Background
Globally, countries are increasingly prioritizing the reduction of health inequalities and provision of
universal health coverage. While national benchmarking has become more common, such work at
subnational levels is rare. The timely and rigorous measurement of local levels and trends in key health
interventions and outcomes is vital to identifying areas of progress and detecting early signs of stalled or
declining health system performance. Previous studies have yet to provide a comprehensive assessment
of Uganda’s maternal and child health (MCH) landscape at the subnational level.
Methods
By triangulating a number of different data sources – population censuses, household surveys, and
administrative data – we generated regional estimates of 29 key MCH outcomes, interventions, and
socioeconomic indicators from 1990 to 2011. After calculating source-specific estimates of intervention
coverage, we used a two-step statistical model involving a mixed-effects linear model as an input to
Gaussian process regression to produce regional-level trends. We also generated national-level
estimates and constructed an indicator of overall intervention coverage based on the average of 11
high-priority interventions
Results
National estimates often veiled large differences in coverage levels and trends across Uganda’s regions.
Under-5 mortality declined dramatically, from 163 deaths per 1,000 live births in 1990 to 85 deaths per
1,000 live births in 2011, but a large gap between Kampala and the rest of the country persisted. Uganda
rapidly scaled up a subset of interventions across regions, including household ownership of insecticidetreated
nets, receipt of artemisinin-based combination therapies among children under 5, and
pentavalent immunization. Conversely, most regions saw minimal increases, if not actual declines, in the
coverage of indicators that required multiple contacts with the health system, such as four or more
antenatal care visits, three doses of oral polio vaccine, and two doses of intermittent preventive therapy
during pregnancy. Some of the regions with the lowest levels of overall intervention coverage in 1990,
such as North and West Nile, saw marked progress by 2011; nonetheless, sizeable disparities remained
between Kampala and the rest of the country. Countrywide, overall coverage increased from 40% in
1990 to 64% in 2011, but coverage in 2011 ranged from 57% to 70% across regions.
Conclusions
The child and maternal health landscape in Uganda has, for the most part, improved between 1990 and
2011. Subnational benchmarking quantified the persistence of geographic health inequalities and
identified regions in need of additional health systems strengthening. The tracking and analysis of
subnational health trends should be conducted regularly to better guide policy decisions and strengthen
responsiveness to local health needs.