganda (particularly among the Sebei) shows that the practice has not been eliminated. There is thus need to build on lessons learnt by the UNFPA and its implementing partners in the promotion of SBCC aimed at changing gender norms, attitudes and practices related to FGM. This will contribute to creating a support network to break the strong social bonds around FGM in communities that make it difficult for survivors to report perpetrators. In addition and in view of the evidence that points to defiance of anti-FGM laws and the continued practising of FGM underground and in hard-to-reach areas across borders, there is need for the EU to support cross-border collaboration (particularly in Uganda and Kenya) to harmonise positions and strategies for the elimination of FGM.

6.4 Best Practices that Provide Opportunities for the Integration of Nutrition, SRH and Gender by Local Governments

Findings indicate that SRH, nutrition and gender are interrelated and that interventions to address them holistically should therefore adopt an integrated approach. The integration of interventions in these three thematic areas should be strengthened through:

1) Integrating gender equality and SRH issues into both SACCOs and VSLAs. These can be used to empower women economically and can also be upgraded to include



forums for teaching and counselling on matters of nutrition, SRH and gender in order to integrate all of these in a more cost-effective way;

2) Promoting interventions that integrate gender into food security by promoting and using high-value foods which can grow locally, combined with SBCC that addresses harmful masculinity and gender norms that prohibit the consumption of nutritious food by women and girls. This should enable gender- and nutrition-sensitive programming in the targeted sub-regions;

3) Given that issues related to staffing, staff training, equipment and standard operating procedures (SOPs) cut across all three thematic areas, it is recommended as a good practice to strengthen efforts to improve the capacity of human resources to deliver an integrated package of quality maternal, infant and young child nutrition (MIYCN) and SRH services while taking into account the relevant gender- and other context-specific issues;

4) Providing messages and counselling on SRH, including family planning, to mothers when they bring their babies for growth monitoring and immunisation by integrating MIYCN and family planning into the services provided. The Reproductive Health Division of the MoH includes a nutrition focal person and is already working on guidelines for the integration of SRH and nutrition;

5) Supporting the inclusion of messages concerning nutrition, SRH and gender in youth economic empowerment programming as a way of providing viable solutions to the economic and social issues that cause poverty among communities;

6) Promoting extracurricular activities to generate appreciation of food production and utilisation through the use of school demonstration plots. This will go a long way toward establishing good eating habits and can be integrated into the dissemination of messages on SRH and gender;

7) Building on the existing efforts of the consortium formed by Renewed Efforts Against Child Hunger (REACH) under the OPM and Development Partners to coordinate the integration of nutrition-sensitive programming into SRH and gender initiatives. Some of the achievements registered by REACH include; nutrition analysis, determination of priority interventions to scale up nutrition, finalisation and costing of nutrition action plans and the integration of nutrition into national development strategies. It is thus recommended that nutritional assessment be based on a multi sectoral approach that considers the interrelationships between nutrition, SRH and gender inequality and how the latter issues impact on nutrition. This can be achieved through the effective involvement of multi-sectoral nutrition committees in nutrition assessment processes;

8) Supporting local governments and sub-counties to formulate a programme for “dialogue days” and integrated outreach that can be used to discuss specific issues on nutrition, SRH and gender and review and give feedback on existing interventions;

9) There is need for the EUD to build on the lessons and best practices of the UNFPA and the collaborative project implemented by the MoGLSD and the Uganda AIDS Commission that encouraged cultural and religious leaders to engage in dialogue, make pronouncements and develop and implement policy statements to address the drivers of maternal health conditions, GBV, family planning, teenage pregnancy and HIV/AIDS in northern Uganda;

10) Ensuring a well-coordinated and gender-mainstreamed multi-sectoral response to SRH, GBV and nutrition at all levels through building capacity within the MoGLSD and its district and sub-county line departments to spearhead the integration of gender planning and budgeting into nutrition, food security and SRH interventions;



11) Building capacity to conduct gender- and human rights-based analysis as part of the integrated planning and programming, implementation and M&E of SRH, GBV and nutrition services, especially at local government level, in northern Uganda;

12) Strengthening community systems (including Health Unit Management Committees, Parish Development Committees and VHTs) to ensure ownership and sustainability through community-led programming, integrated planning, implementation and M&E of SRH, nutrition and GBV programmes at community level;

13) Strengthening coordination of supply chain management systems through enhanced information management for integrated programmes geared toward the promotion of SRH, nutrition and gender equality, especially at local government and facility level;

14) Strengthening mechanisms for capturing community data from non-Government implementers, particularly non-biomedical interventions, that affect SRH, gender and nutrition;

15) Guidelines for the three thematic areas (nutrition, SRH and gender) have not been disseminated widely due to limited financial and human resources. It is therefore recommended to widely disseminate guidelines/SOPs to standardise programming and service delivery for nutrition, SRH and gender equality;

16) There is need for the EUD to support research into and collect evidence of social norms and harmful practices related to GBV, teenage pregnancy, early child and forced marriage (ECFM) and FGM and the impact of these issues on SRH. There is also need to build evidence for effective programming and best practices in relation to the prevention of and responses to GBV, FGM, ECFM and harmful cultural practices that have implications for SRH in respect to: i) health-seeking behaviour; ii) the negotiation of safe sex and iii) the freedom to delay marriage and decide when and how frequently to have children that can be well fed in accordance with infant and young child feeding (IYCF) guidelines.



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Cardno Consortium A n n e x 1 | 1

Annex 1: Mapping Matrix

Name of organisation

Areas Covered (districts, sub-counties)

Thematic areas & activities (nutrition, gender & SRH)

Target Population

Time Span Level of Funding/ funder

Co-funding/ co-funder

Number and cadre and technical staff

Alignment with national strategy

Best Practices Key Challenges and Gaps Remark

KARAMOJA SUB REGION

UNFPA All districts in Karamoja sub-region

Maternal health, gender including FGM related interventions, GBV shelters, HIV prevention, family planning, data system strengthening, human resource capacity building

Youth, women and men, and minimally children

DfID, Norwegian embassy

The ending 2010-2014 country programme was aligned to NDP 1 and the new country programme will be aligned to NDP 2

Use of SGBV shelters

Human resources to deliver the services are still thin

MIFUMI, Moroto Branch

Moroto District -offer temporary shelter -legal aid services -resettlement and reintegration of survivors of GBV

Women, men, and children

Cadre of staff -coordinator -legal desk officer -M&E desk officer -Social Worker -Support staff No. of staff - 10

Follow guidelines for establishment and management of GBV shelters in Uganda

Linking livelihood and GBV programming Shift from Community sensitisation to dialogue

Prescribed gender roles and responsibilities Continued practice of FGM

No donor funded project running at the moment, the last project was being funded by UNFPA, DfID. It run from 2012-2014

WFP All districts in Karamoja sub-region

Maternal Child health and Nutrition-VHTs were used to screen for symptoms of acute malnutrition in children in the community. Food security and emergency food relief. Infrastructure through public works programmes.

School children through the School Feeding Programme. Lactating mother and children less than 2 years. Caretakers of children in the ITC programme. Community members.

UN DfID USAID

The Uganda food and nutrition policy 2003, Child survival strategy for Uganda (2008-2015) and GoU (2011) Uganda Nutrition Action Plan 2011-2016

Use of public works programme to provide food and at the same time provide assets that can conserve environment, water and soil is more appropriate and sustainable.

The region is still food insecure and there is need for programmes that engage community to participate in food production processes and public works to discourage dependency. SRH- negative attitudes on FP and Health workers account for the low contraception use, high maternal & infant mortality rates due to use of TBAs and poor up take of FP. FGM still remains a challenge in some communities that’s needs rigorous campaigns and actions.

Marie Stopes Uganda, Moroto branch

Moroto district Family planning services, general medical practice, cervical cancer screening, laboratory services

Men & Women Cadre of staff -manager -clinical officer -nurses -liaison officer/receptionist -lab technician -centre assistant

Programme activities developed in line with national policies, plans and guidelines on SRH

Targeting adolescents through provision of adolescent friendly services

Myths and misconceptions about contraceptives Poor utilisation of food Poor post abortion care services

Currently the organisation does not have a donor supported project, it is thus providing services at a






Target Population






Number of Staff – 7

Poor hygiene and sanitation cost

Restless Development

Moroto district in Nadunget, south division, north division, and Rupa sub-counties Napak district in

Matany, Lokopo, Lorengchora, Ngoleriet, Lotome sub-counties

Sexual and reproductive health -sessions on SRH within schools -formation of peer educator groups, youth groups and their training

-sensitisation on SRH issues

Youth in school and out of school

August 2014-August 2017

Big Lottery Fund provides 1.8 billion UGX

Cadres of staff -programme manager -finance coordinator -assistant programme coordinator

-programme officers -M&E officer -Support staff Number of staff - 7

Programming in line with school health policy Organisation plans developed in consultation with national plans

Use of community structures Utilisation of existing structures at community level Work with local

government at all levels Working in partnership with other development actors Participatory planning is important

There is no uniformity in SRH messages delivered High expectation of the community

Straight Talk Foundation, Moroto Branch

All sub-counties in Moroto district

-Implements a holistic communication package -Runs a youth centre -Work in specific schools to educate young people on SRH -Provides SRH and rights services

Youth, both males and female in school and out of school aged 10-24

The IrishAid supported project shall run from 2015-2016

IrishAid Cadre of staff -project officers -radio journalist -coordinator -volunteer -driver Number of staff – 8

Programming guided by national laws, policies for example the National adolescent health policy

Reaching targeted beneficiaries through community outreaches Use of radio programming to mobilise the community

Irregular funding Limited availability of youth-friendly services Continuation of the child marriage practice

Even though STF runs other programmes all through the district the IrishAid supported project runs in 6 schools

Karamoja Integrated Development

Moroto district in Katikekile and Tapac sub-counties Amudat district in Loroo, Cheptaboi and Alakas sub-counties Napak district in the town council

-FGM interventions -SRH activities

FGM programming targets women & the elderly SRH programming open to any community member

Running since 2010

UNFPA, Ministry of Gender, The Danish Church

Cadre of Staff -Project officer -Financial officer -Team leaders

In the know of the law against female genital mutilation, reference made to it especially with protection of victims

Use of elders to achieve behavioural change among the population

Rigidity of community members Political interference in service provision

Uganda Red cross Society, Moroto

Moroto district in Nadunget sub county

Condom distribution Young people (10-24 years)

2010-June 2015

UNFPA Cadre of staff -Project manager -Branch manager -Focal person Number of staff – 4

Interventions a response to government call to ensure commodity security, so we are guided by the commodity security plan

Engaging the community in all levels of programming

Irregular or no funding Project was supposed to end in 2014, a one year extension given






Target Population






Andre Food Consult (AFC)

Moroto and Napak districts in all sub-counties

Child nutrition related activities

Malnourished children <5 years

WFP 10 staff Cadre of staff -Directors -other key staff

Projects developed in consultation with national policies, plans and guidelines

Involve community leaders at all levels of planning and implementation

Frequent migration among community people Rationing of food

Is a registered consultancy firm, it among others develops and implements projects

Concern Worldwide

Nakapiripirit, Napak, Amudat and Moroto districts

Provision of food rations, formation of mother care groups, training of lead

mothers, provision of social and behavioural change communication

Pregnant & lactating women

2012-2017 USAID Facilitation of women participation in programming

Promoting male engagement

Project details drawn from project document

Uganda Red Cross Society, Kotido

Kotido Youth-friendly reproductive health services -emergency food response to mother and children

Children and youth

2010-2014 The organisation mainly provides its services through volunteers

Programme activities contributing to overall goal of national adolescent health policy, gender policy and other policies

Use of volunteers in social mobilisation -Establishment of youth corners that are a one-stop centre for youth-friendly health services -Exposure visits

-available facilities in schools and health facilities do not allow for youth-friendly services -Illiteracy and cultural rigidity minimises acceptance

World Vision, Kotido

Kotido Food security, health, child protection and education

In Kotido, the target is vulnerable households with labour capacity-under Public works (food for work

2012-2017 2,969,890,726 UGX

Moving away from food aid to food for work

The burden of food insecurity is too high

Baylor Uganda Moroto, Kotido, Arua

Scaling up paediatric and adolescent HIV/AIDS services

Children and adolescents

Kotido project runs from 2013-2015

Kotido project funding is 164,370,596 UGX

Addressing nutrition needs of the child at early stage

Malnutrition is among all persons of all ages, addressing malnutrition needs for children only doesn’t address malnutrition needs of all family members

Karamoja Integrated Development Programme

Kotido Community Health promotion on HIV/AIDS

Children 10-14, Active youths 15-24 and adults 25+

2013-2016 194,040,333 UGX

Programmes aligned with the national HIV plan especially the social support and protection component

Use of community structures to reach the bigger population

The burden of HIV/AIDS is steadily on the rise Myths and misconceptions on HIV hinder seeking for care

Institute for International Cooperation and Development (C&D)

Moroto, Kotido Fostering children’s access to effective services and systems for improved health and protection

Children Kotido project run from Jan 2014-Dec 2014

50,500,000 UGX for the Kotido project

Referral pathway exists but there are still coordination challenges






Target Population






Doctors with Africa (CUAMM)

All Karamoja districts

Building Health staffs capacity in nutrition, delivery of EMTCT, and psychosocial support)

PLHA, health staff, children and mothers

2013-2015 Health staff capacity building promotes sustainability even after pulling out

Not directly providing MIYCN support (food supplements Need for provision of complete continuum of nutrition care i.e. prevention, cure, response, treatment, rehabilitation. CUAMM is not providing this complete package

MAP (Medical

Assistance Programme) International

Kotido -Food security,

livelihood and water conservation. Specifically households are engaged in public works (work assets) that can build resources e.g. water ponds for climate change adaptation, forests, orchards, sand dams and rock water catchment -Direct Income support i.e. encouraging people to diversify income sources through vegetable growing -Community-led total sanitation education, disease prevention, health promotion and treatment

11,872

households targeted with direct livelihood programmes

Approximately

USD 470,000 annually for direct field interventions under public works -approximately USD 380,000 for the TOGETHER (Community-led total sanitation) project.

Strengthening

capacity of households to produce, store and address causes of malnutrition i.e. inadequate food production, excessive sale of food (poor post harvest practices) and poor sanitation -exchange/exposure visits

Negative cultural practices

e.g. people value rivers so they resist innovation of dams and rock water catchments Women prioritise feeding their husbands

CAFH (Community Action for Health)

Kotido, Kabong and Abim

Child health, nutrition and food security

Children under-5

Project ending 2015

Approximately UGX 600M per annum

-Working with community structures such as VHTs, mother groups -Conducting regular partnership meetings

-Misappropriation of food ratios given to malnourished children. Some is sold or shared among the entire household. This delays recovery -breaks in food supply from WFP. -Cultural rigidity

Nakere Rural Women Activists

Kotido, in all sub-counties

Handle GBV programming, handle forced marriage cases

Target men and women, girls and boys

2014-March 2015

UWONET Work through volunteer structure, have 120 network members who do implement the programmes

Hosting community dialogues Male involvement in GBV programming Having a referral

Detrimental cultural practices Weak follow up mechanism on GBV survivors Low funding

Funding ended but programming continues through community structures i.e.






Target Population






pathway Involve partners at all levels

network members

World Vision Kotido branch

Kotido district in Panyangara & Nakipelimuru sub-counties Abim district in Alarek and

Nyakwae sub-counties Kabong district in Kamion, Lodiko, Loyoro, Kathile, Kapedo, Kawalakol and Lolelia sub-counties

-provision of adequate nutrition to mothers from conception up to 2 years -Provide a specific food basket

-run a behavioural change programme for mothers through the mother care group model -Facilitate access to clean water

Pregnant and lactating women and children <2

2012-2017 USAID We are guided by the Uganda Nutrition Action Plan, our activities contribute to the goal of the plan

Promote community ownership of programmes Utilisation of the council of elders

Prescribed gender roles in the community Negative cultural norms, when it comes to feeding men are the priority

Differences in programme implementation among development partners Health care system cannot attract sufficient human resources for health

LANGO SUB REGION

Plan International

Lira district Ogur, Barr, Agweng sub-counties In Alebtong district in Apala, Aloi, Abia and Akura sub-counties

Adolescent sexual and reproductive health and rights, maternal and child health, EMTCT, WASH, Women economic empowerment, youth economic empowerment, equity and quality education

Young people in and out of school, women and children, also target duty bearer

2012-2015 SIDA Integrating SRH, GBV and HIV Combine interpersonal communication methods with radio talk shows Innovative approach of focusing on young people using young people, also targeting adolescents and the environment around the adolescent to create enabling environment for adoption and sustenance of desirable behaviours

SRH policies and laws are not disseminated and used by most of the stakeholders Sustainability issues, project has a short duration of only three years

Work in partnership with Communication for Development Foundation

Action Aid Lira Awareness raising on GBV through talk shows, community sensitization, public debates, carry out integrated case management, carry out counselling services, carry out

Men and Women and children

2012-2015 UNFPA, DfID Programming usually run in consultation with the domestic violence act, the constitution, the penal code, the land act

Working through a referral pathway Time to time follow up on GBV survivors Build structures in community for sustainability of

GBV champions are also perpetrator Funding is low Narrow interpretation of the gender concept Gender budget allocations






Target Population






alternative dispute resolution, run a GBV shelter, reintegration and resettlement of GBV survivors

programmes are small Staff transfers which weakens the referral pathway GBV programming has left out vulnerable populations like PWDs

Concerned Parents Association

Lira, Otuke, Kitgum, Gulu, Amuru, Oyam,

Alebtong

Activities on gender roles, equality and transformations;

these include community mobilisation, radio drama, reflection and dialogue through existing platforms

Targets adolescent boys and girls

ages 10-19, Very young adolescents 10-14 and older youths and parent

2012-2016 511,508,760 UGX

Funded by USAID

Use of innovative approaches – dialogue, reflection

and action; having radio discussion guides; having activity cards; having community engagement games; life stage tailored small group reflection or dialogue that all address gender equity and roles

Limited implementation of national plans

Areas of youth service delivery is still under funded

World Vision Lira district in Barr and Ngetta sub-counties Kole district in Aboke, Alito and Ayer sub-counties Oyam district in Minakulu and Ngai sub-counties Gulu district in Koro and Bobi sub-counties

-train beneficiaries in farming, good feeding practices, -use agriculture to address micro nutrients -conduct radio programmes on agriculture -promoting fortified crops on nutrition and food security

Target 105,000 households in the 4 districts

250,000 dollars annually Funded by Harvest Trust

Use of agriculture to address micro nutrients deficiency The modality of community dramas has a great impact, also interactive media is key Constant reviews and engagement with the LGs A linkage of agriculture, nutrition, health and livelihoods

Non functionality of the district nutrition coordination committees Nutrition has been taken majorly as a health concern, there is need to view it more holistically The Uganda Action Nutrition Plan was developed without consultation from stakeholders There is scanty or no information on nutrition indicators Information sharing among IPs is low

AIDS Information Centre (AIC), Lira Branch

Lira district Sensitisation about range of issues SRH inclusive Screening and treatment of STDs Cervical cancer screening Assessing PLHA for

Malnourished PLHA

USAID, PEPFAR

Use local leaders as nutrition security champions

AIC has not delved into post abortion care, fertility management and ANC services for PLHA A lot of food goes to waste The traditional practices for food preparation renders food non nutritious

The project is yet to start, it is a pilot project






Target Population






any signs of malnutrition Giving supplements

Uptake of SRH services low

FHI-360, Community Connector project

Lira Nutrition security activities

Women and Children

2011-2016 USAID The project was designed to support the Agriculture Sector Development strategy and Investment 2010-2015 and Uganda

Nutrition Action Plan 2011-2016, the developed plans are being used in programming

Implementing interventions that integrate nutrition and agriculture at community and household level

Focusing on the role of women in the house hold especially regarding food security, decision making processes and the use and distribution of resources

ACHOLI AND WESTNILE SUB REGIONS

UNICEF Mid North Apac, Kitgum, Lira, Pader and Gulu, Karamoja, Acholi, Lango, West Nile

Nutrition, Health.

Conflict Victims in Kitgum Acholi, Lango Karamoja, West Nile- Women and children nutrition and health –emergency response, food and nutrition security assessments and surveillance, Refugees

2006-2009 -On going

EU support Consortium- UNICEF, UNFPA, WFP

Hunter Foundation

Working with and supporting MoH in all districts; using MoH guidelines, OVC Policy, NSPPI-2, Children Act

Building the capacities of local community recognised structures such as the VHT and also lower level health facility staff.

-Entities supported with nutrition support for example health facilities have not yet gained capacity to stand on their own. They have not yet reached a weaning point. This promotes dependency

Save the Children

Northern Uganda –Gulu, Nwoya

Livelihood

targeting for 15-24 year olds – 3,600 in 100 youth groups

Four year grant 2013-2016 this third year

EU funded Local partners are CBO, Acholi Education Initiative

National Adolescent sexual and reproductive health policy.

GREAT, Young fathers, life cycle programming

-Limited district involvement in the implementation

USAID FHI 360/FANTA

Pader, Nebbi, Agago, Dokolo, Oyam, Lira and Amuru

Strengthening District Nutrition Coordination committees’ capacity to plan, budget, advocate for and monitor nutrition activities. Support development and implementation

Local governments Policy makers

5 years 2012-2017

USAID Funded 27.6 million dollars

Co-funders World Bank, UNICEF, SIDA,

National agriculture Policy (2013) The Uganda Food and Nutrition Strategy 2005 (Revised 2010) The Uganda Food and Nutrition Policy, 2003 UNAP

Partnerships at all levels Advocacy with duty bearers at all levels including parliament, line ministries, local government and CSOs Strengthening District Nutrition

-Limited coverage. It is not in all Regions -The targeted District Nutrition Coordination Committees remain dysfunction






Target Population






of a national nutrition advocacy strategy Training nutrition service providers Strengthening the health system’s implementation of nutrition services Developing nutrition programming Collaborating with the Uganda partnership for the HIV free survival to accelerate adoption of the 2010 WHO Guidelines on PMTCT and on HIV and infant feeding

Coordination committees’ capacity to plan, budget, advocate for and monitor nutrition activities.

AVSI Gulu, Lamwo, Pader, Agago, Amuru and Nwoya

Nutrition. Food security and Livelihoods. Health services. Child Protection.

-Works to support at-risk children. -Vulnerable households.

2011-2016 (Five years)

USAID Working within the National OVC Policy 2004 and NSPPI-2. National agriculture Policy (2013) AVSI has carried out meetings and assessments using SCORE’s Organisation Capacity Assessment Tool (OCAT), based on that of the MGLSD.

Collaboration with district and existing partners for community mapping and OVC data collection.

-OVC data availability is a challenge. -Some districts have requested support for initiatives that do not pertain to AVSI’ programming framework.

CARE International

Gulu, Amuru, Nwoya, Pader, Kitgum & Lamwo

Food security and livelihoods Gender (promoting Male role model) Reproductive health. Maternal and Child Health

-Vulnerable communities such as the extreme poor, PWDs, & women & children to provide assistance & opportunities for sustainable development.


DfID, NORAD, USAID, SIDA, EU.

SRHRs frameworks Using of VSLA model in addressing gender equality, food security, reproductive health and economic empowerment. Empowerment of male role models working hand in hand with women for family/household and community transformation

-There are some weaknesses with VSLAs model; Loan amount is small especially at the beginning of the cycle, Loan period is usually short and limits long term investment and Loan funds are not always available at appropriate times.






Target Population






World Vision. Gulu, Amuru, Kitgum, Pader and Nwoya

Nutrition, food security, MCH (EMTCT) Education Gender Water and Sanitation. Livelihoods and resilience. Child Protection

-Children who are malnourished (0-5 years), school children, -Mothers and caregivers with key health and nutrition information, education and communication.

2012-2015 USAID, EU Aligned to UNAP, EMTCT guidelines, OVC policy, Education policy, Children Act

-Most of the projects are grant based and normally not sustainable beyond the grants period.

CARITAS Gulu. Gulu, Amuru and Nwoya

Social Protection-advocacy for inclusion of older persons in local government plans, budgets and implementation

Most disadvantaged members of society especially elderly persons/Older persons. Local governments

2014-2017 (Four years)

HELPAGE International/CORDAID

NDP, Uganda Constitution

-Limited funding opportunities.

Lutheran World Federation (LWF)

Kitgum, Pader and Lamwo

Food security and livelihoods. Water and Sanitation.

General community members

2009-2015 Food and Nutrition policy

Provision of a holistic support in one community creates greater impact.

-Support in the agricultural sector is often highly affected by the unpredictable weather situations. -The VSLA is often very expensive given the packages provided and the required trainings for the Community Based Trainers (CBTs). -There is a difference in programme implementation strategies among development partners that affects communities’ attitudes and participation in projects.

Straight Talk Foundation

Amuru Adolescent Reproductive Health. Gender

Adolescents aged 10-14 yea


USAID Adolescent Sexual reproductive health policy.

Targeting the young adolescent and the environment around as the best way for transformation of gender norms. Targeting both in and out of school adolescents

-Addressing reproductive health needs of adolescents is seen as inadequate as long as their economic empowerment is not integrated.






Target Population






GWED-G Gulu, Amuru and Nwoya

Women, children nutrition, gender and reproductive health.

Women and girls faced with serious human rights violation and abuse, -female headed household.


CARE International, UN Women

- SRHRs frameworks OVC policy

Using of VSLA model in addressing gender equality, food security, reproductive health and economic empowerment.

Continuous dependency on donors for support As a community based organisation, it has no proper financial back up.

KIWEPI Kitgum and Lamwo

Child Protection. Gender. HIV/AIDS.

-Women and child mothers, -OVC and OVC households

-PLHA Persons with disabilities -GBV survivors -Elderly /aged group -War survivors


CARE International

These programme activities are aligned to Children Act, National OVC Policy.

Becoming the sole partners in the whole of Kitgum and Lamwo which stretches the organisation given its

capacity and human resources.

SNV-Arua. Arua, Nebbi, Moyo and Yumbe

Vocational Education. Livelihoods. Agribusiness. Water and sanitation

-In- and out-of-school youth aged 15-30 -local governments -community members

2015-2017 (Three years)

EU. Programming was in consultation with the relevant line ministry MGLSD and MoES and within National guidelines for BTVET.

Use of partners with expertise in the areas of youth vocational programmes is valuable to the project outcomes.

-Limited skilfulness of Out of-school youth -Limited market orientation of youth skilling programmes and, -Untapped business opportunities

It’s still a new project which is yet to learn some best practices.

WellShare International

Arua -Scaling up HIV/AIDS Prevention Services -HIV and Family planning ( FP/HIV integration) PMTCT

-Government and private health facility staff -discordant couples, married couples of unknown HIV status, truckers and boda boda cyclists, fisherfolk, commercial sex workers, and out-of-school youth - Health facility staff -VHTs

2012-2015 USAID CSF

EMTCT guidelines, National Policy Guidelines and Service Standards for Sexual and Reproductive Health and Rights 2012.

Coordination of efforts with key FP service delivery providers in the district, such as Reproductive Health Uganda (RHU), Marie Stopes-Uganda (MSU), and Uganda Health Marketing Group (UHMG) to multiply efforts in FP service delivery. -Use of local partners (RICE) with specialty in an area such as focusing on what they do best like community prevention component.

-Low FP/HIV integration at community level and among MARPs aged 15-49 living in rural areas (including married and co-habiting couples, discordant couples, fisher folk, transport workers, and commercial sex workers) and out-of school youth ages 15-24. - Few youth have access to youth-friendly reproductive health services,

Rural Initiatives for Community Empowerment (RICE)

Arua HIV prevention, capacity building of health workers and community workers, Health Nutrition and

Health facility staff VHTs

WellShare EMTCT guidelines, National Policy Guidelines and Service Standards for Sexual and

Use of already trained CORPs from the beneficiary groups and developing specific approaches to reach

Most VHTs have not been trained on FP and yet expected to implement FP.






Target Population






agriculture interventions.

Reproductive Health and Rights 2012.

these groups coupled with building on already this existing framework and only adding FP BCC and services.

Baylor Uganda Nebbi, Zombo, Arua, Maracha, Adjumani, Koboko, Yumbe and Moyo

districts

-Scaling up Comprehensive HIV/AIDS Services Including Provider Initiated Testing and

Counselling, TB/HIV, OVC, Care and ART for Adults and Children. -Support the target districts, health facilities and Civil Society Organisations (CSO) to provide quality and sustainable comprehensive HIV/AIDS services. -Sexual and Maternal Health.

-Line district department officials. -Health facility staff.

-Staff of CSO. -Adolescent Youth/Children -Adults.

2013-2015 PEPFAR EMTCT guidelines, OVC Policy, Adolescent Sexual reproductive

health policy.

Focusing on strengthening organisational and technical capacities of targeted districts

to enable them plan and manage sustain programmes for comprehensive HIV/AIDS services



Annex 2: Institutional Capacity Assessment

Institution Mandate(ideal role) Performance (Actual role)

Strengths/achievements Gaps

MoH Reduce morbidity and mortality as a contribution to poverty reduction

Attract, motivate and retain health sector human resources

Improvement of maternal and child health services including reproductive health

Implement control of HIV/AIDS

Improve primary healthcare (disease prevention and health promotion, functionality of lower-level health facilities)

Formulate health-related policies

Coordinate dialogue with Health Development Partners

Support resource mobilisation and budgeting, strategic planning and regulation and advise other Ministries on health matters

Set standards, QA, capacity development and technical support related to health

Provide national coordination of health services such as epidemic control, health research and M&E of overall sector performance

Recruitment, training and mentoring of health staff

Development and review of guidelines and standards

Resource mobilisation

Provision of health leadership

Development of Implementation plans such as the Reproductive, Maternal, Newborn and Child Health Sharpened Plan for Uganda (2013) and the Uganda Family Planning Costed Implementation Plan (2015-2020)

Improved proportion of births attended by skilled health personnel (from 39% in 2002/03 to 58% in 2010/11 according to the Statistical Abstract 2013)

Development of a standard SRH monitoring tool (checklist) which captures commodities, human resource, training, VHT activities, infection control, maternal and perinatal death audits

Mentoring of 120 health workers in the provision of long-term family planning and emergency obstetric care in both public and private health facilities (MoH Ministerial Policy Statement 2014/15)

Accreditation and scale-up of more health facilities to higher levels

Increase in % of approved posts filled by health workers (public facilities) from 58% in 2011/12 to 63% in 2012/13 (Annual Health Sector Performance Report (AHSPR), 2012/13)

Decline in stock-out of Depo-Provera as one of the 6 tracer medicines

Improvement in the functionality of Health Centre IVs from 25% in 2011/12 to 36% in 2012/13 (AHSPR, 2012/13)

A slight increase in the percentage of Health Centre IVs providing blood transfusion services from 26% in 2011/12 to 27% in 2012/13 (AHSPR, 2012/13)

Major recruitment by MoH for all Health Centre IVs and Health Centre IIIs during 2012/13

High rates of teenage pregnancy (24%) indicate a gap in SRH services (UDHS, 2011)

Staffing levels remain low and improvements fail to meet targets

Coverage of all SRH indicators remains below HSSIP targets (AHSPR, 2012/13)

Investment (human resources and finance) in health by the GoU continues to fall short of HSSIP targets which themselves are already below those globally recommended (AHSPR, 2012/ 13)

There has been a decline in financial investment in health by the GoU over the years from 9.6% in 2009/10 to 7.4% in 2012/13 (AHSPR, 2012/13)

Over the years, poor functionality of Health Centre IVs has been attributed to inadequate human resources, specifically medical officers

Limited supply of health commodities

Low support supervision

OPM Coordinate M&E of the implementation of government policies and programmes

Coordinate the implementation of government policies, programmes and projects including JAF indicators and actions and PIRT decisions through the National Institutional coordination Framework

Coordinate implementation of the National Development Plan (NDP)

Coordination and monitoring of the implementation of government- and development partner-driven recovery programmes essential to enabling community members to uptake SRH, gender and nutrition interventions. Examples include the Northern Uganda Social Action Fund (NUSAF), the Peace, Recovery and Development

The Peace, Recovery and Development Programme (PRDP) provides a framework against which all development actors (government and non-government) are expected to align their interventions in northern Uganda

Through PRDP, the OPM is promoting community access in northern Uganda to healthcare, education services and clean water in areas where these services were previously lacking or inadequate

Through PRDP, the OPM supports districts in northern Uganda to move toward achieving national

Weak coordination

Thin staffing, especially in the Nutrition Secretariat

Gaps in support supervision

Inability of the OPM to adequately roll out the UNAP to local governments

Gaps in system strengthening in relation to accountability

More intense focus on agricultural production and food security than on nutrition by some of the





Coordinate and manage public relations to ensure good GoU image, effective coverage of national events, communication of policies/practices and definition of the ideal National Character and Values for Development

Coordinate the development of capacities for natural and man-made disaster prevention, preparedness and response (including refugee crises)

Coordinate and monitor the implementation of Special Government Policies and programmes for northern Uganda (Luwero-Rwenzori, Karamoja, Bunyoro and Teso Affairs)

Programme (PRDP), the Karamoja Livelihoods Programme (KALIP) and the Agricultural Livelihoods Recovery Programme (ALREP)

average levels for the main socio-economic indicators

Through NUSAF II, OPM is improving access among beneficiary households in northern Uganda to income-earning opportunities and better basic socio-economic services

Under ALREP and KALIP, the OPM is contributing to the restoration of farmers’ productive capacity and the strengthening of their linkages to agricultural service provision

programmes being coordinated by the OPM

Uganda AIDS Commission (UAC)

Oversee, plan and coordinate HIV/AIDS prevention and control activities throughout Uganda

Provide overall leadership in the coordination and management of an effective HIV/AIDS National Response

Improve access to services by people living with HIV/AIDS (PLHA), orphans and vulnerable children (OVCs) and other vulnerable populations

Overseeing of HIV prevention

Overseeing of HIV care and treatment

Overseeing of HIV social support and social protection

Overseeing of HIV M&E

System strengthening

The incidence of new HIV infection has declined over the last 3 years from 162,294 in 2011 and 154,589 in 2012 to 140,908 in 2013 (Mid-Term Review of the National HIV/AIDS Strategic Plan (NSP), 2011/12-2014/15)

Proportion of those enrolled in anti-retroviral programmes for the prevention of mother-to-child transmission increased from 52% in 2011 to 72% in 2013 (HIV/AIDS NSP MTR, 2011/12-2014/15)

Some PLHA receiving nutritional support

The UAC has a well-equipped and facilitated M&E unit

Estimated number of PLHA (the burden of HIV/AIDS) increased from 1.2 million in 2011 to 1.6 million by the end of 2013

Rise in HIV/AIDS prevalence from 6.4% in 2004/05 to 7.3% (2011)

HIV/AIDS prevalence is higher among women (8.3%) than men (6.1%) (HIV/AIDS NSP MTR, 2011/12-2014/15)

Many PLHA remain in dire need of nutritional support despite support from partners

MoES Provide technical support, guidance, coordination, regulation and promotion of quality education, training and sports coaching to all persons in Uganda for national integration, development and individual advancement

Ensure universal and equitable access to quality basic education for all children

Improve the quality of education in all primary and post-primary schools

Ensure equal access in all districts by gender and according to any special needs at all levels of education

Build the capacity of districts by helping Education Managers to acquire and improve knowledge, skills and attitudes in order to enable them to plan, monitor,

Assurance of equal access to education by both boys and girls

Provision of technical support to local governments

Strategic planning for the sector

The sector continues to maintain gender parity at primary level. In AY 2013/14, a total of 8,174,433 children (4,082,579 boys and 4,091,854 girls) were enrolled in primary school with boys and girls each constituting an equal 50% (Education and Sports Sector Annual Performance Report (ESSAPR), 2013/14)

The GER (Gross Enrolment Ratio) improved from 110.9 % (111.3% boys; 110.3% girls) in 2013 to 110% (109.7% boys; 110.3% girls) in 2014 (ESSAPR, 2013/14)

The Net Enrolment Ratio (NER) also improved from 95.3% (94.57% boys; 96% girls) in 2013 to 93.7 % (92.9% boys; 94.6% girls) in 2014 (ESSAPR, 2013/14)

The GER in secondary education improved from 26.8% (28.8% boys; 24.8% girls) in 2013 to 28.1% (29.1% boys; 27.1% girls) while the NER increased from 24.7% (25.9% boys; 23.6% girls) in 2013 to 25.1% (26.1% boys; 24% girls) in 2014 (ESSAPR, 2013/14)

Obsolete policy framework largely based on the GWP-Government white paper of 1992 (ESSAPR, 2013/14)

Inadequate infrastructure, especially classrooms and sanitation facilities

Funding challenges (e.g. for the FY 2013/14 only 85% of the approved budget was funded)

Limited investment in EMIS, DEMIS and M&E: e.g., EMIS and DEMIS are starting to be rolled out but there is no budget to operationalise their interface

The M&E section is also inadequately resourced to cope with the ever-expanding scope of investment in the sector

Inadequate school inspection services

Limited collaboration between school inspectors,





account and perform managerial functions

The total number of female students has increased due to a favourable policy mix of affirmative action for girls, scholarship programmes and bursary schemes

The number of pit latrines increased by 3% (from 132,143 in AY 2012/2013 to 136,687 in AY 2013/2014) (ESSAPR, 2013/14)

The number of schools accessing water sources increased by 5.7% (ESSAPR, 2013/14).

The Pupil-to-Latrine Ratio in primary schools improved from 1:63 (1:71 government; 1:41 private) in 2012/13 to 52:1 (58:1 government; 33:1 private) in 2013/2014

Review of the National Strategy for Girls’ Education

Dissemination of the Female Teacher study in 2013/14

Development of a Gender in Education Strategic Plan

Dissemination of the Reader on the Management of Menstruation with support from UNICEF, Plan Uganda and the UN Joint Programme on Gender Equality

Strengthening of networks to address key barriers to education through the monitoring of gender issues in 10 districts; reports to international conventions; holding of the first conference on menstruation management in Uganda and the establishment of a gender thematic working group

school communities and primary teacher training institutions

Inadequate monitoring of school outcomes, which is attributed to lack of clear articulation of quality goals and targets to be achieved by various curricula at all levels of the education system

Persistent socio- economic and cultural barriers to girls’ education attributable to gender-based discrimination, early marriage, teenage pregnancy, poverty and unsafe school environments)

Schools have not been funded to provide sanitary materials, despite this being encouraged

Inactivity of the Presidential Initiative on AIDS Strategy for Communication in Youth

Lack of finalisation of school health policies

Lack of school feeding programmes, which affects the retention of girls in school (especially in Karamoja sub-region)

MAAIF Enhancing crop production, improving food and nutrition security

Formulate, review and implement national policies, plans, strategies, regulations and standards and enforce laws, regulations and standards along crop, livestock and fishery value chains

Control and manage epidemics and disasters and support the control of sporadic and endemic diseases, pests and vectors

Regulate the use of agricultural chemicals, veterinary drugs, biological, planting and stocking materials as well as other inputs;

Support the development of infrastructure and the use of water in agricultural production along livestock, crop and fishery value chains

Promotion of irrigation to reduce over-dependence on rain-fed agriculture

Increased fertiliser usage

Crop pest and disease control

Investment in QA of agro-inputs

Training in production technologies, crop pest, disease and vector control

Creation of an enabling environment for increased production and productivity

Agricultural research

Provision of advisory services to farmers

Adequate land resources for agricultural production

Surveillance systems exist in the MoH and MAAIF, and the GoU has set up a surveillance system for coordination and collaboration with organisations dealing with food security and nutrition

Farmer institutions exist and can be powerful advocates for new policies to support agricultural development. e.g. the Uganda National Farmers’ Federation, the National Farmers’ Forum, National Agricultural Advisory Services (NAADS) and the Uganda Cooperative Alliance

Low production and productivity

Usage of fertiliser remains low

Challenges to the transformation of livelihoods

The growth rate of the agricultural sector remains far lower than the average growth rate of the economy

Low value addition to agricultural produce

Insufficiently skilled agricultural labour force

Multiple and contradictory land tenure systems, often leading to land fragmentation, land degradation and insecurity of tenure

High population growth (3.4%) which is reducing the per capita availability of land for agricultural production;

Climate change effects





Establish sustainable systems to collect, process, maintain and disseminate agricultural statistics and information

Support the provision of planting and stocking materials and other inputs to increase the production and commercialisation of agriculture for improved food security and household income

Develop public infrastructure to support production, QA and value addition along the livestock, crop and fishery commodity chains

Monitor, inspect, evaluate and harmonise activities in the agricultural sector including local governments

Strengthen human and institutional capacity and mobilise financial and technical resources for the delivery of agricultural services

Develop and promote collaborative mechanisms nationally, regionally and internationally on issues pertaining to the sector

Ensure household and national food and nutrition security for all Ugandans

Develop human resources for agricultural development

Unhealthy and malnourished agricultural workforce, with almost half (48%) of Ugandans being food energy-deficient

Northern Uganda is the most food-insecure region with 59% of the population affected (Food Security and Vulnerability Analysis report, UBOS and WFP, 2013)

Low level of acceptance of farmer organisations

MoGLSD Empower communities to harness their potential through cultural growth, skills development and labour productivity for sustainable and gender-responsive development

Promote gender equality, labour administration, social protection and community transformation.

Empower communities to appreciate, access, participate in, manage and demand accountability in public and community-based initiatives

Protect vulnerable persons from deprivation and livelihood risks

Create an enabling environment for increasing employment opportunities and productivity for improved livelihoods and social security for all, especially the poor and vulnerable

Empowerment, support, care and protection of vulnerable groups

Community mobilisation for development

Prevention of and response to child labour

Review and dissemination of laws and policies

Development of vocational, entrepreneurial and life skills among vulnerable groups and individuals

Provision of technical support to other Ministries and local governments to mainstream gender and rights

The Social Assistance Grants for Empowerment (SAGE) programme is reaching vulnerable households and the elderly

The National Youth Fund is attempting to address youth unemployment

The sector has good human resource capacities, especially in the old districts

Partners are playing a significant role in furthering the agenda of the sector

Abim district had the highest proportion of married children at 22.3% (Government Annual Performance Report 2012/13)

Gender mainstreaming remains a peripheral intervention at national and local government level

Financial marginalisation of the sector

Over-dependency on partners to fund sector programmes and plans





Ensure that issues of inequality and exclusion in access to services across all sectors and at all levels are addressed

Improve the performance of social development institutions to coordinate and implement the Social Development Sector Strategic Investment Plan (SDIP) at various levels

MoLG Inspect, monitor, and where necessary offer technical advice and assistance, support supervision and training to all local governments.

Guide, harmonise, mentor and advocate for all local governments in support of the GoU’s vision of bringing about socio-economic transformation of the country

Provision of technical guidance and monitoring of local government performance

The Ministry has structures that can deliver if empowered, supervised and facilitated

Local government is operating at 51.7% of its required human resource requirements

Gaps exist in support supervision; where this happens, it is irregular and inadequate

Population Secretariat

Promote and coordinate population policies and programmes in Uganda

Influence GoU policies and programmes to address population trends and patterns

Formulation of population-related policies

Coordination of policy implementation

Enactment of the National Population Council Act 2014

Formulation of an explicit National Population Policy, promulgated by the GoU in 1995 and revised in 2008

Coordination of the implementation of the National Population Policy and programmes countrywide.

Increased understanding of inter-linkages between population and development issues places them high on the agenda

Support to the integration of population variables into development plans and programmes at national, sectoral, district and lower levels

Establishment of an institutional framework for the implementation of population policies and programmes at district and lower levels

Establishment of strategic partnerships with Government Line Ministries and agencies, Parliament, CSOs, international organisations and development partners on population and development issues

Mobilisation of resources for the implementation of the National Population Policy and Programme.

Development of a Strategic Plan, M&E Framework and a National Population Action Plan for operationalisation of the National Population Policy

Successful launching of the National Advocacy Strategy at Imperial Royale Hotel, Kampala on

Limited visibility and public knowledge of the Secretariat’s mandate and role





27 February 2015

Issuing of the State of Uganda Population Report (under the theme Harnessing Uganda’s Demographic Dividend for Socio-Economic Transformation) on 21 November 2014

Local Government Directorates (Health, Community Development, Production and Agriculture, Education)

Represent and implement the mandates of their respective parent Ministries

Implement all decentralised and devolved agricultural, health, education and community-based services

Develop and implement appropriate by-laws to regulate food security,

Monitor the implementation of agricultural, health, education and community-based services, plans and policies within districts and lower-level local governments

Mobilise and empower farmers, farmer groups and communities in general to produce, process and market their commodities

Sensitise and guide communities and implementers on how to address traditional and cultural issues affecting the selection, promotion and utilisation of strategic agricultural enterprises, health, education and community-based services

Increase awareness among farmers and communities of the need to protect natural resources, especially land and water, during agricultural production

Inter-sectoral planning and sharing

Accreditation and scale-up of more health facilities to higher levels

Local government priority setting

Partnership with development partners

Community outreach

Scale-up of health facilities from lower to higher levels

Accreditation of new health facilities to increase service coverage and access

Recruitment of staff (albeit below staffing norms)

Local government departments are more concerned about food security and there is not much emphasis on nutrition

Limited nutrition-sensitive planning and budgeting among sectors at district level

limited engagement of community and leadership

Districts lack District Nutrition Action Plans even as the UNAP nears its end

Most interventions are curative rather than preventative

Minimal community engagement and under-utilisation of community nutritional structures

Dysfunctional district and sub-county nutrition coordination committees

Nutrition is not prioritised and some districts do not even have District Nutritionists

Gender is treated as a cross- cutting issue at time of planning and does not receive specific financing

Dependence on partners for the implementation of SRH, nutrition and gender programmes

Limited support supervision from higher to lower-level local government

Irregular integrated community outreach involving SRH, gender and MIYCN

CSOs Mobilise communities to access financial products and services, farm inputs, markets and other relevant agricultural goods and services

Advocate for improvement in agricultural services, gender relations and access to SRH services within the prevailing policy and regulatory environment

Monitor the implementation of government programmes

Develop and implement

Advocacy

Community mobilisation

Direct intervention and implementation

Partnering with development partners e.g. World Vision

Capacity building for local government e.g. CUAMM

Gap filling

Relatively higher level of community engagement

Emphasis on upward and downward accountability

Promotion of contextually appropriate approaches and interventions

Relative efficiency and effectiveness

Interventions are project-based and leave a vacuum when they end

Exit strategies are sometimes poor

Donor dependence

Minimal engagement of district local governments

Duplication of interventions

Operation at a limited scale, e.g. in a few sub-counties of a district or one or two districts in a region





complementary nutrition, gender and SRH programmes in line with GoU policy and plans

Contribute to policy formulation and review at all levels

Private sector, e.g. private service providers and PNFPs

Invest in agricultural production and health service provision

Participate actively in the development, multiplication and dissemination of technologies (e.g. water and, farming)

Participate in the marketing of agricultural inputs and outputs and SRH commodities

Provide consultancy services

Provide agricultural finance services to support investment in the production, processing and marketing of agricultural produce

Advocate for improved policy, regulatory and institutional frameworks that effectively support private sector activities

Liaise with government and other stakeholders on strategic actions for nutrition, gender and SRH

Invest in rural infrastructure through public-private partnerships

Running of clinics and/or health facilities that provide health commodities for SRH and nutrition, e.g. Pentecostal Assemblies of God Hospital in Lira district

Extension of farm loans to farmers as individuals or groups

Provision of business loans to health service providers including pharmacies, clinics and drugstores which provide SRH services

Filling of gaps left by inaccessible or poor-quality public services

Advocacy, support and monitoring of service delivery and performance

Competence research and consultancy

Inability to generate comprehensive reports due to lack of HMIS tools, capacity gaps in their utilisation, lack of feedback on reported data, failure to appreciate the need for reporting and failure to transmit compiled HMIS datasets. Most private sector facilities lack the required human resources, equipment and infrastructure to effectively report

Some are private sector actors driven by profit motives and even market poor-quality products and services

Development partners

Share good practices and alternative approaches to nutrition, SRH and gender

Provide financial and technical support to nutrition, SRH and gender issues

Human resource capacity building

Documentation and sharing of good practices on nutrition, SRH and gender

Support to supplies

Financing of nutrition, SRH and gender

Provision of technical support to nutrition, SRH and gender

Provision of guidance to central and local governments and CSOs

Identification and support of implementing partners

Human resource capacity building

Financial competencies

Technical competencies

Alignment of programmes with national priorities

Knowledge of current discourses on nutrition, SRH and Gender

Human resource capacities

Case points

According to the Consolidated Mid-Term Review (MTR) of the National HIV/AIDS Strategic Plan (NSP) 2011/12-2014/15:

Over the period 2011/12-2013/14, the Civil Society Fund (CSF) supported CSOs in the provision of therapeutic food to 1,508 PLHA;

In 2013, PEPFAR funded implementing partners (IPs) to provide food and nutritional support to 116,256 individuals;

In 2013, PEPFAR-supported programmes reached 543,833 individuals with interventions that explicitly addressed

Absence of consideration of context

Limited commitment of time and resources to situational assessment, the identification of actual issues and gaps and the identification of models that work so as to replicate and build on these with due respect to contextual differences

Tight and inflexible work plans that allow no room to benefit from lessons learnt along the way





gender-based violence (GBV); 609,020 individuals with interventions and services that addressed the legal rights and protection of women and girls impacted by HIV; and 943,964 individuals with interventions that explicitly addressed norms about masculinity related to HIV



Annex 3: Annotated Bibliography

Category Analysis Remark/key message

1. Policy-related strategic plans, guidelines

Uganda Vision 2040 Areas of Focus Maternal and Child Nutrition

Improve the nutritional status of the population, especially young children and women aged 15-49

Develop and implement a school feeding policy SRH and Population Growth

Focus on creating a more sustainable age structure

Focus on building an efficient health service delivery system

Introduce incentive-orientated population control policies and laws Gender

Introduce policies, laws and programmes to facilitate women’s equal participation in the development process

Ensure total elimination of harmful and non-progressive socio-cultural practices that affect the health, wellbeing and progress of both men and women

Reduce fertility among Ugandan women to about 4 children per woman

Trigger nutrition security through supporting agriculture There will be a paradigm shift from a facility-based to a household-based health delivery system Gender mainstreaming is a core part of the planning process

National Development Plan 2010/11-2014/15 Areas of Focus Maternal and Child Nutrition

Encourage and support ante-natal care services through health and nutrition education

Promote dietary diversification, growth monitoring, and counselling

Support infant and young child feeding (IYCF) in the context of HIV

Promote and support exclusive breastfeeding for the first six months, timely introduction of adequate complementary feeding and continuous breastfeeding to at least 24 hours

SRH and Population Growth

Integrate population factors and variables at various levels of development planning

Reduce unmet needs for family planning

Mobilise resources for the effective implementation of the National Population Policy and Programme

Develop a monitoring and evaluation system for the implementation of the National Population Policy

Promote awareness among men, women and communities of their roles and responsibilities in the area of sexual and reproductive health and rights

Advocate for SRH commodity security

Promote the strengthening of youth-friendly SRH services

Advocate for the linking of SRH and HIV/AIDS programmes

Advocate for adherence to SRH rights, especially for women and girls, including Gender-Based Violence

Advocate for improvement of maternal and child mortality through campaigns to reduce teenage pregnancy, ensure healthy spacing of pregnancies and improve the quality of maternal care

Gender equality

Promote gender mainstreaming in development plans, programmes and projects

Reduce gender-based violence and promote women’s rights

Promote the economic empowerment of women

Prioritises implementation of the Uganda National Minimum Healthcare Package (UNMHCP) although it also recognises inadequate capacity to deliver it, specifically in the areas of maternal and child health, non-communicable disease and nutrition

National Health Policy II (2009/10-2014/15) Areas of Focus

Strengthen health systems in line with decentralisation

Re-conceptualise and organise supervision and monitoring of health systems at all levels

Establish functional integration both within the public sector and between the public and private sectors in healthcare delivery, training and research

Address the human resource crisis and re-define the institutional framework for the training of health workers, including the mandates of all actors

Prioritises the effective delivery of the Uganda National Minimum Healthcare Package (UNMHCP)

Health Sector Strategic Plan III (2010/11-2014/15) Areas of Focus Maternal and Child Nutrition

Reduce the incidence and prevalence of macro- and micro-nutrient deficiencies and associated mortality among vulnerable groups

Improve access to and quality of nutrition services at facility and community levels

Review, formulate and enforce nutrition-related regulations and standards

Strengthen advocacy and social mobilisation for behavioural change

Strengthen nutrition information management systems Gender-Based Violence

Prevent morbidity and mortality due to gender-based violence

A minimum healthcare package is delivered to all people in Uganda since the resource envelope is limited




Build the capacity of health workers, their respective institutions and communities to manage cases of GBV

Strengthen information, education and communication activities on the effects of SGBV

Strengthen the capacity of the health sector to conduct GBV-related monitoring and evaluation activities

SRH and Population Growth

Reduce, perinatal, neonatal, infant and maternal mortality and morbidity

Strengthen information, education and communication activities for sexual and reproductive health

Build institutional and technical capacity at national, district and community levels for SRH

Expand the provision of SRH services

Strengthen adolescent sexual and reproductive health services

Strengthen the legal and policy environment to promote the delivery of SRH services

The Social Development Sector Strategic Investment Plan (SDIP II), 2011/12-2015/16 Areas of Focus The focus of the plan is to promote employment and the rights of vulnerable groups to effectively participate and improve their wellbeing for gender-responsive development. The Strategic Objectives are:

Promote decent employment opportunities and labour productivity

Enhance effective participation of communities in the development process

Improve the wellbeing of vulnerable, marginalised and excluded groups

Address gender inequality in the development process

Improve the capacity of social development institutions to coordinate, implement, monitor and evaluate the SDIP at all levels

A priority area of the SDIP is gender and women’s empowerment. The key interventions therein are: promoting gender mainstreaming in sectors and local government, promoting the economic empowerment of women and addressing gender-based violence and the promotion of women’s rights.

Guidelines for the Establishment and Management of Gender-Based Violence Shelters in Uganda (2013) Areas of Focus These are guidelines to stakeholders on the establishment and management of GBV shelters in Uganda. They reflect a community- and rights-based approach to GBV prevention and response and are intended for use alongside existing sectoral GBV Standard Operating Procedures (SOPs) and referral systems. The guidelines expound on the establishment of shelters, the management of shelters, the minimum standards of a shelter and collaboration with other service providers.

National Population Policy (2008) Areas of Focus

Integrate population factors and variables at various levels of development planning

Monitor population trends and patterns and relate them to socio-economic development

Improve the health status of the population.

Advocate for improved nutrition and food security, increased household incomes, protection of the environment and sustainable use of natural resources

Promote positive health-seeking behaviour

Reduce unmet needs for family planning.

The current rate of population growth is unsustainable given the relatively slow growth of the economy and the already high levels of poverty and low living standards

The National Population Policy Action Plan (2011-2015) Areas of Focus

Integrate population factors into development policies, plans and programmes

Monitor the interrelations between population and development

Improve capacity to provide for healthy lives and positive health-seeking behaviours

Improve food security and nutrition

Reduce unmet needs for family planning

The linkage between improved quality of life, human development and population dynamics is a central point in the process of eradicating poverty in Uganda

Reproductive, Maternal, Newborn and Child Health Sharpened Plan for Uganda (2013) Areas of Focus The plan’s vision and duty is to end preventable deaths in the context of attaining Millennium Development Goal (MDG) targets and beyond by ensuring a strategic shift to “doing business” and universal coverage of high-impact health interventions using all 3 delivery platforms (communities, population scheduling

7 and individual clinical services).

The sharpened plan focuses on advocacy, resource mobilisation and the prioritisation of high-impact interventions to accelerate progress toward achieving targets

7 This refers to populations with unique characteristics that make them more vulnerable and susceptible to risk such as

populations in hard-to-reach areas, populations exposed to harmful gender norms such as FGM, early marriage and teenage pregnancy and populations perceived to suffer discrimination and/or marginalisation. Therefore in this context the concept of “population scheduling” offers the opportunity to appreciate and respond to the unique SRH, newborn and child health-related needs of the diverse population groups and their contexts.




The Strategic Objectives are:

Accelerate greater coverage in high-burden districts and populations

Expand the coverage of high-impact interventions that directly reduce maternal, newborn and child mortality

Harness non-health sector interventions that impact on maternal, newborn and child vulnerability and death

Develop and sustain collective action and mutual accountability for ending preventable maternal, newborn and child death

under MDGs 4 and 5

Uganda Family Planning Costed Implementation Plan (2015-2020) Areas of Focus The operational goal of the plan is to reduce unmet needs for family planning to 10% and increase the prevalence of use of modern contraceptives among married women and women in unions to 50% by 2020. The plan has five priority areas:

Increase age-appropriate information about, access to and use of family planning among young people aged 10-24

Promote and nurture change in social and individual behaviour to address myths, misconceptions and side effects and improve the acceptance and continued use of family planning to prevent unintended pregnancies

Implement task sharing to increase access, especially among rural and underserved populations

Mainstream the implementation of family planning policy and interventions and the delivery of services in multi-sectoral domains to facilitate a holistic contribution to social and economic transformation

Improve forecasting, procurement and distribution and ensure full financing for commodity security in the public and private sectors

Scale-up of family planning services is one of the most cost-effective interventions to prevent maternal, infant, and child death globally

Uganda country commitments to FP2020 Commitment 1: Develop and implement an integrated family planning campaign Commitment 2: Accelerate the passing of the National Population Council Bill into law, thereby immediately operationalising the inter-Ministerial structure and appropriating the necessary budget support through a supplementary request Commitment 3: Improve sexual and reproductive health (SRH) commodity distribution and effective service delivery and review post-shipment testing policy to reduce delays in the release of vital SRH supplies, including family planning supplies, from the National Drug Authority Commitment 4: Finance commitments Commitment 5: Strengthen the technical and institutional functionality of the Uganda Health Marketing Group and National Medical Stores in a dual private and public sector distribution system for SRH supplies Commitment 6: Scale up partnerships with CSOs and the private sector for family planning outreach and community-based services, including social marketing, social franchising, and task sharing under a comprehensive training programme Commitment 7: Partner with appropriate private sector bodies and institutions for the integration of maternal and child health, family planning, SRH and HIV/AIDS information and services for their employees and families Commitment 8: Roll out youth-friendly services in all government Health Centre IVs and district hospitals Commitment 9: Ensure timely completion of the annual household panel surveys conducted by the Uganda Bureau of Statistics (UBOS) to ascertain progress on health, including family planning service delivery) and conduct a robust evaluation of all family planning investments in Uganda Commitment 10: Conduct bi-annual joint supervision and bi-annual family planning/SRH national review meetings Commitment 11: Strengthen the institutional capacity of public health facilities and community-based distributors to provide family planning and increase choice and quality of care at all levels

Reproductive Health Commodity Security Strategic Plan (2009/10-2013/14) Areas of Focus The vision of the strategy is to ensure that every person in Uganda is able to choose, obtain and use quality contraceptives and other sexual and reproductive health commodities whenever s/he needs them. The goal of the Strategic Plan is to contribute to accelerating the reduction of maternal and neonatal morbidity and mortality in Uganda. The objectives of the Strategic Plan are:

Increase the rate of use of modern contraceptives from 23% to 50% and reduce the unmet need for contraceptives from 40% to 5% by 2015

Increase the proportion of health facilities with NO stock-outs of selected SRH commodities to 80% by 2015

Increase public sector/government budget allocation and expenditure on SRH commodities, including contraceptives, to 80% by 2015

Provides a structure for moving beyond the emergency mode of responding to stock-outs toward more predictable, planned and sustainable country-driven approaches to ensuring the availability and use of essential supplies




Roadmap for accelerating the reduction of maternal and neonatal mortality and morbidity in Uganda 2007-2015 Areas of Focus The vision of the roadmap is for women in Uganda go through pregnancy, childbirth and the post-natal period safely and for their babies to be born alive and healthy. Its goal is to accelerate the reduction of maternal and neonatal morbidity and mortality in Uganda. The objectives of the plan are:

Increase the availability, accessibility, utilisation and quality of skilled care during pregnancy, childbirth and the post-natal period at all levels;

Promote and support appropriate health-seeking behaviour among pregnant women, their families and the community;

Strengthen family planning information and service provision for women/men/couples who want to space or limit their childbearing

The Roadmap for the Reduction of Maternal and Newborn Mortality, National Child Survival Strategy has prioritised high-impact interventions, which are appropriate for vulnerable populations including the less advantaged

National HIV/AIDS Strategic Plan 2015/16-2019/20 (Draft) Areas of Focus The goal of the prevention thematic area is to reduce the number of new youth and adult HIV infections by 70% and the number of new paediatric HIV infections by 95% by 2020. Under Objective 1, which seeks to increase the adoption of safer sexual behaviours and reduce risky behaviours, a number of actions intend to address SRH issues among people living with HIV/AIDS (PLHA). These include:

Procuring and distributing adequate numbers of male and female condoms (free and socially marketed) and expanding condom distribution across settings and at community level

Scaling up condom education (with emphasis on correct and consistent use) to address complacency and fatigue associated with condom use

Integrating sexual and gender-based violence (GBV) prevention and human rights into HIV prevention programming

Scaling up comprehensive sexual and reproductive health (SRH)/HIV programmes targeting adolescents (both inside and outside schools) and young people

Providing a comprehensive package of SRH and HIV prevention, care and treatment through harmonised programming and ensure access by vulnerable populations such as women, girls and the disabled

National Adolescent Health Policy for Uganda, 2004 Areas of Focus This policy aims to double the rate of contraceptive use among sexually active adolescents and targets a reduction in the proportion of women who have their first child before the age of 20 from 59% to 30%. The overall goal of this policy is to mainstream adolescent health concerns into the national development process in order to improve the quality of life, participation and standard of living of young people. SRH

Double the rate of contraceptive use among sexually active adolescents

Halve the number of women who have their first child before the age of 20 (from 59% to 30%)

Raise the average age at first sexual intercourse by one year

Increase the proportion of adolescents abstaining from sex before marriage

Increase the practice of protected/safe sex among sexually active adolescents, including dual protection (against both disease and pregnancy)

Integrate post-abortion care into all tertiary and secondary care facilities and appropriate primary care facilities with emphasis on post-abortion family planning

Ensure the readmission of pregnant schoolgirls to the education system after they have delivered

Double the proportion of mothers under 20 who deliver in health facilities (from 42% to 80%)

Increase the use of emergency contraception in family planning programmes that target adolescents

Reduce harmful traditional practices through appropriate policies, legislation and programmes

Incorporate adolescent sexual and reproductive health into the curricula of all health training institutions

Nutrition

Strengthen the nutrition component of the national school health programme

Strengthen the community-based nutrition programmes of the Ministry of Health (MoH)

Support a national nutritional survey of adolescents

The National Adolescent Health Policy is an integral part of the National Development process and reinforces GoU commitment to the integration of young people in the development process

The National Action Plan for Women (2007) Areas of Focus The goal of the NAPW is to achieve equal opportunities for all women in Uganda by empowering them to become active participants in and beneficiaries of social, economic and political developments in the country. The plan identifies five critical areas for action:

A shift in focus under each priority area was ensured so that the implementation of the plan i) is prioritised in government




Legal and policy framework and leadership

Social and economic empowerment of women

Sexual and reproductive health, rights and responsibilities

Girls’ education

Peace building, conflict resolution and freedom from violence

programmes, ii) is easy to popularise, and iii) generates activism

The Uganda Gender Policy (2007) Areas of Focus The goal of the policy is to achieve gender equality and women’s empowerment as an integral part of Uganda’s socio-economic development. Its purpose is to establish a clear framework for the identification, implementation and coordination of interventions designed to achieve gender equality and women’s empowerment in Uganda. The objectives of the policy are:

Reduce gender inequalities in order to enable all women and men, girls and boys to move out of poverty and achieve improved and sustainable livelihoods

Increase knowledge and understanding of human rights among women and men so that they can identify violations, demand access to justice, seek redress and enjoy their rights

Strengthen women’s presence and capacities in decision making for their meaningful participation in administrative and political processes

Address gender inequalities and ensure the inclusion of gender analysis in macro-economic policy formulation, implementation, monitoring and evaluation

The emphasis on gender is based on the recognition that “gender” is a development concept useful in identifying and understanding the social roles and relations of women and men of all ages and how these impact on development

Uganda Nutrition Action Plan (UNAP), 2011-2016 Areas of Focus The goal of the Uganda Nutrition Action Plan is to reduce levels of malnutrition among women aged 15-49, infants and young children from 2011-2016 and beyond. The objectives of the plan are:

Improve access to and utilisation of services related to maternal, infant and young child nutrition

Enhance the consumption of diverse diets

Protect households from the impact of shocks and other vulnerabilities that affect their nutritional status

Strengthen policy, legal, and institutional frameworks and the capacity to effectively plan, implement, monitor and evaluate nutrition programmes

Create awareness of and maintain national interest in and commitment to improving and supporting nutrition programmes in the country

The UNAP calls for scale-up of multi-sectoral interventions that place greater emphasis on community-based initiatives that have proven to yield cost-effective results, as well as targeting areas and groups with the highest levels of malnutrition

Agricultural Sector Development Strategy and Investment Plan 2010/11-2014/15 Areas of Focus

Ensure that nutrition activities form an integral part of the work plans of the Ministry of Agriculture, Animal Industry and Fisheries (MAAIF)

Complete the legal framework for food and nutrition as applicable to agriculture

Enhance collaboration with other key stakeholders (notably the Ministry of Health) to jointly address the nutrition security challenge

Operationalise the Uganda Food and Nutrition Policy

Operationalise and implement the MAAIF component(s) of the National Food and Nutrition Strategy

Promote appropriate agricultural technologies and crops that provide significant nutritional advantages

Assist local governments to prioritise food and nutrition security in their budgets and to prepare plans for implementation

Assist the MoH to conduct surveys on nutritional status

Advocate for the prioritisation and integration of food and nutrition security in relevant government frameworks, policies and strategies, along with the provision of adequate resources for implementation

In aggregate, Uganda is food-secure. Most people have enough food to eat and also enjoy a varied diet. However, the food and nutrition security situation remains unsatisfactory

National Agricultural Policy (NAP) 2011 Areas of Focus The overall objective of the NAP is to promote food and nutrition security and household incomes through coordinated interventions that focus on enhancing sustainable agricultural productivity and value addition, providing employment opportunities and promoting domestic and international trade. With regard to nutrition the NAP calls for the development of a well-coordinated system for the collection, collation and dissemination of information on food and nutrition security to households and communities. It also calls for promotion of the production and consumption of diversified nutritious foods (including indigenous foods) at household and community level.

Calls for the strengthening of partnerships between the Ministries responsible for Agriculture, Health and other partners to ensure that issues of nutrition and health are mainstreamed in their programmes

Peace, Recovery and Development Programme for Northern Uganda (PRDP) (2012-2015) Areas of Focus The overall goal of the PRDP is to consolidate peace and strengthen the foundations for development in northern Uganda. The PRDP has four strategic objectives:

Consolidating state authorities

Empowering communities

The PRDP was designed to provide a GoU-led and harmonised approach to recovery efforts in northern Uganda, relative to the ad-hoc provision of support during the years of




Economic revitalisation

Peacebuilding and reconciliation One of the core areas of the social pillar of the PRDP is improved nutrition whereby the GoU seeks to put in place a strong foundation for the appreciation and practising of good nutrition.

insurgency, while also addressing the drivers and consequences of conflict

The Domestic Violence Act (2010) Areas of Focus The Domestic Violence Act provides:

Protection and relief of victims of domestic violence and the punishment of perpetrators

Procedures and guidelines to be followed by the court in relation to the protection and compensation of victims of domestic violence

Jurisdiction of courts

Enforcement of orders made by the court

Empowerment of families and children court to handle cases of domestic violence and for related matters

The Act clearly spells out that there is no excuse for domestic violence and that there can be no “consent” to acts of domestic violence or dismissal of them as the “ordinary wear and tear of marriage”. However, the Act does not mention marital rape

The Prohibition of Female Genital Mutilation Act (2010) Areas of Focus The Act provides for the prohibition of female genital mutilation (FGM), the prosecution and punishment of offenders and the protection of victims as well as girls and women under threat of FGM and related matters. The Act criminalises the carrying out or attempting to carry out of FGM on oneself or another as well as procuring, aiding, abetting or participating in the act of FGM.

Implementation of this law remains limited

The Reproductive Health Policy (2005) Areas of Focus The Policy prioritises:

Safe motherhood, including breastfeeding and nutrition, pre-natal care, safe delivery and post-natal care;

Information, education and counselling on reproductive health and sexuality;

Abortion and post-abortion care;

Family planning

Adolescent sexual and reproductive health including emergency contraception, voluntary counselling and testing and care for HIV/AIDS and other STDs, including support to the prevention of and protection from harmful traditional practices such as female genital mutilation.

The policy seeks to make SRH programmes and services accessible and affordable to the majority of target groups and to promote sexual and reproductive health rights

The Uganda Food and Nutrition Policy (UNFP) 2003 Areas of Focus The overall goal of the UFNP is to ensure food security and adequate nutrition for all people in Uganda, for the benefit of their health as well as their social and economic wellbeing. The overall objective of the policy is to promote the good nutritional status of all people in Uganda through multi-sectoral and co-coordinated interventions that focus on food security, improved nutrition and increased household incomes. Some of the key specific objectives are:

Ensure the availability, accessibility and affordability of food of sufficient quality and in sufficient quantity to sustainably satisfy the dietary needs of individuals

Promote good nutrition among all populations

Incorporate food and nutrition issues into national, district, sub-county and sectoral development plans

Ensure that nutrition education and training is incorporated into formal and informal training

Create an effective mechanism for multi-sectoral coordination and advocacy for food and nutrition

Adequate food and nutrition is a human right

Child survival strategy for Uganda (2008-2015) Areas of Focus The strategy prioritises high-impact child survival interventions with focus on malaria prevention and treatment, the appropriate treatment of major childhood diseases, vaccinations against preventable diseases, nutrition interventions, newborn health and care, Nevirapine and replacement feeding, water and sanitation interventions and interventions targeted at reducing maternal mortality and lowering fertility rates.

2. Selected Literature on Nutrition

GoU (2011) Uganda Nutrition Action Plan 2011-2016

Many of the nutritional problems that women and children experience in Uganda are hidden

Child malnutrition in Uganda remains largely a “hidden problem.” Most children affected are moderately malnourished, the identification of which is difficult without regular assessment. Micronutrient deficiencies are similarly difficult to detect

Inadequate political commitment to and public funding for nutrition has limited the development of the required policies and legislation to create an enabling environment for increased investment in nutrition

MoH (2010): Health Sector Strategic Plan III 2010/11-2014/15

Anthropometric and other equipment for managing and monitoring nutrition programmes is found in very few health facilities

Historically low prioritisation of and commitment to nutrition in the health sector has




led to inadequate resource allocation, both human and financial

Nutrition is a cross-cutting issue and requires the involvement and effective coordination of multiple sectors and stakeholders

WFP and UNICEF (2014): Food Security and Nutrition Assessment (FSNA) in Karamoja

Two-thirds of households across Karamoja region exhibit inadequate food consumption

A clear deterioration of food consumption patterns across Karamoja was seen in the period February-June 2014. During this time, the proportion of households with adequate or acceptable food consumption decreased by more than 10%

A sizeable percentage of households report practising extreme coping strategies such as consuming seed stock and begging

The prevalence of wasting in most districts is serious (>10%). Moroto has the highest prevalence of wasting (22.2%) and is categorised as critical. In Moroto the prevalence of wasting is nearly triple that of the national average

The highest prevalence of underweight (wasting and severe wasting) among mothers is seen in Amudat, Napak and Kaabong districts

UNICEF (2013): Food security and nutrition assessment in Karamoja

High levels of malnutrition were observed in all districts of Karamoja

The rate of exclusive breastfeeding of children under 6 months was 71.9% in pooled analysis with Kotido having the highest prevalence (83.7%) while Nakapiripirit (58.3%) and Amudat (58.3%) had the lowest prevalence

Overall, the initiation of complementary feeding was timely in most of the districts. Among children aged 6-8 months, only 8.8% of had not received any complementary food in the 24 hours preceding the survey

Over 50% of children aged 6-23 months in all districts combined had a low or moderate Individual Dietary Diversity Score (IDDS) with the worst district being Moroto where 72.8% of children had low IDDS

In pooled analysis, 58% of children and 50% of mothers were anaemic

Body Mass Index (BMI) measurements indicated that 19.8% of mothers were wasted while 3.4% were overweight or obese

3. Selected Literature on SRH and Population Growth

GoU (2008) National Population Policy 2008

Uganda has a very young population, with a large number of children compared to a relatively small number of people of working age

The current rate of population growth is unsustainable given the relatively slow growth of the economy and the already high levels of poverty and low living standards

Uganda has a weak and vulnerable health system as well as a severe shortage of human resources for healthcare provision

Uganda will, sooner rather than later, enter a demographic window of opportunity which if not planned for, may result in a demographic burden

Increased budgetary allocation and better focused and targeted investments are needed in the areas of safe motherhood and child survival

Community mobilisation and empowerment as a means of building capacities at grassroots level should be implemented and should receive the attention they deserve

Existing laws have not been sufficiently reviewed to promote positive aspects of Ugandan culture and discourage negative ones in order to enhance the status and welfare of women and children

UNFPA (2014): Assessing the cycle of accountability for sexual, reproductive, maternal, neonatal and child health (SRMNCH) and human rights in Uganda

Access to SRMNCH services which could avert morbidity and mortality in women, e.g. family planning and adolescent health services are limited and abortion is “criminalised”

High maternal and infant mortality rates, adolescent health concerns, FGM, domestic violence, issues surrounding safe abortions and access to family planning services have featured prominently in universal periodical reviews and reports by special rapporteurs

Laws such as the Marriage and Divorce Bill and Sexual Offences Bill remain pending on the floor of Parliament

SRMNCH is elaborately articulated in Uganda’s national plans, policies and strategies, although such commitments have not always translated into good SRMNCH outcomes

Government spending on health remains far below the Abuja commitment to spend up to 15% on health. In past decades the percentage of total government expenditure has hovered around 7.4-9%

Reproductive and maternal health accounts for 12% of all health expenditure in Uganda to which households contribute 48.7%, largely through the purchase of reproductive health commodities

Newborn and Child Health accounts for 14% with households contributing up to 68.5% as out-of-pocket payments

Basic infrastructure such as electricity, water, communication, means of referral,




adequate staff quarters and security (especially at night) remain obstacles to the running of 24-hour quality services (including emergency obstetric care), especially in remote and rural areas in health facilities

Across the board, human resources for health are lacking, especially among critical SRMNCH staff

Morale among health workers is low, promotional career opportunities (especially for midwives) are limited and overall, the distribution of staff is skewed toward urban areas and disregards rural, poor and hard-to-reach areas, despite recent deliberate government effort to recruit and retain staff

At national level, coordination of SRMNCH programmes is relatively efficient but the quality and depth of supervision and mentoring remains questionable at the periphery where SRMNCH services are sorely needed

Good development practice requires that the sustainability of interventions be dependent on ensuring the protection of gains achieved, either by formal or informal mechanisms

Gaps exist in SRMNCH legislation and in the interpretation of existing legislation (e.g. for safe abortions)

MoH (2014): Uganda Family Planning Costed Implementation Plan 2015-2020

Uganda has a high level of unmet need for family planning in that many women who want to delay or limit childbearing are currently not using any method of family planning

Current staffing, skill levels and service structures within the Ugandan healthcare system do not provide adequate or equitable family planning services to the population

There is need to maintain a robust and reliable supply of contraceptive commodities to meet clients’ needs, prevent stock-outs and ensure contraceptive security

Discrepancies exist between the overall positive policy environment for family planning and the allocation of national financial resources to meet need for family planning services

Stewardship, management and accountability for family planning services are weak On-going interventions and remaining gaps in satisfying existing and creating additional demand

The National Family Planning Advocacy Strategy 2005-2010 is in place, but is due for review

A policy for the community-based distribution of injectable contraceptives was developed and piloted, but there has been no optimal scale-up of the intervention

The male involvement strategy for supporting sexual and reproductive health and rights is in place, but the male action groups created in some districts still need to be introduced throughout the country

Momentum and advocacy for increasing family planning budgets at national and lower local government level should be sustained

National champions exist but the plan should be extended to district and community level

On-going interventions and remaining gaps in service delivery and access

Service providers in both public and private health facilities have been trained in the provision of long-acting family planning methods through a public-private partnership; however, this training needs to be scaled up

Several models of service delivery are employed, including routine service provision, outreach, social franchising (through the private sector) and community-based distribution of commodities

Efforts to scale up service delivery using task sharing have been implemented, such as community-based distribution of injectable contraception by village health teams, tubal ligation by trained clinical officers and the provision of long-acting family planning methods by midwives; however, this has been mainly done on a pilot basis

Promotion of long-acting family planning methods through public-private partnerships is beginning to result in increased uptake of these methods

Innovations such as voucher schemes, postpartum IUDs and postpartum family planning are increasing access

Integration of family planning into other services is crucial to the scale-up of family planning service provision and coverage

On-going interventions and remaining gaps in contraceptive security

A single harmonised national quantification for all sectors (public, PNFP, private and social marketing) exists

Monitoring of stock levels is strong at central level, but coordination roles must be supported

Institutionalisation of alternative strategies is still on-going

The second major supplier of emergency supplies, Joint Medical Stores, does not carry contraceptives

GoU and partners are gradually working toward the transition from a “push” to a “pull” system for lower-level facilities

Involvement of the private sector in supply planning and commodity tracking




remains inadequate

Real-time reporting of consumption and stock status at facility level remains inadequate

Task sharing/shifting strategies are being used to address human resource issues in the short to medium term

On-going interventions and remaining gaps in policy and the enabling environment

The GoU’s FP2020 commitments strongly advocate improvement of the policy environment for family planning

Family planning commodities are included in the Uganda Implementation Plan for Life-Saving Commodities for Women and Children

Key SRMNCH-related policies integrate family planning holistically, but task sharing of family planning is not yet operationalised

Family planning has yet to be concretely embedded in broader development issues and the addressing of family planning on a multi-sectoral level across line ministries remains a challenge

On-going interventions and remaining gaps in financing

Budget allocation from the GoU to the health sector has increased by 20% over the period covered by the Health Sector Strategic Investment Plan

Recent family planning advocacy efforts have seen positive effects in terms of increased financial resources, especially for commodities. More advocacy is required for districts and lower-level local governments

Clear systems to track financial resources to “the last mile” need to be established Progress and remaining gaps in stewardship, management and accountability

Strong collaboration exists between the MoH and private sector partners, especially private not-for-profit organisations

Some coordination of inter-Ministerial efforts is on-going

Civil society involvement in accountability monitoring is weak or non-existent

Family planning indicators are not usually present in key documents, especially in other related sectors

Supervisory and management skills of health staff need to be strengthened

UNFPA (2010): Uganda Country Programme Action Plan 2010-2014

Major population challenges in Uganda include rapid population growth, a very young and highly dependent population, high infant and maternal mortality and high total fertility rates

Many of the underlying causes of high fertility and maternal mortality rates relate to socio-cultural practices and values, including women’s low status and low male involvement, but also the generally limited use and accessibility of modern contraception

There is limited capacity for midwifery service delivery and transfer of skills is hindered by the absence of counterpart personnel

Linkages between SRH and HIV/AIDS are weak, with HIV programmes still delivered in a vertical manner

4. Selected Literature on Gender Equality

UNFPA (2014): Assessing the cycle of accountability for sexual, reproductive, maternal, neonatal and child health and human rights in Uganda

Violations of women’s rights to equality and non-discrimination are sadly central to women’s experience of sexual, reproductive and maternal health and impact negatively on the survival of their children, both born and unborn

Uneven power dynamics often prevent women from negotiating voluntary, non-coerced, protected sex

Gender inequalities limit women’s access to education, thereby depriving them of the basic literacy and numeracy skills required for economic independence, as well as fundamental information on sexuality and health

Bandiera, O.N., Buehren, R., Burgess, M., Goldstein, S., Gulesci, I. Rasul & M. Sulaiman (2014)

Uganda has one of the highest rates of unemployment among young women (86% as opposed to 58% in 14 sub-Saharan countries)

There exist high gender disparities in unemployment rates among youth

Interventions targeting the transition of adolescent girls from school to employment can offer a cost-efficient and effective tool to policy makers

Focus on the development of self-employment skills among adolescent girls is crucial to the addressing of gender disparities in youth unemployment rates

Campos, F., Goldstein, M., McGorman, L., Muñoz, B.A & Pimhidzai, O. (2013)

There is need for women to break into male-dominated sectors

Information must be provided early to youth about the profitability of certain sectors

Supportive engagement is needed with individuals who can guide female entrepreneurs

Efforts should be made to facilitate active exposure to sectors through apprenticeship

Figures of influence should be engaged within communities to avoid potential opposition




Ali, D., Bowen, D., Deininger, K. & Duponchel, M. (2014)

Women in Uganda contribute 56% of crop labour

On average, plots managed by women produce 17% less (in terms of gross value of outputs) per acre than plots managed by men or jointly by other family members

Women’s childcare responsibilities, access and returns to hired labour and lower levels of schooling all serve to widen the gender gap

The gender gap in the agricultural sector is driven primarily by differences in the returns that men and women receive from productive factors

Female plot managers are less likely to receive extension services and technical information

There are differences between men and women in terms of i) the availability and use of farm labour and ii) access to and use of non-labour inputs

Female plot managers complete on average 1.9 fewer years of schooling than male managers

Agricultural policy intervention should help women overcome their labour disadvantages, re-examine the extension service model, expand women’s use of improved inputs and invest in adult education for women

Policies should aim to further ease women’s childcare responsibilities (e.g. through community-based childcare), improve the accessibility and quality of farm labour (e.g. through labour cooperatives or vouchers), secure equal access to and use of non-labour inputs and support women’s education and training

World Bank (2005): A gender perspective on legal and administrative barriers to investment, International Finance Corporation/World Bank

Divorced women, widows and married female heads of households are particularly prone to poverty

Delays in seeking and receiving care are linked to important gender differences in access to and control of resources, as well as to differences in decision making at household level

The disparate and unbalanced roles of men and women in the Ugandan economy and household have a negative impact on growth due to the disproportionate cost borne to women as a result of reproduction and household management responsibilities

The following gender-related barriers to access to justice have been identified: o gender-biased laws (notably concerning divorce, adultery and rape) and

differences in evidentiary (burden of proof) requirements; o the administration of legal issues including physical access and delayed

access to justice; o the role of culture, religion and patriarchy in community management;

power imbalances in the household and community dispute resolution which fails to be gender-inclusive or gender-responsive

Women tend to be economically dependent and there are differences between men and women in the control of economic resources and assets

Women do not always share the benefits of production

Strong links exist between certain traditional practices (notably polygamy and dowries) and women’s heightened risk of HIV infection

Women’s economic dependency and cultural subordination underpin their vulnerability to domestic violence and HIV/AIDS

There is need to address the linkages between culture and poverty with particular reference to issues of dowry, polygamy, widow inheritance, the prevalence and costs of domestic violence and their impact on poverty

Uganda Participatory Poverty Assessment Process/Second Participatory Poverty Assessment (UPPAP/PPA II), 2002

There is a marked gender gap in control over resources and decision-making power, to the detriment of women

The workloads of men and women differ significantly, again to the detriment of women

Implications for gender-based differences are far-reaching and intertwined in complex and multi-dimensional ways that affect virtually every aspect of life

MOGLSD (2007): National Action Plan for Women 2007 Poor health among women is mainly due to a number of sexual and reproductive health (SRH) issues which include among others:

Limited control over their sexuality

Early marriage and pregnancy among adolescents

Poor or no access to emergency health services

Limited awareness of sexual and reproductive rights and responsibilities and capacity to enforce them

Limited or no access to family planning information and services

Inequalities in power relations at household level that affect women’s ability to make health-related decisions

The World Bank (2014): Gender, Economic Productivity and Development in Uganda: Recent Evidence and Policy Conclusions




Africa Region Gender Innovation Laboratory/World Bank

Gender-related norms, perceptions and practices fuel gender inequality

Women are marginalised in business ownership, skills development, access to financial resources, non-agricultural employment and inheritance rights

There is a marked gender gap in access to and control over productive resources

Women have less access to health and education services than men

Women who do manage to make the transition to paid employment face additional challenges as their revenues are much lower than those of male counterparts

Bukuluki, P & Mugisha, J. (2011). Knowledge, attitude and practice survey on gender equality in selected districts in northern Uganda, Acholi sub-region (CARE International Uganda)

Study results indicate that generally, perceptions of and attitudes to gender equality and human rights in the quantitative domain of the study were positive

The attitudes of respondents did however condone sexual and gender-based violence and were susceptible to blaming and stigmatising women who speak out and demand their rights in the context of violence

The results of this study indicated that women have developed tendencies to accept male dominance (masculinity) in sexual relations

In terms of gender roles, study findings indicated that both men and women held perceptions that assign subordinate positions to women in relation to men

Knowledge of existing policies and laws on gender equality and human rights was relatively low

Gibson, S., Kabuchu, H., Watkins, F. (2014): Gender Equality in Uganda: A situation analysis and scoping report for the Gender Development Partners’ Group Department for International Development (DfID)/IrishAid

There are multiple pathways to empowerment – for each country and for individual women

It is clear that a growing economy does not necessarily bring greater gender equality

A strong women’s movement is essential to making progress on a number of key frontiers: women’s equality in the workplace, reduction of GBV and ensuring greater equity in national budgets, to name a few

Uganda has the highest proportion of young people of any country, and girls and young women have a vital role to play in sustaining Uganda’s growth and development

There is considerable scope in Uganda to look across traditionally defined sectors to identify potential multiplier areas, such as changing social norms and working to reduce the vulnerability of adolescent girls in secondary schools, developing economic opportunities for women in rural areas and building their confidence to use legislation to access resources and support

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