[stop-imf] Lancet: Evidence of a flawed economic policy in Uganda

[robert weissman]

[snip]

A policy of user-fees imposed as a financing reform by donors,
especially the World Bank in the early 1990s, did a great disservice to
social welfare. Despite the theoretical benefits of such fees (equality,
resource mobilisation, quality of care, and efficient use of services),
the reality was starkly different. The envisaged fund generation through
user-fees was clearly negligible, always less than 5% of total health
expenditure. There were no demonstrable benefits of these fees on the
quality or efficiency of social services. Under political pressure, and
with nothing tangible to show from user-fees, the policy was abolished
by the government in 2001. The surge of more than 100% in the use of
public services soon after the abolition of the fees shows the extent to
which poor people were excluded from social services by an inappropriate
policy.

[snip]

Dying for economic growth? Evidence of a flawed economic policy in Uganda

Sam Agatre Okuonzi

Lancet 2004; 364: 1632-37

National Council for Children, PO Box 21456, Kampala, Uganda (S A
Okuonzi MD), sokuonzi@infocom.co.ug

Uganda is now regarded as a success for having achieved remarkable
economic progress. Nevertheless, no substantial improvement in social
welfare is apparent. The World Bank, the International Monetary Fund,
and latter-day free-market converts, including welfare-state donor
countries and Uganda's own finance ministry, love to describe the
country as an economic star, but shy away from explaining in a
convincing way why, for such a brilliant economic performance, the
country has a miserable social-welfare situation, as epitomised by
persistently high maternal and infant mortality.

The reason for this paradox is that the economic policy has succeeded
specifically at the expense of social welfare. This policy extols
export-oriented private-sector investment, which is expected to lead to
economic growth and increased household incomes. Better incomes are said
to be the only way to ensure social welfare. But to create the necessary
macroeconomic environment for investment and the private sector, public
expenditure, particularly for social services, must be highly
restricted,1 and any social-welfare targets, such as the Millennium
Development Goals, that cannot be achieved within these constrained
social spending limits must be abandoned.2 According to the government's
policy, welfare should therefore be postponed until economic growth has
reached some arbitrary optimum.

Under this approach, inflation is presently 5=FA7%,3 and has been
controlled at below 10% per year since 1990. Government expenditure is
23% of gross domestic product (GDP), and half this expenditure is
external aid. There has been tremendous investment, especially of
foreign origin, in trade, manufacturing, and infrastructure. The economy
has grown at a rate of 6=FA5% GDP per head from US$190 in 1989 to $250 in
2003.3 Income poverty is said to have fallen greatly from 56% in 1992 to
35% in 2000, but it increased to 38% in 2002.

However, these statistics hide sad economic and welfare realities.
First, the definition of income poverty for Uganda is based largely on
lack of food, but this term has become synonymous with poverty as whole.
Those who praise Uganda's so-called economic miracle say without a
second thought that the country's entire poverty has reduced from 56% to
35%. Yet this notion of poverty excludes or grossly understates the
scarcity of social services such as health services, and child and
family protection and support, which have got worse.4 Further, the
simplification of poverty into lack of income has excluded non-monetary
aspects of poverty such as powerlessness, exclusion, and hopelessness,
which cannot be expressed in statistics but have also worsened.5

Second, mean income inequality increased from a Gini co-efficient (a
measure of inequality where 0=3Dtotal equality and 1=3Dtotal inequality) of
0=FA35 in 1992 to 0=FA43 in 2003, with huge regional disparity against
northern and eastern Uganda, which has been under rebellion since the
advent of the National Resistance Movement government in 1986.3
Government economists blame the civil war for the regional economic
disparity. Since the war has been of constant intensity throughout these
years, it cannot fully explain the widening economic gap, which also
exists in peaceful areas of the country.5 Poor people across the country
have, through a participatory approach to poverty definition, said many
times that they are finding it increasingly difficult to access social
services, and that whatever services are available are becoming less
complete and of poorer quality.5 These problems can only be explained
for the most part by a flawed economic policy that arbitrarily reduces
social services.

Third, Uganda's economy is heavily dependent on external aid. Uganda has
hit an all-time high debt burden of US$4=FA3 billion,6 which has become
unsustainable since the country's entire GDP is just over US$6 billion.
Some analysts say that aid is the reason for Uganda's economic growth,
and that internal revenue generation is relatively insignificant in its
so-called economic success.6 But, they argue, this aid has made Uganda
poorer, not better off.

Nevertheless, progress has been made in other aspects of development.
Social stability has been established in a large part of Uganda, after a
turbulent past before 1986.7 Some progress has been made in establishing
democratic governance, after a series of dictatorships and military
governments since independence in 1962. Universal primary education
introduced in 1997 has attained 90% enrolment of children in 2004 with
near equal participation by boys and girls. The frequency of HIV has
fallen greatly from about 30% in the early 1990s to about 4=FA1% in 2004.8
Progressive policies and laws have been introduced to target vulnerable
and often marginalised groups such as women, children, and the disabled;
however, most of these policies have remained largely unimplemented
because of lack of funding.7

But overall, Uganda's social conditions have not improved, and some have
got worse. Uganda's infant mortality rate increased between 1995 and
2000,9 and child mortality in those younger than 5 years increased
during the same period (table 1). These figures were obtained from
surveys that did not cover the remote, unstable, and largely neglected
districts. In fact, a recent study in Uganda7 concluded that infant and
child mortality has not improved since 1970, when the infant mortality
rate was 120 per 1000. This rate was 122 per 1000 according to the 1991
national census,12 and the next reliable survey was the 2002 national
census, whose results are still being analysed.

=09=091990-95=092000-04=09Change
=09Nutritional status (wasting in children)=096=FA2%=097-8%=09Deterioration
=09Access to safe water =0939=FA4%=0953=FA8%=09Improvement
=09Access to proper sanitation =0934%=0951%=09Improvement
=09Infant mortality rate (per 1000)=0981 (97)*=0988 (101)*=09Deterioration
=09Neonatal morality (per 1000)=0927=0933.2=09Deterioration
=09Malaria morbidity proportion =0925%=0937%=09Deterioration
=09Rate of diarrhoea =0917=FA7%=0917=FA8%=09Deterioration
=09Income Gini coefficient =090=FA35=090=FA43=09Deterioration
=09Maternal mortality (per 100 000)=09506=09505=09No change
=09Child mortality (per 1000)=09147=09151=09Deterioration
=09Life expectancy (years)=0950=0947=09Deterioration
=09Delivery in health facilities =0938%=0938%=09No change
=09Fertility rate (number of children)=097=FA4=096=FA9=09Little change
Sources: Uganda Demographic Health Surveys 199510 and 2000-01.11 Data
are percentage of total population unless otherwise indicated. *By
indirect method.  Source of income Gini coefficient is Government of
Uganda.3
Table 1: Health and welfare status from 1990 to 2004

Maternal and childhood mortality are intricately linked. Therefore,
Uganda's persistently high maternal mortality ratio of more than 500 per
100000 livebirths for the past two decades (according to demographic and
health surveys) is not surprising. WHO asserts that these surveys, which
are done routinely around the world, have generally underestimated
maternal mortality.13 It estimates that Uganda's real rate could be
about 1200 per 100000 livebirths. Therefore, despite its spectacular
economic performance, Uganda has been cited as one of eight countries
that account for most of the world's maternal deaths.14 The importance
of persistently high mortality is profound; it defies and questions the
basis of any social or economic progress a country may claim to have made.

2=FA5 million orphans and other helpless children--a tenth of the entire
population--have no social support.15 Community and family social safety
nets are overstretched or have broken down as a result of population
mobility and the adoption of the western lifestyle of nuclear families.
Yet there is no publicly funded nationwide programme to support such
children. Access to basic needs such as food and nutrition, safe water
and sanitation, and health care has remained low and is very unfairly
distributed. Humanitarian and multilateral organisations, to which the
government has increasingly relegated social services, provide scattered
and fragmented welfare, which has had no substantial positive effect
nationwide. Table 1 provides a snapshot of the stagnation in Uganda's
health and social welfare status.

Four possible reasons for the declining social welfare are HIV/AIDS,
conflict, poverty, and contraction of the economy that happened more
than 20 years ago. The HIV/AIDS pandemic has contributed to Uganda's
high mortality rates, but it cannot account for their persistence at
such a high level, or for their rising trend; HIV frequency fell from
1990 to 2004.8 Moreover, studies16 have shown that the effect of a
moderate and low rate of this infection, such as Uganda has had for 10
years, is that it does not halt or reverse falling or stable child
mortality. Instead, as Uganda's HIV frequency rapidly declined, its
child mortality increased. The 18-year-old war in the north of the
country cannot also fully account for the persistence of high mortality
rates, which are present in peaceful areas as well. Furthermore, for
countries in which universal social welfare policies have been pursued,
overall mortality rates can be controlled where there is conflict (eg,
Sri Lanka).17

Poverty, as measured by GDP per person, cannot explain Uganda's
deteriorating social welfare, because several countries that have been
or are at the same economic level had or have much better social
services. Some have argued that one possible reason for the welfare
decline might be because Uganda had negative economic growth in the
1980s and is just catching up. Having achieved consistent economic
growth for two decades, and having even surpassed the GDP per person of
countries that are more stable socially and politically, the contraction
of the economy over more 20 twenty years ago cannot convincingly explain
why Uganda's welfare is decreasing. Therefore, the most plausible
explanation for this welfare stagnation or decline can only be economic
policy, which has created an arbitrary limitation on social spending.

Uganda is pursuing an aggressive free-market policy whose target is that
by 2025 a certain level of economic transformation will be attained,
which will not be reversible.18 It is envisaged that, based on the
country's natural resources and labour, manufactured goods and services
will be produced for the domestic market and for export. These changes
are expected to raise incomes through increasing self and wage
employment. Over time, with the expansion of the economy, wage
employment is expected to become the most important source of household
income.1

For this policy to be followed through, the economy should be
restructured. Inflation and this public expenditure, should be kept to a
minimum. The principle of minimum public spending plus the overwhelming
need to support and protect the private sector mean that donor funds
meant for social welfare can be rejected.2 Too high a fiscal deficit
(spending beyond internally generated revenue), even when funded by
donor aid, could well generate inflation and penalise the local private
sector by making local currency artificially strong.

However, according to Sachs,19 the risks of currency overvaluation from
donor-financed health spending are overstated. He argues that there are
no precedents in the world where such risks have occurred. He concludes
that there are no justifiable reasons to prevent donors from providing
grants to obtain the necessary inputs for provision of health care in a
poor country in which most people have no reliable access to basic
health care or other forms of social protection.

Uganda and other developing countries have embraced a mythical
free-market policy. The policy entails, among other things that: (a) a
government should have a low budget deficit or even run a surplus; (b)
the government should take a minimum role in business or economic
production, which should be run by the private sector; (c)
social-welfare institutions and services should be privatised, except
perhaps for very basic services for the poor; (d) an environment should
be created for competition; and (e) there should be deregulation of the
economy to remove bureaucratic obstacles for effective private-sector
participation.

But donor countries advocating free-market policies do not themselves
practice what they preach. The USA is the most ardent free-market
advocate but practices something different.17 For example, the two main
political parties in the USA now accept that when a country is in
recession, it is not just permissible but desirable to run budget
deficits. Yet developing countries are told that central banks should
focus exclusively on price stability.

That the role of the government in the economy and social protection is
dominant is even more obvious in western Europe, which has welfare
states. Donor governments therefore have welfare of their people as
their primary focus, and they manipulate economic control variables
(inflation rate, interest rate, public debt, balance of payment, and
money supply) to ensure they have an optimum balance between social
welfare and economic growth. But poor countries are told to concentrate
only on macroeconomic stability.

In Uganda, a wide range of reforms is being undertaken to support the
creation of a private-sector driven, export-led and industry-based
economy. Although such reform policies are often introduced with clear
promises of improved social services, social benefits have not been
achieved. Similar results are evident in other developing countries,
that have embarked on this path.20,21 Typically, economic reforms are
introduced with promises to improve the quality, access, and efficiency
of public services. However, the actual results have either been that no
improvement has been made in these indicators or they have got worse.
Reforms have generally had a negative effect on social welfare.22

Although decentralisation, a major institutional reform, has transferred
power to communities, this transfer has not been matched with the
resources that can make improvements.23,24 Owing to the different stages
of development of the local authorities, inequality in provision of
social welfare has increased because of this change.25 Decentralisation
has encouraged sectarianism, by which local authorities prefer people
from their ethnic background to work in a local authority, even when
they are less qualified.24 Such authorities, eager to reduce expenditure
(and often anxious to save money to meet administrative costs such as
paying allowances to council members), have retrenched social-welfare
staff. Authorities often prefer less costly, but less qualified staff
(eg, nursing aides) to professional staff (eg, nurses).24

With a deregulation programme in place, through which as few laws as
possible are encouraged to reduce bureaucracy, and to enable investment
and the private sector to flourish, decentralisation has created fertile
ground for corruption.24 Various forms of corruption, but mostly dubious
contract procedures by which local councils swindle public funds with
impunity because they are greatly empowered by law, make it impossible
for social benefits to reach target communities.

Civil service reform has had two major effects on social welfare. First,
the number of social service staff, which is already insufficient, has
been reduced. Second, much of the remaining incentive for work has been
removed because staff remain grossly underpaid, are under constant
threat of being fired, and lack career prospects.23 A policy of
user-fees imposed as a financing reform by donors, especially the World
Bank in the early 1990s,26 did a great disservice to social welfare.
Despite the theoretical benefits of such fees (equality, resource
mobilisation, quality of care, and efficient use of services), the
reality was starkly different. The envisaged fund generation through
user-fees was clearly negligible, always less than 5% of total health
expenditure. There were no demonstrable benefits of these fees on the
quality or efficiency of social services. Under political pressure, and
with nothing tangible to show from user-fees, the policy was abolished
by the government in 2001.27 The surge of more than 100% in the use of
public services soon after the abolition of the fees shows the extent to
which poor people were excluded from social services by an inappropriate
policy.28

Public-private partnership is the new policy being established. If
interpreted and applied for the benefit of social welfare, such
partnership could improve delivery of social services through the use of
private organisations, on a contract basis, to provide services to
complement an overstretched public system of social-services delivery.
However, if partnership is used as a strategy to enable the
private-sector to maximise profit, then social welfare will still be doomed=
.

A basic philosophy behind free-market reforms is that as much health
care as possible should be provided privately, because it is a tradable
commodity.29 As such, public investment in health infrastructure should
not be allowed. Besides, it is argued, such expenditure takes away
resources needed to create a stable macroeconomic climate. As a result,
Uganda's current health-care infrastructure is physically accessible to
(ie, within 1 h of walking or travel) about half the population and
economically accessible (or affordable) to much less than this
proportion. Table 2 presents the situation of health facilities in terms
of emergency obstetric care, which is illustrative of the whole
health-care system.

=09=09Actual=09Required/acceptable
=09Facilities that have some services=0942=FA1%=09100%
=09Facilities offering such care=0914=FA2%=09100%
=09Women delivering in health facility=094=FA0%=09100%
=09Adequate staff number and training=0912-41%=09100%
=09All essential emergency functions =093=FA9%=09100%
=09Met need for such care=095%=09100%
=09Caesarean sections=095%=0915%
=09Case fatality rates (deaths from =09126-620%=0930%
obstetric complications as % of all
obstetric complications seen)
Source: Government of Uganda (2003).30
Table 2: Emergency obstetric care in Uganda

The study from which the data in table 2 were taken30 concluded that the
pathetic situation of facilities for obstetric care in Uganda was a
deliberate policy not to expand such services countrywide, because they
are thought to be expensive, and by extension, wasteful, since they do
not directly lead to export-oriented investment. And yet the economic
cost of maternal illness, disability, and death is estimated to have
been US$1=FA55 billion over 10 years (panel).31,32

Panel: Effect of economic policy on maternal health
Calculations based on the worst scenario of a possible maternal
mortality rate of 1200 per 100000 for 10 years.
cirf=09150000 maternal deaths.
cirf=09100000 infant deaths due to maternal deaths
cirf=0940000 infant deaths from neonatal tetanus
cirf=0930000 infant deaths due to iodine deficiency
cirf=09220000 deaths due to malaria
cirf=09600000 children vulnerable because of maternal deaths
cirf=095 million women with disabilities due to lack of health care
(disabilities include incontinence, anaemia, emotional stress, and so on)
cirf=09US$750 million loss of productivity from maternal death
cirf=09US$800 million loss of productivity from child death and disability
Source: Okuonzi (2002).31,32

In the 1990s, a fashionable policy (and the epitome of health-sector
reform) was not to invest in hospitals; they were regarded as too costly
and unnecessary.23 Funds were judged to be better spent in prevention
and primary health care. The results are that basic curative care is
hard to get in Uganda today, except for those who can buy it from
private facilities at exorbitant prices. Table 3 summarises the results
of health-sector reform in Uganda, and table 4 assesses progress in
terms of key objectives of health-sector performance.

=09=09Envisaged results=09Actual results
=09Prepayment/insurance=09Generate own fund=09Not feasible in Uganda for no=
w
=09=09Improve use of services
=09Greater role of non-governmental organisations=09Improve efficiency and
equality=09No clear advantages
=09Hospital autonomy=09Improve efficiency=09No substantial advantages
=09Restructuring of ministry of health=09Restrict ministry of health size
and structure to policy =09Ministry of health size reduced only slightly, b=
ut
=09=09and technical guidance=09service delivery programmes maintained
=09Basic package=09Government to fund cost-effective package for everybody
Package defined but costs much higher than can be
=09=09=09afforded; has made no difference
=09Sector-wide approach=09Sustainable partnership between donors, governmen=
t
and non-=09Formalisation of existing partnership; budget funding
=09=09governmental organisations; move away from project to budget =09has
increased but has made no measurable differences
=09=09funding=09in service delivery
Adapted from Okuonzi and Birungi (2000).23
Table 3: Results of individual health reforms

=09=09Expected outcome=09Actual outcome
=09Access=09Increased physical access=09Increased physical access through t=
he
private sector, but reduced economic access
=09=09Increased economic access
=09Equality=09Increased equality=09Reduced equality
=09Quality=09Increased technical quality=09Same or reduced overall quality =
of
health services
=09=09Reduced consumer-based quality
=09Efficiency=09Increased output/outcome for given input=09No evidence of
improved efficiency
=09Sustainability=09Increasing proportion of internal financing of public
services=09Over 50% dependence on donors
=09=09=09More dependence on external support expected
=09Health status=09Improved nutrition status=09Persistently high mortality =
and
childhood malnutrition
=09=09Reduced mortality rates
Table 4: Overall assessment of health sector reforms by performance
objectives

These worsening social conditions, characterised by increasing mortality
rates, are not unique to Uganda. In 14 African countries, present rates
of child mortality are higher than they were in 1990. 35% of Africa's
children are at higher risk than they were 10 years ago.18 A study20
compared 20 years of globalisation (1980-2000) with the previous 20
years (1960-80), and found that for all indicators of social welfare
(income per person, life expectancy, mortality rates of children and
mothers, literacy, and education), there was a clear fall in progress in
the past two decades compared with the previous two. These are the
results of neoliberal economic policies in Uganda and these countries.
Economic policy is therefore the major cause of the decline of welfare.

What is happening in Uganda and other developing countries has happened
before. Humankind has failed to learn lessons from history. Examples of
exploitative economic strategies include money lending in 15th century
Europe, rationalisation of slavery, and forceful dispossession of people
of their land in England, forcing them into destitution. Widespread
poverty, despite a general rise in prosperity brought about by the
industrial revolution in Europe, led to the Napoleonic wars and other
revolts. As a result, publicly funded welfare systems had to be
established in western Europe. Some have argued that the kind of
economic policy that Uganda is pursuing is not a genuine economic and
social development strategy; rather it is a misguided strategy that
effectively expands the market for multinationals, which are driven by
greed for profit, and the need to service the ever-accumulating capital
surplus in industrialised countries.33

Since the start of the classic market economy, there have been two world
wars and several economic systems, which have taught us hard lessons.
First, it is the inescapable responsibility of the state to maintain
minimum social and economic security. Second, there are no truly free
markets; in developed countries, markets are supported by the state,
which acts in the interest of multinationals. Third, by contrast with
the optimism created by market economic systems and globalisation, there
has not been an appreciable rise in prosperity; instead, poverty has
spread around the world as a result of reckless globalisation. Fourth,
unacceptable social consequences of a bad economic system can only be
handled by government intervention; therefore, a minimalist state policy
is untenable.33 These lessons have been distilled into a clear
social-policy framework for all nations: economic growth with fair
household incomes; gender equality; healthy lifestyles; nutrition and
food security; participatory governance; peaceful coexistence (avoid
violent conflict); social justice and equity; stable ecosystem;
universal access to safe water and sanitation; universal education; and
universal health care.34

The UK's 200-year history of mortality decline, guided and facilitated
by the government, is instructive.35 Before 1820, the UK's infant
mortality rate was about 300 per 1000. The industrial revolution
(1820-81) brought about economic growth and better household incomes. On
its own, economic growth had no impact on infant mortality. But between
1850 and 1920, adequate resources had been made available to construct
municipal sewers and safe water systems. There were also pioneering
advances in public-health measures and legislation. These measures
included establishment of local government boards for service provision,
compulsory education, the poor law, and health boards.

Using such a combination of public measures, the UK reduced its infant
mortality rate from about 150 per 1000 in 1850 to 80 per 1000 in 1920.
 From 1920 to 1960, further government interventions included better
housing, universal health care, health visitors, and regulation of milk
supply to control contamination. The discovery of antibiotics and
vaccines in the 1940s and 1950s accelerated improvements in health care
and further reduced infant mortality to 18 per 1000 in 1970.35

Economic growth is therefore not the leading guarantor of a nation's
wellbeing. How a country deploys its resources for public use determines
mortality outcome. This outcome is not a passive product of economic
growth but a deliberate, persistent, and consistent government intervention=
.

Social welfare can be achieved by poor countries too. It is not true
that welfare and reduction in mortality must always be accompanied by
economic growth. Although economic growth is a good thing, it should not
compromise social welfare. Such welfare should be the best possible from
existing wealth, however little this may be. It should not be ignored
until some arbitrary level of economic growth has been reached. Several
poor countries (Costa Rica, Sri Lanka, Cuba, Kerala State in India,
Vietnam) did not use the UK's model for improvement of social welfare
facilitated by economic growth. These countries took only 20-30 years to
attain the same reduction in mortality that took the UK 200 years. Table
5 shows how income per head is unimportant relative to social policy in
determining social welfare.

=09=09Infant mortality rate (per 1000)=09Life expectancy (years)=09Per capi=
ta
income (US$)
=09Costa Rica=0921=0973=091430
=09Cuba=0920=0975=091000
=09Kerala (India)=0920=0966=09160-270
=09Sri Lanka=0934=0969=09320
=09China=0913-22=0980=09310
=09Uganda=0988-101=0947=09350
=09Saudi Arabia=0928=0962=09>5000
=09UK=0912=0980=0916550
Adapted from Abel-Smith (1994).35 Saudi Arabia, UK, and Uganda included
for comparison.
Table 5: Reduced mortality rates at low cost

These countries ensured deliberate and focused government intervention
in nutrition, land reform, education, water supply, sanitation, health
care, community participation, and overall social welfare. Economic
considerations were simply complementary to these goals. The key reasons
for poor countries' success are: government commitment to social
welfare, evidenced by sustainable, predictable, and reasonably high
public expenditure; links between sectors and participatory process; and
universal welfare. Broadly, countries have attained economic growth in
two ways: industrialisation and exploitation of natural resources such
as oil or timber. Uganda's economic strategy (presently being embraced
by many developing countries) is the third way--namely, to reduce public
spending and to leave investment in people and social infrastructure to
individuals and charities, so as to save money to support the private
sector and direct foreign investment. This strategy is flawed and doomed
to fail because, as history teaches us, it compromises people's welfare,
and inevitably gives rise to rebellion and social instability.

Uganda could compromise its economic growth strategy. It could pursue
its dream of economic prosperity, but factor in social welfare in
determining its pace of economic growth. However, the country does not
have the work culture, tradable economic base, and institutional
capacity to undergo rapid economic transformation. It needs to do a lot
more to develop its capacity, work ethic, and natural resources to
generate wealth. The short-cut option should not be to artificially
mobilise money by underfunding social services. If macroeconomic
stability cannot be achieved for private-sector and direct foreign
investment to flourish without grievously damaging social welfare, then
clearly the policy is wrong for Uganda.

The sacrifice of human life for an economic model that largely favours
foreign investors and multinational companies, and undermines the
welfare of indigenous populations, is flawed and immoral. Such a policy
will probably backfire through revolts, and lead to political and social
instability. It should be abandoned. The decline of welfare from a
reckless and heartless economic strategy must teach countries to observe
an absolute obligation: at the very least, no country should sacrifice
existing welfare or postpone achievement of a reasonable welfare target
to implement an economic strategy. Any such policy should allow the most
rapid attainment of the highest possible welfare for a given level of
economy.

References

1 Government of Uganda. Poverty Eradication Action Plan Draft. Kampala:
Ministry of Finance, Planning and Economic Development, 2004.

2 Brownbridge M. Financing the Millennium Development Goals: is more
public spending the best way to meet poverty reduction targets?  Health
Policy Development 2004; 2: 40-47.  [PubMed]

3 Government of Uganda. Background to the Budget for Financial year
2004/2005. Kampala: Ministry of Finance, Planning and Economic
Development, 2004.

4 Government of Uganda. Implementation of the UN Convention on the
Rights of the Child in Uganda. Kampala: Ministry of Gender, labour and
Social Development, 2004.

5 Government of Uganda. Uganda Participatory Assessment/ Uganda Poverty
Status Report. Kampala: Ministry of Finance, Planning and Economic
Development, 2004.

6 Mwenda A. The Monitor (Kampala, Uganda), July 25, 2004: 14.

7 Government of Uganda. Infant and maternal mortality in Uganda: Causes,
interventions and the way forward. Kampala: Ministry of Finance,
Planning and Economic Development, 2003.

8 Government of Uganda. Uganda National HIV and AIDS Policy. Kampala:
Uganda AIDS Commission, 2004.

9 Uganda Bureau of Statistics. 2002 Statistical Abstract. Entebbe/
Kampala: Uganda Bureau of Statistics, 2002.

10 Uganda Bureau of Statistics and Macro International. Uganda
Demographic and Health Survey 2000-2001. Claverton, MD, USA: UBOS and
ORC Macro, 2001.

11 Ministry of Finance, Planning and Economic Development and Macro
International. Uganda Demographic and Health Survey 1995. Claverton, MD,
USA: Uganda Bureau of Statistics and Macro International, 1996.

12 Moller LC. Infant mortality in Uganda 1995-2000: why the non
improvement?  Uganda Health Bull  2002; 8: 211-14.  [PubMed]

13 WHO. Revised 1990 Estimates of Maternal Mortality: A New Approach by
WHO/UNICEF. Geneva: WHO, 1996.

14 Ross L. Promoting Quality Maternal and Newborn Care: A Reference
Manual for Programme Managers. Washington, DC: CARE and USAID, 1998.

15 Government of Uganda. Health Sector Review Report. Kampala: Ministry
of Health, 2003.

16 Adetunji J. Trends in under-5 mortality rates and the HIV/AIDS
epidemic.  Bull World Health Organ  2000; 78: 1002-06. [PubMed]

17 Rannan-Eliya. Strategies for improving the health of the poor: Sri
Lanka case study. Boston: Mimeo, Harvard School of Public Health.

18 Government of Uganda. Vision 2025: a strategic Framework for National
Development. Kampala: Ministry of Finance, Planning and Economic
Development, 1999.

19 Sachs J. The Need for Increased Investment in Health.  Uganda Health
Bull  2002; 8: 113-14. [PubMed]

20 Weisbrot M, Baker D, Knev Egov, Chen J. The scoreboard on
globalisation 1980-2000: twenty years of diminished progress. Washington
DC: Centre for Economic and Policy Research, 2001.

21 World Health Organization. The World Health Report: Shaping the
Future. Geneva: Ministry of Health, 2003.

22 Stigliz J. Globalisation and its discontents. London: Penguin Books,
2002.

23 Okuonzi S A, Birungi H. Are lessons from the education sector
applicable to health care reforms? The case of Uganda.  Int J Health
Plann Manage 2000; 15: 201-19. [PubMed]

24 Saito F. Decentralization and Development Partnerships: Lessons from
Uganda. Tokyo: Springer-Verlag, 2003.

25 Jeppsson A, Okuonzi A. Vertical and holistic decentralization of the
health sector: experiences from Zambia and Uganda.  Int J Health Plann
Manage 2000; 15: 273-89. [PubMed]

26 Okuonzi S A, Macrea J. Whose policy is it anyway? International and
national influences on health policy development in Uganda.  Health
Policy Plan  1995; 10: 122-32. [PubMed]

27 Kiyonga C. Policy statement: abolition of user-charges and
introduction of a dual system. Uganda Health Bull 2001; 7: 31.

28 Yates R. Voting with their feet: what lessons can be learned from
increased consumption of health services in Uganda.  Health Policy
Development 2004; 2: 48-51.  [PubMed]

29 Rice T. Health Economics Reconsidered Chicago: Health Administration
Press, 1998.

30 Government of Uganda. Status of Emergency Obstetric care (EMOC) in
Uganda: a national needs assessment of EMOC process indicators. Kampala:
Ministry of Health, 2003.

31 Okuonzi S A. Commodities security: the solution for preventing
maternal deaths.  Uganda Health Bulletin 2002; 8: 228-31. [PubMed]

32 Ebanyat F, Sentumbwe-Mugisa O, Mirembe R. Ensuring maternal survival
and health as pathway to development in Uganda.  Uganda Health Bull
2002; 8: 259-62 [PubMed]

33 Shutt R. The trouble with capitalism: an enquiry into the causes of
global economic failure. London and New York: Zed Books, 1998.

34 WHO. Ottawa Charter for Health Promotion. Geneva: WHO, 1986.

35 Abel-Smith B. An introduction to health: policy, planning and
financing. London and New York: Longman, 1994.
Top