01 Chapter 1
01 Chapter 1
INTRODUCTION
Geography
The Republic of Uganda is in East Africa within the equatorial zone with the equator cutting across
part of the country. It is a landlocked country bordering Kenya in the East, Tanzania and Rwanda in the
South, Zaire in the West and Sudan in the North. The country has an area of 241,039 square kilometres, 18
percent of which is open water and swamps and 12 percent forest and game parks.
Uganda has a favourable climate because of its relatively high altitude. The Central and Western
Regions of the country have two rainy seasons in a year, with heavy rains from March to May and light rains
between September and December. The level of rainfall diminishes towards the North turning into just one
rainy season a year. The soil composition varies accordingly, being generally fertile in the Central and
Western Regions and becoming less fertile as one moves to the East and the North. Due to these
combinations of climatic conditions, Uganda varies between tropical rain forest vegetation in the South and
savannah woodlands and semi-desert vegetation in the North. These climatic conditions determine the
agricultural potential and thus the land's population carrying capacity, with high population densities in the
Central and Western Regions and declining densities towards the North.
History
Uganda became independent of British colonial rule in October 1962. Uganda had close economic
linkages with the other two East African countries of Kenya and Tanzania. This was partly because all three
countries were British colonies and used English as an administrative language and partly because the three
countries formed the East African Community in the late 1960s. Although the Community broke up in 1977,
it was revived in early 1996.
The country is composed of many tribal groupings of Bantu, Nilotics, Nilo-Hamites, and those of
Sudanese origin. Some of these tribal groupings cut across the boundaries with neighbouring countries
causing another natural linkage. Some tribal groups historically constituted monarchies or kingdoms which
were abolished in the 1960s, but were recently re-introduced. Luganda is the most widely spoken language,
followed by Swahili and English. English is the officiaI language of the country.
At present, Uganda is divided into four statistical (not administrative) regions--Central, Eastern,
Northern and Western (see map). The country is further divided into 39 administrative districts t, which do
not necessarily represent tribal groups. Districts are further divided into counties, sub-counties and parishes.
In most cases, parishes are divided into sub-parishes. The above system is administered by appointed chiefs.
There is also a system of elected administrators which runs parallel to the above hierarchy called the
Local Councils (LCs). Their equivalency is as follows:
J At the time of the survey design, there were 38 districts. Ntungamo district was gazetted later.
District - Local Council 5 (LC5)
County - Local Council 4 (LC4)
Sub-county - Local Council 3 (LC3)
Parish - Local Council 2 (LC2)
Village or group of villages - Local Council 1 (LCI).
Economy
Between 1979 and 1985, Uganda faced a period of civil and military unrest resulting in the
destruction of the economic and social infrastructure. This seriously affected the growth of the economy and
the provision of social services such as education and health care.
Since 1986, however, the National Resistance Movement Government has introduced and
implemented a recovery programme which is steadily moving the country towards economic prosperity. For
example, during 1994-95, the economy was projected to have grown by 10 percent per annum, much higher
than the previous year when the economy grew by 5.5 percent. In the same period, agricultural production
increased by 6.1 percent per annum, of which food crop production increased by 7.7 percent per annum. The
manufacturing sector grew by 17.7 percent in 1994-95 compared to 15.2 percent in 1993-94 (Statistics
Department, 1995d).
In the past, most demographic statistics in Uganda were derived from population censuses which
started in 1948. National surveys have not been major sources of demographic statistics due to the small
number that have been conducted. Two relevant surveys are the Demographic and Health Surveys of 1988-
89 and of 1995. Other institutions, particularly Makerere University, have conducted small-scale surveys
mainly for research purposes.
Civil registration has not frequently been used as a source of demographic statistics because its
coverage is incomplete, although it was made compulsory in 1973. Efforts to streamline the system were
made between 1974 and 1978, but the achievements that were realised were later frustrated by the economic
and civil instability between 1979 and 1985. Concrete plans to revive the civil registration system are now
underway.
Table 1.1 gives the demographic indices as compiled from the censuses since 1948. The table shows
that Uganda's population is growing at a high rate because fertility is still high. Mortality is seen to be
declining.
Table 1.1 Demographiccharacteristics
Census year
Index 1948 1959 1969 1980 1991
Population (thousands) 4,958.5 6,536.6 9,535.1 12,636.2 16,671.7
lntercensal growth rate - 2.5 3.9 2.7 2.5
Sex ratio 100.2 100.9 101.9 98.2 96.5
Crude birth rate 42 44 50 50 52
Total fertility rate 5.9 5.9 7.1 7.2 7.1
Crude death rate 25 20 19 20 17
Infant mortalityrate 200 160 120 115 122
Percent urban - 4.8 7.8 8.7 I 1.3
Density (pop/kin2) 25.2 33.2 48.4 64.4 85.0
Family planning activities in Uganda started in 1957 with the establishment of the Family Planning
Association of Uganda (FPAU), an affiliate of the International Planned Parenthood Federation. Since the
inception of the FPAU, family planning services have been largely limited to urban centres, despite the fact
that over 80 percent of the population resides in rural areas. With the acceptance and introduction of its
primary health care strategy, the government since 1984 has integrated family planning into the overall
maternal and child health programme as a means of reducing maternal morbidity and mortality in Uganda.
Currently, family planning services are provided through clinics administered by FPAU, government,
and non-government health institutions. Available data indicate that most users use oral contraceptives,
female sterilisation, injectables and condoms, while few couples use IUDs. Natural family planning has
gained some support in Uganda. A natural family planning programme organised by the Uganda Catholic
Medical Secretariat covers most dioceses in Uganda and provides services through health units and home
visits.
In 1994, an integrated reproductive health project catled the Delivery of Improved Services for Health
(DISH) was initiated by the Ministry of Health with United States Agency for International Development
(USAID) funding. The project goals are to reduce total fertility rates and decrease the incidence of HIV
infection in 10 of Uganda's 39 Districts. 2 The objective of the project is to increase the availability and
utilisation of basic reproductive health services including family planning, diagnosis and treatment of sexually
transmitted diseases, HIV testing and counselling, and maternal health services.
In 1995, Uganda adopted the National Population Policy which has as its overall goal to influence
future demographic trends and patterns in desirable directions in order to improve the quality of life and
standard of living of the people. The policy aims at increasing the contraceptive prevalence rate from 7.8
percent to 15 percent by 2000 (Population Secretariat, 1995:28). The policy has separate targets for
demographic trends, for health services, and for other social services.
2 The 10 DISH districts are Jinja, Kampala, Kamuli, Kasese, Luwero, Masaka, Masindi, Mbarara, Ntungamo
(included in Mbarara District in the UDHS), and Rakai.
1.4 Health Priorities and Programmes
According to the National Population Policy, the goal of achieving adequate health services for the
entire population is likely to be made more difficult by the prevailing high levels of fertility and mortality and
the recent surge in the acquired immune deficiency syndrome (AIDS) epidemic. The difficulty will be
exacerbated by the expected rapid growth in the population of high risk groups, such as children under age
five and women of childbearing age.
The geographical distribution of health personnel and health facilites in Uganda does not reflect
actual needs. The government runs 60 percent of the 1,398 health institutions, but some of the government-
run institutions are in-equipped and in a poor state of repair. The policy also notes that other indices of
general health care, such as the number of persons per doctor, sources of antenatal care, the number of babies
delivered by trained personnel, and the annual average per capita expenditure on health, are still
unsatisfactory.
The 1995 UDHS was a follow-up to a similar survey conducted in 1988-89. In addition to including
most of the same questions included in the 1988-89 UDHS, the 1995 UDHS added more detailed questions
on AIDS and maternal mortality, as well as incorporating a survey of men. The general objectives of the
1995 UDHS are to:
provide national level data which will allow the calculation of demographic rates,
particularly fertility and childhood mortality rates;
analyse the direct and indirect factors which determine the level and trends of fertility;
measure the level of contraceptive knowledge and practice (of both women and men) by
method, by urban-rural residence, and by region;
collect reliable data on maternal and child health indicators; immunisation, prevalence, and
treatment of diarrhoea and other diseases among children under age four; antenatal visits;
assistance at delivery; and breastfeeding;
assess the nutritional status of children under age four and their mothers by means of
anthropometric measurements (weight and height), and also child feeding practices; and
assess among women and men the prevailing level of specific knowledge and attitudes
regarding AIDS and to evaluate patterns of recent behaviour regarding condom use.
4
Sample Design
A sample of 303 primary sampling units (PSU) consisting of enumeration areas (EAs) was selected
from a sampling frame of the 1991 Population and Housing Census. For the purpose of the 1995 UDHS, the
following domains were utilised:
Uganda as a whole;
urban and rural areas separately;
each of the four regions: Central, Eastern, Northern, and Western;
areas in the USAID-funded DISH project to permit calculation of contraceptive prevalence
rates.
Districts in the DISH project area were grouped by proximity into the following five reporting
domains:
The sample for the 1995 UDHS was selected in two stages. In the first stage, 303 EAs were selected
with probability proportional to size. Then, within each selected EA, a complete household listing and
mapping exercise was conducted in December 1994 forming the basis for the second-stage sampling. For
the listing exercise, 11 listers from the Statistics Department were trained. Institutional populations (army
barracks, hospitals, police camps, etc.) were not listed.
From these household lists, households to be included in the UDHS were selected with probability
inversely proportional to size based on the household listing results. All women age 15-49 years in these
households were eligible to be interviewed in the UDHS. In one-third of these selected households, all men
age 15-54 years were eligible for individual interview as well. The overall target sample was 6,000 women
and 2,000 men. Because of insecurity, eight EAs could not be surveyed (six in Kitgum District, one in Apac
District, and one in Moyo District). An additional two EAs (one in Arua and one in Moroto) could not be
surveyed, but substitute EAs were selected in their place.
Since one objective of the survey was to produce estimates of specific demographic and health
indicators for the areas included in the DISH project, the sample design allowed for oversampling of
households in these districts relative to their actual proportion in the population. Thus, the 1995 UDHS
sample is not self-weighting at the national level; weights are required to estimate national-level indicators.
Due to the weighting factor and rounding of estimates, figures may not add to totals. In addition, the percent
total may not add to 100.0 due to rounding. Appendix B contains examples of sampling errors for some of
the survey variables.
Questionnaires
Four questionnaires were used in the 1995 UDHS. A Household Schedule was used to list the names
and certain individual characteristics of all usual members of the household and visitors who had spent the
previous night in the household. Some basic information was collected on characteristics of each person
listed, including his/her age, sex, education, and relationship to the head of the household. The main purpose
of the Household Questionnaire was to identify women and men who were eligible for the individual
interview. In addition, the Household Questionnaire collected information on characteristics of the
household's dwelling unit, such as the source of water, type of toilet facilities, materials used for the floor
of the house, and ownership of various consumer and durable goods.
The Women's Questionnaire was used to collect information from women age 15-49. These women
were asked questions on the following topics:
The Men' s Questionnaire was used to collect information from a subsample of men age 15-54 (those
living in every third household). The Men's Questionnaire collected much of the same information found
in the Women's Questionnaire, but was shorter because it did not contain questions on reproductive history
and maternal and child health.
The Service Availability Questionnaire was used to collect community level information on the health
and family planning services near each selected LC 1 (see section 1.1 for explanation). An enumeration area
sometimes consists of more than one LC1. In such cases, one questionnaire was completed for each of the
LC I s within the selected enumeration area.
The questionnaires were developed in English by a Steering Committee which was chaired by the
Population Secretariat. All except the Service Availability Questionnaire were translated into and printed in
six major languages (Ateso, Luganda, Lugbara, Luo, Runyankole/Rukiga, and Runyoro/Rutoro).
The 1995 UDHS questionnaires were pretested in November 1994. Fourteen interviewers (seven
teams of one female and one male interviewer) were trained for two weeks to implement the pretest. The
pretest field work in the six local languages was carried out in seven districts for three days. Approximately
150 pretest interviews were conducted, debriefing sessions were subsequently held with the pretest field staff,
and modifications to the questionnaire were made based on lessons drawn from the exercise.
Training of field staff for the main survey was conducted over a three-week period in March 1995.
Permanent staff from the Statistics Department, guest lecturers, and staff and consultants from Macro
International Inc. trained 94 interviewers and data entry operators. Computer operators participated in
interviewing during the first rounds of fieldwork to acquaint themselves with the questionnaires. The training
course consisted of instruction in general interviewing techniques, field procedures, a detailed review of items
on the questionnaires, instruction and practice in weighing and measuring children, mock interviews between
participants in the classroom, and practice interviews with real respondents in areas outside the 1995 UDHS
6
sample points. Supervisors and editors were trained exclusively for three days to discuss their duties and
responsibilities. Emphasis was given to the importance of ensuring data quality.
Fieldwork for the 1995 UDHS started in the fourth week of March and ended in mid- August 1995.
Ten interviewing teams were deployed, each consisting of one supervisor/team leader, one female field editor,
three female interviewers, one male interviewer, one reserve interviewer of either sex, and a driver. In
addition, a senior officer from the Statistics Department was assigned to each of the major languages.
Data Processing
All the questionnaires for the UDHS were returned to the Statistics Department for data processing,
which consisted of office editing, coding of open-ended questions, data entry, and editing of computer-
identified errors. All data were processed on microcomputers. Data entry and editing were accomplished
using the computer program ISSA (Integrated System for Survey Analysis) that was specially designed for
the DHS programme. Data processing was performed during April-October 1995.
Response Rates
Table 1.2. Out of 8,093 households selected, 7,671 Number of households, number of interviews, and response
were occupied, the shortfall being a result mostly rates, Uganda 1995
of vacant houses. Of the existing households,
7,550 were interviewed, for a response rate of 98 Residence
percent. The main reason for non-response was the Result Urban Rural Total
interviewer's failure to find a respondent at home
after at least three visits. Household i n t e r v i e w s
Households sampled 2,682 5,411 8,093
Households occupied 2,483 5,188 7,671
In the interviewed households, 7,377 eli- Households interviewed 2,410 5,140 7,550
gible women were identified and of these, 7,070 Household r e s p o n s e r a t e 97. I 99.1 98.4
were interviewed, yielding a response rate of 96
percent. In the subsample of households selected Individual interviews
Number of eligible women 2,573 4,804 7,377
for the man's interview, 2,224 eligible men were Number of eligible women
identified, of which 1,996 were successfully inter- interviewed 2,439 4,631 7,070
viewed (90 percent response). The principal rea- Eligible w o m a n r e s p o n s e r a t e 94.8 96.4 95.8
son for non-response among both eligible men and
women was the failure to find them at home de- Number of eligible men 766 1,458 2,224
Number of eligible men
spite repeated visits to the household. The lower interviewed 657 1,339 1,996
response rate among men than women was due to
Eligible m a n r e s p o n s e r a t e 85.8 91.8 89.7
the more frequent and longer absences of men.
The response rates are lower in urban areas due to long absence of respondents. One-member
households are more common in urban areas and are more difficult to interview as they keep their houses
locked up most of the time. In urban settings, neighbours often do not know the whereabouts of such people.