BioMed Central Page 1 of 11 (page number not for citation purposes) International Journal for Equity in Health Open Access Research Changes in utilization of health services among poor and rural residents in Uganda: are reforms benefitting the poor? George W Pariyo*1, Elizabeth Ekirapa-Kiracho1, Olico Okui1, Mohammed Hafizur Rahman2, Stefan Peterson1,3, David M Bishai4, Henry Lucas5 and David H Peters2 Address: 1Department of Health Policy, Planning and Management, Makerere University School of Public Health, P.O. Box 7072, Kampala, Uganda, 2Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 North Wolfe Street, Baltimore, MD 21205, USA, 3Division of International Health (IHCAR), Karolinska Institutet, S-171 77 Stockholm, Sweden, 4Department of Population and Family Health Sciences, Johns Hopkins Bloomberg School of Public Health, 615 North Wolfe Street, Baltimore, MD 21205, USA and 5Institute of Development Studies, at the University of Sussex, Brighton, BN1 9RE, UK Email: George W Pariyo* - gpariyo@musph.ac.ug Elizabeth Ekirapa-Kiracho - ekky01@gmail.com Olico Okui - ookui@musph.ac.ug Mohammed Hafizur Rahman - hrahman@jhsph.edu Stefan Peterson - stefan.peterson@ki.se David M Bishai - dbishai@jhsph.edu Henry Lucas - H.lucas@ids.ac.uk David H Peters - dpeters@jhsph.edu * Corresponding author Abstract Background: Uganda implemented health sector reforms to make services more accessible to the population. An assessment of the likely impact of these reforms is important for informing policy. This paper describes the changes in utilization of health services that occurred among the poor and those in rural areas between 2002/3 and 2005/6 and associated factors. Methods: Secondary data analysis was done using the socio-economic component of the Uganda National Household Surveys 2002/03 and 2005/06. The poor were identified from wealth quintiles constructed using an asset based index derived from Principal Components Analysis (PCA). The probability of choice of health care provider was assessed using multinomial logistic regression and multi-level statistical models. Results: The odds of not seeking care in 2005/6 were 1.79 times higher than in 2002/3 (OR = 1.79 95% CI 1.65 - 1.94). The rural population experienced a 43% reduction in the risk of not seeking care because of poor geographical access (OR = 0.57 95% CI 0.48 - 0.67). The risk of not seeking care due to high costs did not change significantly. Private for profit providers (PFP) were the major providers of services in 2002/ 3 and 2005/6. Using PFP as base category, respondents were more likely to have used private not for profit (PNFP) in 2005/6 than in 2002/3 (OR = 2.15 95% CI 1.58 - 2.92), and also more likely to use public facilities in 2005/6 than 2002/3 (OR = 1.31 95% CI 1.15 - 1.48). The most poor, females, rural residents, and those from elderly headed households were more likely to use public facilities relative to PFP. Conclusion: Although overall utilization of public and PNFP services by rural and poor populations had increased, PFP remained the major source of care. The odds of not seeking care due to distance decreased in rural areas but cost continued to be an important barrier to seeking health services for residents from poor, rural, and elderly headed households. Policy makers should consider targeting subsidies to the poor and rural populations. Public private partnerships should be broadened to increase access to health services among the vulnerable. Published: 12 November 2009 International Journal for Equity in Health 2009, 8:39 doi:10.1186/1475-9276-8-39 Received: 5 February 2009 Accepted: 12 November 2009 This article is available from: http://www.equityhealthj.com/content/8/1/39 �� 2009 Pariyo et al licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

International Journal for Equity in Health 2009, 8:39 http://www.equityhealthj.com/content/8/1/39 Page 2 of 11 (page number not for citation purposes) Background Several factors such as proximity to health care providers, perceived quality of care, fees charged and perceived sever- ity of illness have been shown to affect access and utiliza- tion of health services [1-6]. Uganda implemented a number of health sector reforms in an attempt to improve access to health services. These included introduction and then abolition of user-fees, decentralization of responsibility for delivery of health services to local authorities, restructuring of Ministry of Health (MOH), introduction of the Uganda National Minimum Health Care Package (UNMHCP), and auton- omy for the National Medical Stores (NMS). There were also various experiments with prepayment and commu- nity health insurance schemes, contracting with health workers, and hospital autonomy. Some of the main rea- sons in favour of reforms for the health sector included failure to make appreciable progress towards the primary health care (PHC) goals of equitable health care, fragmen- tation of the health sector, and inability of the MOH to take charge of the health sector through sound policy and legislation [7]. These reforms took place along with other changes in the public sector consisting of liberalization and privatization, constitutional reforms, civil service reforms, and broader decentralization efforts [8]. Some of these reforms, however, were not based on locally gener- ated ideas, objective assessments of the existing situations, or local adaptation of interventions tried elsewhere, but on pre-packaged interventions designed by donor agen- cies [7]. In one response to reduce this problem and better harmonise resource inflows for planning in the health sec- tor, budget support mechanisms were introduced with significant amounts of donor funding channelled through the national budget process in a sector wide approach (SWAp) [9,10]. The political and civil instability during the 1970's through to the mid 1980's greatly affected health service delivery in Uganda. There was stagnation of health policy formulation, infrastructure development, health service organization and delivery. Expansion of health service delivery to rural and underserved areas was virtually impossible because of the limited health budget and inse- curity in some areas. With return of relative peace in the mid-1980s there was an influx of international humani- tarian organizations. Some of these organizations initially provided relief services like food, first aid and emergency requirements for settlement, but eventually registered locally as Non Governmental Organizations (NGO), and became involved in providing or supporting health care delivery. In the absence of a national health policy, vari- ous stakeholders and projects led to the dominance of selective vertical health programs. In an attempt to address this situation, the Ugandan government embarked on a mission of rebuilding the health sector [7,11]. One of the early reforms was the introduction of user fees in the 1980's. It was hoped that this would result in improved quality of services and subsequently increase utilization. User-fees reforms require specific design ele- ments, complementary government policies and contex- tual requirements for them to have positive efficiency and equity impacts [11]. This policy change was, however, implemented in a fragmented manner. Limited attention was paid to the design elements and contextual issues within the country, hence the policy did not result in the generation of significant additional funds or improved quality of services instead there was reduced utilization of services [7]. This was accompanied by an outcry about inability by the poor to access services, and consequently the abolition of user fees in 2001, with resulting increase in utilization in public facilities [12,13]. However, cata- strophic expenditure did not decrease among the poor [14]. Another major reform that influenced health service deliv- ery was large-scale decentralization of governance to dis- tricts with devolution of powers to allocate resources and deliver services (including health care), which was initi- ated in the early 1990's. In Uganda, decentralization was initiated largely to achieve political objectives but not pri- marily as an instrument for reforming the health sector [15]. However, the objectives for introducing decentrali- zation usually include improving planning and manage- ment through decision making that is more responsive to local needs, improving service organization by reducing duplication, increasing accountability and promoting popular participation to encourage self reliance [11]. Ena- bling frameworks, both policy and legal, were enacted in the country and it resulted in both positive and negative modifications in the organization of health services and policy formulation. On average physical access to health facilities increased from 49% (2001) to 72% (2004) of the population living within 5 km of a health facility. How- ever, changes in the health status of the population did not improve significantly as evidenced by the high infant and maternal mortality rates [15-17]. Another reform involved the provision of subsidies to the private not for profit (PNFP) health facilities since 1997. In return these facilities were expected to reduce the amount of fees levied. Some facilities were able to reduce fees substantially whereas others did not [4,18]. The fail- ure to reduce fees was attributed to the challenge of ever rising operational costs [19,20]. The PNFP's also argued that the subsidies from government only covered one third of the cost of providing care, the other two thirds being met from PNFP solicited external donors and user