Feminist Knowledge | Other Resources

Gender Equity and Equality in Health: a Ugandan Analysis

By Margaret Kemigisa

Acknowledgements

Writing this piece of work would not have been possible at this time without the financial support of the African Gender Institute. The work has not only helped me to explore further areas for study, but also heightened my interest on women’s health issues. I am grateful to the AGI staff for their material and moral support, and to my fellow Associates for their inspiration and teamwork. I am particularly grateful to Mulumebet Zenebe and Nikoli Zezumah for proof-reading my first draft. I also thank Ms Elise Levanda of the Progressive Primary Health Care Network for her discussion of the paper at the AGI Associates Conference.

List of Acronyms and Abbreviations

CAO Chief Administrative Officer

CBOs Community-based Organisations

DANIDA Danish Agency for International Development

DHSP District Health Services Project

DSC District Service Commission

FOWODE Forum for Women in Democracy

HIV/Aids Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome

HSSP Health Sector Strategic Plan

LC Local Council(s)

LG Local Government

MFEP Ministry of Finance and Economic Planning

MFIs Micro Finance Institutions

MOES Ministry of Education and Sports

MOGCD Ministry of Gender and Community Development

MOH Ministry of Health

MOLG Ministry of Local Government

NAPW National Action Plan on Women

NGO Non-governmental Organisation

PFA Platform for Action

PHC Primary Health Care

SDS Service Delivery Surveys

STI/STD Sexually Transmitted Infections/Diseases

TBAs Traditional Birth Attendants

UNDP United Nations Development Programme

UNICEF United Nations Children’s Fund

UPE Universal Primary Education

USAID United States Agency for International Development

WHO World Health Organisation

Introduction
This paper presents a preliminary analysis of the issues of gender equity in health and health care in Uganda. It provides an overview of the health care delivery framework, the actors involved, and also examines the health status of women, as well as access to health services and participation in decision-making in health planning. While critical gender analysis is limited in the health sector, by examining some of the issues of gender equity in the sector, I hope to explore ways of understanding the inequality of health between women and men.

There are important structural issues that need to be considered in promoting gender equity and equality in health in Uganda. These not only relate to family and community, but also institutional arrangements through which health is influenced and health care provided. Until recently, the health policy had not focused on gender issues in health. The emerging concerns for gender and health, as seen in the 2000 National Health Policy and health sector strategic plan (HSSP), are promising, but gender equity is clearly not yet being addressed in health and health care. While there is limited literature on advocacy strategies for gender and health issues, existing work by NGOs on women’s health shows the need to re-examine current advocacy strategies on women’s health. Women are significantly inequitably positioned with regard to accessing health resources and other vital productive resources that would enhance their health. This is partly attributed to structural factors such as culture and tradition, political participation, and administration. A look at government’s commitment to women’s health indicates that there has been a cursory attempt to address gender issues in health and health care, often as a response to international obligations. This paper therefore seeks to establish a comparative analysis of health and gender in order to highlight the importance of gender equity in health and health care.

The paper attempts to answer the following questions:

1) What is equity, and how can it be applied in understanding gender equity in health, policy and advocacy issues in health in Uganda?

2) Is gender equity a concern in health care planning and service delivery in Uganda?

3) What are the challenges and constraints that prevent the realisation of gender equity in health in Uganda, and how can these challenges be addressed?

The first section of the paper gives a background to the health system in Uganda, looking at how the past affects the present, and considering policy issues and outcomes. An overview of health management and crises faced in the past is provided.

The second section defines key concepts and provides a conceptual framework for analysing gender equity in health in Uganda. A framework for understanding issues of equity in relation to advocacy and policy is also provided based on the understanding of health as a state of “complete physical and mental well being and not just the absence of disease”.

The third part of the paper comprises an analysis of gender equity in health in Uganda, as informed by this conceptual framework. The remaining sections attempt to analyse the sources of gender inequalities in health, the opportunities for promoting gender equity in health, and the challenges facing efforts to promote gender equity in health. In the final section, possible means of addressing challenges and constraints to gender equity in health are provided. These are by no means the only possible strategies, but rather possible solutions in relation to the constraints and challenges identified by this paper.

Overview of Uganda’s health system

This section provides an overview of the health system in Uganda and gives insights into the policy orientations underlying health care delivery. The health sector consists of a number of health care providers. These include public (government) and private modern health care sectors, traditional health practitioners, households and civil society organisations. Excluding the households, statistics indicate that there are about 1637 health facilities in the country, comprising 102 hospitals, 671 health care centres, 16 maternity units, and 848 dispensaries and sub-dispensaries. The national government controls 71% of the health facilities, while NGOs (including private facilities) control the remainder. It is estimated that the national health care ratios for curative medical facilities are 798 persons per bed and 12,500 persons per health facility. In addition to these curative services, government as well as NGOs provide preventive and health-promotion services, including health education and advocacy. Advocacy work is mainly undertaken by NGOs. The Ministry of Health (MOH) itself includes various departments, autonomous bodies, professional councils, and other entities providing different services, including nine regional referral hospitals (see Appendix 2).

The health policy framework
Primary health care (PHC) is considered the “ basic principle and strategy for national health development” (MOH 1999). The World Health Organisation (WHO) presents a PHC model that takes into consideration the following critical principles:

· the need to build self-reliance at personal and community level

· intersectoral collaboration

· efficiency in resource use

· attention to vulnerable groups to effect equity in health outcomes and health care access;

· appropriate technology

· support for community participation in health care programmes and in health and development.

In pursuing a PHC approach, the government is committed to adopting the above principles in the delivery of health. Issues of gender equity are thus now accorded the attention they deserve. Indeed, the National Health Policy considers gender responsiveness in the national health system to be one of the central principles of this policy (see Appendix 1). This is further reflected in the HSSP, where under the decentralised health care system, the community empowerment and participation component gives consideration to gender-sensitive community participation and empowerment strategies, such as:

· mobilising communities using gender-specific strategies

· attention to gender balance in the selection of community health workers

· gender sensitive training in the human resource development component (MOH, 2000).

The health care delivery system is managed at two levels, central government and local government. At central government level, the MOH has the following functions:

· policy formulation, setting of standards and quality assurance

· resource mobilisation

· capacity development and technical support;

· provision of nationally co-ordinated services, e.g., epidemic control;

· co-ordination of health services

· monitoring and evaluation of the overall sector performance

· training (MOH, 2000).

Although the structure of health care delivery changes according to the needs of the time, the above provides the main divisions within the higher level of government through which health planning and delivery of services is undertaken. It is through this structure that central government is expected to fulfil its roles. The Health Services Commission is an independent organ established under the Constitution, Article 169 (1). Its roles include:

(a) advising the President on performing, in relation to health services, his or her functions under Article 169 of the Constitution;

(b) appointing persons to hold or act in office in the health service, including the power to confirm such appointments, to exercise disciplinary control over those persons, and to remove them from office;

(c) reviewing the terms and conditions of service, standing orders, training and qualifications of members of the health service and matters connected with their management and welfare, and making recommendations on them to the government (Republic of Uganda, 1995).

Within local government, health planning is provided under the Local Council (LC) structure, a five-tier system. comprising five levels of political governance (LC I – LC V). Within local government, each district is responsible for:

· implementation of national health policies

· planning and management of district health services

· provision of disease prevention, health promotion, curative and rehabilitative services

· vector control

· health education

· provision of safe water and environmental sanitation

· health data collection, management, interpretation, dissemination and utilisation (MOH, 2000).

The different health care professionals are either employed within the macrostructure of health care delivery or at the LG level. They provide services within the various institutions, such as public hospitals, private health care units, church-based hospitals and other NGOs. Community-based organisations (CBOs) generally operate within localised settings.

Private health care
Health care by the private sector comprises both the profit-making entities and non-profit-making organisations. The private profit-making sector comprises clinics, nursing homes, pharmacies and drug shops. These are mainly concentrated in the urban centres. According to Asiimwe and Lule (1992), the non-profit-making sector is well-equipped, with resources coming from donors and health service fees, as well as training fees. Although the profit-making health units are well-equipped, unqualified personnel render their services questionable. The distribution of private services is not known, and this makes it difficult to monitor their activities. However, a look at Table 1 shows the considerable contribution by the private sector to health care provision.

Table 1: Government and non-government health units in Uganda by 1987

Source: UNICEF, 1989

It can be seen that government owns most of the health infrastructure. Most hospitals are located in urban areas, but with the exception of some health units, most other health infrastructures are located in trading centres

The NGO sector and health care provision
Previously, the non-profit-making sector comprised missionary and community organisations providing a variety of services, including hospitals and health education programmes. The missionary centres also provided training of health personnel. However, with increasing civil society participation in development programmes, NGOs and CBOs now undertake healthcare and/or development programmes at different levels. They include national and local NGOs, as well as foreign and international organisations. Missionary hospitals were historically established under their religious affiliations, mainly Protestant and Catholic. For almost 100 years, these have provided curative health care to many Ugandans. They still account for about 45% of the hospital-bed capacity of the country.

International NGOs, and donors participate in health care in a variety of ways. Donors, for example, have been heavily involved in the health policy-making processes. In the past, they have provided financial support to government in the form of grants and loans to rehabilitate health sectors. International organisations also provide funding to the government, but also directly fund the activities of individual NGOs and CBOs. Most NGO and CBO activities focus on preventive health care programmes, such as health education. A look at the support given by some shows that most of the support cuts across different health care programmes, and is aimed at disease prevention.

· The United Nations Children’s Fund (UNICEF) funds among others, the Uganda Expanded Immunisation Programme, and Control of Diarrhoea Diseases (CDD), as well as sanitation projects.

· The Danish International Development Agency (DANIDA) previously funded the Essential Drugs Programmes.

· The World Health Organisation (WHO), the United States Agency for International Development (USAID), UNICEF and the United Nations Development Program (UNDP), among others, fund various Aids prevention programmes.

· Other health-related programmes with external assistance include Water Aid Program, Family Planning Association of Uganda, Uganda National Program of Action for Children (UNPAC), Programme to Enhance Adolescent Reproductive Health (PEARL).

· The World Bank funded, among other projects, the Hospital Rehabilitation Programme.

In conclusion, the policy framework for health service delivery shows that equity and quality health care are priority issues for the government. While the health policy emphasises community ownership of health plans, the vertical linkages suggest control by outside leadership and limited community participation. PHC is not a new phenomenon in the health sector, and neither is local government planning. PHC has formed the framework for health care delivery since 1993, and local government planning has been emphasised since the late 1980s. Overall, these approaches did not embrace gender equity, but now there is recognition that in order to realise the policy aims of equity in health, gender inequalities must be fully addressed.

The above discussion has also shown that the private sector plays a significant role in the provision of health services, even though the focus tends to be on treatment rather than prevention and health promotion. Given the profit-driven approach, private sector practitioners may fail to address gender inequality issues. Thus government, NGOs and development partners remain the main actors in the promotion of gender equity and equality in health care. The role of professional associations is also important in this regard

Gender, Equity and Advocacy in Health Policy

Equity is one of the principles of the national health policy in Uganda. This is not a new concern. In the colonial period (1895–1961), inequality of access to health care was a major policy issue, which was addressed by providing free treatment. When Uganda gained independence in 1962, equity of access and unequal health status were identified as priorities, as can be seen in the policy issues of 1962–1970. From 1986 until the present, the issues of equity of access have remained critical in health care policy. In spite of these commitments, realising equity and equality in health and health care has remained elusive for most of the population. Of particular importance in this paper is the issue of gender equity in health and health care. Gender analysis in health care has not received adequate attention, and until recently, the Ministry of Health did not specifically address gender concerns in policy development. The purpose of this section is to provide a framework of the key concepts that guide this analysis.

Gender: In undertaking gender analysis in health equity issues, one has to look at the inequalities that stem from being fe/male, unequal power relations among wo/men and between the sexes. A gender analysis would, for example, seek to understand differences in health status, and access to health services that derive from the social construction of being fe/male. Does being fe/male influence one’s attitude to healthcare, or does it dictate the work environments that predispose one to specific health hazards? While it is easy to see the differences between wo/men in terms of health status and access to health services, addressing these differences effectively requires critical analysis of the causes of these differences. Gender can be used to understand the social construction of health and a comparative approach to the health contexts of wo/men.

Equity and gender equity: Equity is a broad term that can be applied in diverse fields. According to the Oxford English Dictionary, equity refers to justice or fairness in treatment or opportunities. This reflects the sense of equal opportunities. In the understanding of gender equity, it therefore follows that equal opportunity to access development resources for wo/men is critical. Gender equity may therefore be achieved through policies that promote equal opportunities among wo/men. Literature on equity in health and health care identify the critical aspects of equality of access, equality of utilisation, equality of distribution, equality of need and equality of health. Equity is the gauge against which equality among populations is measured (Culyer 1993; Lairson et al 1995; Denton and Walters 1999; Blackmore 1998). The meaning of equity adopted in this paper is that of fair opportunities in accessing health resources and other resources that enhance the well being of people. Gender equity as used here, refers to equal opportunities for men and women in accessing health and health related resources. If women or men are under-represented in any given indicator of national health, then more resources should be allocated to the affected group (the under-represented one). As the review will indicate, the group mostly inequitably represented in accessing health resources and other vital productive resources that would enhance their health, is women.

Advocacy: The term advocacy is normally used to promote equal rights among wo/men in different fields; it also suggests championing a cause for the marginalised groups in society. Many NGOs involved in women’s health identify advocacy as either a strategy or an activity aimed at realising better health for women. I view advocacy as a strategy to speak on someone’s behalf, either with or without their permission, for a just cause. The aim is to promote positive changes in policies (resource allocation), which will eventually lead to increased investment in a given sector. Advocacy in health and in other sectors aims to influence policy change to realise desired outcomes. This means shifting resources in order to address the desired change. In this context, advocacy for gender equity means acknowledging the inequities faced by wo/men in health, and making conscious efforts to redress the resulting inequalities. It calls for increased resource allocation to the marginalised group.

Any meaningful advocacy requires analysis of the problem and existing policy frameworks, and assessing the advocacy issue in terms of the required change, stakeholders, and advocacy strategy with regard to related issues. While the case for advocacy on women’s health in Uganda has received some policy focus, considerable progress can only be realised if there are sustained efforts in seeking gender equity in the health sector.

Collaboration is essential in advocacy for health. It is vital that professionals and politicians work together to address the causes of gender inequalities in health. Collaboration also calls for the examination of the state of health of wo/men and an understanding of the reasons for gender differentials in health status, among other things. A gender analysis will therefore take into consideration the structural view of health inequalities. In the following section, I attempt to examine the health status of wo/men, their access to health services and representation in health professions and health management structures.

The Need for Gender Equity in Health in Uganda

The state of health in any country’s health care system provides a measure against which effectiveness of health care delivery is gauged. Although this is usually indicated by the burden of disease in the population, health is not confined to disease. Understanding the state of health of wo/men provides the impetus to design health care programmes that address specific health concerns. However, this approach is likely to suffer the limitations of focusing on the symptoms and treatment and not underlying cause of the problems. Thus, gender analysis is vital in understanding wo/men’s health issues. The need for gender equity and equality in health and health care in Uganda can be demonstrated by the persistent inequalities among wo/men regarding specific health aspects. This section looks at gender variations in health status, access to health services and representation in the health professions and power structures of the health system and other sectors.

Health status of women and men
Data for the key health indicators shows the gendered disparities that exist in the health statuses of men and women in the country. Uganda’s women constitute 51% of the country’s population of 22, 210, 400 people. The population growth rate of women is higher than that of men. For example, between 1980 and 1991, the growth rate for women was 2.6%, while that of men was 2.4% (MGCD, 1998). This explains why the total number of women continues to be higher than that of men over the years. Infant mortality for boys of 87.4 deaths/1000 live births is higher than that of girls at 84.9 deaths/1000 live births (World Bank 1999). Maternal mortality remains one of the worst in the world at 506 deaths per 100,000 live births, constituting about 17% of deaths among women aged between 15-49 years (World Bank 1999; Ministry of Health 2000). Fertility rates remain high at 6.9 children per woman, while contraceptive use is only 15%. With high fertility rates and low contraceptive use, women remain susceptible to maternal mortality.

Although women form the majority of the population, they are under-represented in terms of resource access in all sectors. Although, as in most parts of the world, women in Uganda enjoy greater longevity than men, and are less likely to die at birth, they face a greater risk of morbidity than men (World Bank 1999). According to the 1991 data, life expectancy for women is estimated to be 50.5 years, whereas it is 45.7 years for men (Ministry of Finance and Economic Planning 1991). However, this has declined over the years, and has been projected at 42 years as a result of HIV/Aids (World Development Report 1997).

Although there is limited data on current HIV infection rates among women and men, between 1990-93 and 1994-95 the infection rate among pregnant women decreased by 29% (from 21% to 15%), and decreased by 35% in both 15-19 and 20-24 year olds. Existing data indicates that more women than men are infected with HIV (see Figure 3). Women’s greater vulnerability to HIV is attributed to culture, low economic status and biological make-up. Due to their dependence on men, as well as the gendered roles assumed during sexual intimacy, women may experience difficulty in negotiating the use of condoms or other methods to control HIV infection, and prevent other STIs (World Bank 1999).

Source: UNAIDS, 2000

This information suggests the following gender issues in health status of wo/men:

· Women live longer than men

· Women experience poorer health than men

· More women are infected with HIV than men

· Population growth rate for women in higher than that for men

· Infant mortality of boys is higher than that of girls

· Maternal morality is very high at, 506 per 1000 live births

· Fertility rates are very high, putting women’s health at risk

· There is limited use of contraceptive, implying that women’s risks of unwanted pregnancies are high.

The control of diseases largely depends on access to health care services including health education and information. In the next section, I briefly examine the population’s access to health services.

Access to health services
Access to trained medical personnel is limited throughout the population. For example, in 1996 the staffing ratios for all types of medical personnel were very low compared to the population needs (Table 2).

Table 2: Staffing ratios by population in 1996

Source: Ministry of Health 1996

Women in Uganda, as in many parts of the world, are believed to be demanding more health services, mainly due to their reproductive role. There are certain health services that are exclusively for women, and from which men benefit only indirectly. These include antenatal and postnatal care. Yet, in spite of their gender exclusivity, these services meet only a small proportion of the demand. It is estimated that only 13.7% of pregnant women receive prenatal care in the first trimester, while only 35% of births take place within a medical facility (see Figure 4). Consequently, about 66% of all births in Uganda are considered high risk (World Bank 1999). Even for those women who are able to access health care during delivery, only a few are attended to by qualified medical personnel.

While there is limited data on gendered access to and use of curative services, there are indications that women tend to rely heavily upon self-medication (usually non-modern), and are most likely to use traditional as well as modern health care systems. This may be due to the high morbidity rates found among women as compared to men (World Bank 1999). A burden of disease health study undertaken in Uganda in 1995 indicated that preventable diseases caused the most deaths (75% of all deaths) in the general population, and that the disease burden was mostly borne by women and children. These included perinatal and maternal conditions (20.5%), malaria (15.4%), acute respiratory tract infections (10.5%), Aids (9.1%) and diarrhoea (8.4%) (Ministry of Health 2000). Others diseases include tuberculosis, malnutrition, trauma/accidents, skin infections, mental health and cardiovascular conditions. Emerging conditions of ill-health include hypertension, cancer, diabetes, mental illness and chronic cardiovascular diseases (Ministry of Health, 2000). However, little is known about the extent of these diseases in the general population.

From the above analysis, one can point to the following gender issues in access to health services:

· Women demand more health services because of their reproductive roles

· There is a very low level of access to medical facilities at time of delivery (35%)

· The majority of women do not have medical assistance during delivery (52%)

· Fewer health units available to men and women. In 1996, there were 12,957 people per health unit

· Fewer trained medical personnel available to the population.

These require various actions to ensure that gender equity and equality in health is addressed.

Gender representation in decision-making and professional positions in the health sector
Gender representation in decision-making and professional positions in the health sector can be a useful gauge to assess equity in the health sector. While little data is available to indicate the gender breakdown of staff in the sector, the majority of women occupy the lower end of decision-making positions. Men occupy all the key positions: ministers, directors, commissioners, and heads of planning and community services.

The low level of representation of women in the health sector correlates with their low overall representation in the total managerial and professional positions within the general labour force. For example, only 0.05% of women are in managerial positions, compared to 0.27 % of the men. Only 0.13% of women hold professional positions compared to 0.45% of men. In professional and technical workplaces, 2.05% of women are employed as managers, compared to 5.05% of men (MGCD 1998). It is only in the agricultural sector that women constitute the highest percentage (81.79%) compared to 68.86% of the men.

The under-representation of women in the lower paying jobs in the health sectors is clearly reflected in some of the district health human resources profiles. In the case of Luweero District, there are about 400 health workers constituting 300 trained and 100 untrained workers. Of these, 80% are female (District Directorate of Health Services-DDHS). However, these are mainly in the lower ranks (nursing aids 122, midwives 51) (Luweero District Development Plan 1999-2000). Women’s contribution in terms of physical labour and the financial costs of health delivery also surpasses that of men (District Delivery Health Survey, Luweero).

In this brief review, the following gender issues are identified:

· Limited data on the representation of wo/men in the health sector

· Men dominate decision-making positions in the health sector

· Women are mainly in the lower-paying professions (nursing)

· More men are enrolled in medical training course than women (see Table 3)

It is important to note that the analysis of gender equity and equality in health care in this section is limited to only a few issues. This is partly due to the fact gender-desegregated data on health is difficult to access. With the exception of data from hospital and health unit records, most health information is not specified according to gender. In this paper, it was not possible to obtain such data for detailed analysis. However, the available data does suggest that women are marginalised within the decision-making structures of the health system, under-represented in medical and related professions, suffer more morbidity, and bear exceptional burdens of disease and health care provision. The sources of these inequalities are explored in the next section.

Sources of Gender Inequalities in Health in Uganda
Given the data cited above, it is clear that gendered inequalities exist in Uganda’s health sector. In the following section, I will attempt to analyse the sources of these inequalities, and explore possible opportunities for addressing them.

Physiological factors have been noted to underlie certain health inequalities, which may be exacerbated by gender inequities (Doyal 1995). For example, because of their biological make-up, women are more easily infected by STIs than men. Social and structural inequalities in the society can greatly impact on health. For example, Anyinan and Stock (1992) argue that colonial administrations in Africa favoured health development along centres of commercial activities, mining, administrative and education centres, giving raise to health disparities between rural and urban areas. However, gender inequalities in health can mainly be attributed to the fact that women do not have the same opportunities to maintain good health or to improve their health that men do. This is clearly reflected in the gendered and unequal access to the resources that enhance health. Furthermore, differential opportunities exist within women as a group, resulting in further variations in health status.

There is widespread inequity among wo/men within different sectors. For example, women's under-representation in labour, education, communication, information, and other economic sectors has undermined their ability to realise their desired levels of well-being. These structural factors feed into the gender inequality in health, which means that reducing gendered disparities in health requires more than simply promoting equal access to health services. This section looks at the issues of differential access to social economic resources and socio-cultural practices.

Differential access to socio-economic resources
Pearce (1992) argues that differential access to income, food, education, leisure, information and other services affects women’s health and well-being quite markedly. She argues that physicians normally do not address these wider social problems and are likely to treat the person and send them back to the very conditions that caused the illness in the first place. Statistics indicate that women are under-represented in major economic activities and underpaid in those activities where they are the major participants. In the agricultural sector, for example, only 7% of Ugandan women own land, the resource that provides basic sustenance. Women access land mainly through what has been termed use rights; consequently, their control over the land is limited. This undermines their decision-making ability to use proceeds from the land, for example, to improve their health. Although women form the bulk (97%) of the agricultural labour force, most of them do not have control over the use of the proceeds from agriculture, except for food consumption within the household and other family subsistence needs.

Access to health services

There are significant gender variations in accessing health services. Some of the factors that determine women’s access to health include:

· A household’s ability to prioritise a mother’s health and allocate adequate resources to it

· Whether women have autonomy over decisions regarding their own health

· Whether women have their own financial resources to cater for their health needs

· Whether women allocate time to attend to their health

· Whether they show an awareness of their personal health needs (World Bank 1999).

The integrated household surveys of 1992-1996 revealed that women were more likely to report illness than men were[1]. However, this was mostly among women of child-bearing years, implying that women would only seek health services for reproductive health matters.

Reporting of illness does not necessarily imply that women would receive the required health service or medical care. The ability to pay often dictates the type of service women may seek out or receive. This is likely to be true for complications experienced in reproductive health. However, no data is available to distinguish between factors that determine choice of treatment for reproductive and non-reproductive health care. What is clear is that expenditure on health services is higher for women of reproductive age than for men of the same age group (World Bank 1999).

The World Bank assessment of equity of access to health services in Uganda (1999) indicated a slightly higher expenditure for treating men’s illnesses compared to that for women. The mean annual expenditure for males and females below the age of 16 years was 4.6 dollars for men and 4.57 for women. For the population aged 16-30, mean expenditure was 1.95 for men and 2.55 for women. This is the age group when women are most likely to be reproductively active, so it is likely that their illnesses are related to reproductive health. For the population above 31 years, expenditure was 5.34 for men and 4.34 for women.

Source: Integrated health surveys 1992-1996

The limited use of preventative and curative services among women is attributed to different factors such as proximity[2], lack of money (Jitta et al 1996) and lack of time[3]. When women earned a higher income, they tended to increase expenditure on their own health, but only if all other important household needs had been met first (World Bank 1999). According to the Ministry of Finance and Economic Planning (1996), other social and demographic factors such as education, age, income or type of health facility did not significantly influence women’s use of curative services. However, factors such as the number of nursing staff at a facility and the availability of in-patient services increased women’s use of health facilities.

Access to education

Gender inequalities in Ugandan education stem from colonial structures that favoured men’s access to full educational opportunities over women. Women were restricted to education for domesticity, which included subjects such as knitting and cooking (Ministry of Education 1992). Later, when women gained access to further education, this tended to concentrate on the arts. It is only recently that there has been a concerted effort to promote girls’ education in science and related fields. This sustained denial of women’s entrance into the education system systematically hindered their access to gainful employment. This inequality continues today, where more men are represented in the education system, particularly at the higher levels and in the science disciplines.

The integrated household survey (1992) indicated education as one of the key factors determining use of curative and preventive health services among women and men. Women, however, form the majority of the non-literate population. In 1995, for example, 57% of rural women were non-literate compared to 29% of the men. In the urban areas, these figures dropped to 24% for women compared to 14% for men (Labour and Social Development [MGL&SD] 1999). Modern health services are geared towards a literate population, and for anyone who is non-literate, attainment of appropriate health care is an arduous task. With increased literacy, matters improve dramatically. One woman had this to say about the benefits of adult education programmes for women in Arua:

“I had been suffering from a toothache for long and when it became unbearable, I went to the hospital. At the hospital, they advised me to go to room number 4. I spent the whole day looking for room number 4 and when finally somebody showed me where it was, the doctor was leaving and told me to come back three days later! So when the adult literacy class started I joined, and now I am sure I will never go through the same experience again![4]”

Table 3: Percentage intake of female/male students in medical courses at Makerere University

Income variations within communities
The link between low income and poor health is widely acknowledged. For many wo/men, lack of income limits their ability to receive appropriate health care. In welfare states, this has been shown by a rise in deaths among pensioners after welfare cuts. Health care costs may include payment for the actual services, as well as associated costs such as medicines, transport and maintenance during illness. Different economic activities within regions dictate the amount of money that a district may have at its disposal for health care expenditure and other services. In urban areas, women face the pressure to engage in income-generating activities, which are often time-consuming and may reduce the time they would otherwise devote to attend to their health.

Statistics indicate that the majority of economically active women between the ages of 15 and 49 are employed in agriculture and domestic work, and receive payment mainly in kind. Of these, 58% engage in agriculture as their main activity. Only 43.1% of men are engaged in agricultural activities as their primary activity, and they are paid in cash. These figures suggest that women have less access to the necessary cash to access the health care system. In addition, their health may be further compromised by their heavy workload. Women in Uganda generally work between 12 and 18 hours a day, with a daily average of 15 hours, whereas men work for 8-10 hours a day on average (World Bank 1999).

Geographic variations
Factors such as geographic location simply compound the inter- as well as intra-gender inequalities that limit women’s access to health care. In the rural mountainous areas such as Kisoro, Bundibugyo, Kabarole, Moroto and Mbale, communities face an extra burden accessing health care facilities because they are not within easy reach. Similarly, women in urban areas are likely to access health resources far more easily than their rural counterparts because health facilities are nearer, and communication facilities are more easily available.

The variation across geographic regions has resulted in some areas being better serviced. More than 50% of the hospitals are located in urban areas. In addition, most health care centres are located near trading centres, thus further limiting remote, rural dwellers’ access to health care. On average, only about 27% of the population live within 5 km of some health facility, and it is estimated that each of these facilities serves about 12,000 people. However, there are substantial variations across the different districts. Some sub-counties are more disadvantaged than others, some even operating without any health centre at all (Uganda Social Sector Strategy Report 1992 ).

There is also great variation across the regions as regards access to resources that promote general health, such as access to safe water sources. By 1989, only 20% of the total rural population had access to safe water. In regions like Kumi, only 2-5% of the population had access to safe water, as compared to 70% of the population in Moyo district (MFEP 1992).

Social and cultural practices
Like several African countries, Uganda is a patrilineal society, with a number of cultural practices that undermine women’s health. Such practices in Uganda include polygyny, which exposes women to the risk of STIs and emotional stress. Few studies exist that examine the effects of socio-cultural practices on the health of women in Uganda. However, available data from elsewhere on the African continent indicates that some of these practices are extremely harmful to women’s health.

Female circumcision or female genital mutilation (FGM), which is still practised in Kapchorwa, for example, is a traumatic life experience that negatively affects women’s reproductive health and can result in death. Women who undergo this frequently experience birth-related traumas and deprivation of sexual pleasure, while others die due to infections. Intermittent bleeding, anaemia, depression, frigidity and psychoses are some of the health complications suffered by women who have undergone FGM (Inter African Committee 1998).

Women also experience occupational health hazards that are related to their socio-cultural roles in their communities. In Karamooja, for example, it is customary for women to build the house where the family resides. This exposes them to certain occupational risks that women in other communities may not experience.

In all communities, women experience the hazards of cooking with firewood or