Figure 21. Bujwanga Health Centre in Namayingo where an national ID card is mandated to access health care. Existing challenges to health care in Uganda The Ugandan government struggles to provide quality, accessible, and affordable health care to women like Nyirira. Maternal mortality remains high, with current estimates standing around 336 deaths per 100,000 live births;115 to compare: Sustainable Development Goal 3 calls on countries to reduce the maternal mortality rate to 70 per 100,000 by 2030. Uganda also has a high rate of adolescent pregnancy, with 25% of adolescents ages 15–19 already beginning childbearing which accounts for their high numbers of maternal health issues.116 In 2019–20, 36% of maternal deaths occurred among young mothers under 24 years of age.117 Gender and social norms, particularly when it comes to reproductive health, often prevent women and adolescent girls from accessing health care, especially family planning services.118 There are also high rates of gender-based violence, which— even when not a direct cause of health issues—has many other secondary effects, such as preventing women and girls from accessing health care. Many Ugandans, particularly those in remote and rural areas, struggle to access quality health care.119 The public healthcare system has been significantly under-resourced, 120 with funding consistently falling far short of the Abuja Declaration target of 15% of the annual budget; in the 2020/21 Budget, the percentage of spending on the health sector reached a new low of 5.9%.121 The healthcare system remains largely donor dependent and spending is fragmented on different programmes of work. Investments in physical infrastructure have not been matched by sufficient investment in staff recruitment, training, and retention, particularly in rural areas. Health centres frequently experience shortages of essential drugs122 and have limited access to clean water, electricity, and internet connectivity. Meanwhile there is low morale among medical staff, who often work for low wages in poor condition, as evidenced by the recent strikes planned by nurses and junior doctors.123 Shortcomings in the public healthcare system result in high out of pocket costs for Ugandans seeking medical assistance. This includes both informal fees, usually in the form How a National Security Approach to Uganda’s National Digital ID Has Led to Wholesale Exclusion of Women and Older Persons 51