Before doing so, we use data from the Demographic and Health Survey (DHS) to describe the health characteristics and to gain an appreciation of the quality of health services in Uganda over time and in international comparison.<sup>5</sup> The upper panel of table 1 uses DHS data, all of which were collected before the abolition of user fees, to highlight that, even though Uganda’s health system had improved considerably before 1995, the rate of improvement had slowed considerably, and was in some cases even reversed, thereafter. For example, one notes that infant mortality for children under the age of one (in deaths per 1,000 live births) declined from 98 in 1988 to 81 in 1995 but then increased to 88 in 2001. Coverage of 1-2 year old children with BCG vaccinations improved from about 41% and those for DPT3, polio and measles improved from slightly above 20% in 1988 to 79%, 55%, 53% and 45% in 1995, just to drop to 75%, 42%, 50% and 42% for BCG, DPT3, polio, and measles, respectively, in 2000. Progress in reducing the prevalence of diarrhea, stunting, and antenatal care slowed down or stalled in 1995-2001 as compared to 1988-95. This drop in health indicators is even more puzzling as it occurred in a period that, according to available macro statistics and household surveys, was characterized by high levels of economic growth and significant reduction in poverty (UBOS, 2001; Appleton, 2001). As the survey dates do not coincide with the periods before and after the imposition of user fees, it is impossible to establish a clear relationship. The marked slowdown of service quality is often interpreted in the sense that, rather than improving quality and access, imposition of user fees may indeed have either decreased the outreach of the health system or at least slowed down progress (Mwesigye, 2002).

Comparing Uganda with other African countries, as in the lower panel of table 1, adds to the questions by illustrating that, even for Africa, the country ranks close to the bottom for many of the indicators conventionally used to compare quality of health delivery systems. Rates of infant mortality in Ghana, Kenya, Nigeria and Zimbabwe were significantly lower than those of Uganda for most of the periods under concern, notwithstanding the fact that some of these countries also failed to make consistent progress in reducing infant mortality. With the exception of Nigeria (and Burkina Faso in the case of stunting), Uganda has the lowest vaccinations coverage, and the highest incidence of stunting and prevalence of diarrhea, compared with the other countries in the sample. The fact that in Uganda, coverage with antenatal care was among the highest for all of Africa suggests that there were differences across types of health services but at the same time raises the possibility that the problem may have been related to access. Below we explore to what extent the abolition of user charges may have helped to improve this without affecting the quality of service provision.

> 5 Demographic and health surveys, which have been conducted in a large number of developing countries, with significant support from USAID, provide information on family planning, maternal and child health, child survival, HIV/AIDS/sexually transmitted infections (STIs), and reproductive health to monitor and evaluate population, health, and nutrition programs. For more information see <u>http://www.measuredhs.com/.</u>

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