At the first London Summit on Family Planning in 2012, Uganda was among the 36 developing countries to set out ambitious goals for themselves. President Yoweri Museveni committed to increasing Uganda’s annual budget allocation for family planning from $3.3 million to $5 million over five years, and to mobilizing additional donor funds.
As the summit reconvenes this week to take stock of progress, advocates in Uganda will be watching closely to see if the East African nation, which has one of the world’s fastest growing population rates, can maintain the momentum.
Five years on, family planning advocates and aid practitioners said Uganda got one key thing right: Political commitment. The president’s public stance set the tone for policymaking and appears to have changed the minds of previously wary cabinet members, as well as leaders in society. Yet many are still disappointed with the pace of change. The government has reduced funding and pressure from religious groups has complicated education and access.
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Uganda’s progress and challenges make the country ripe for examination as policymakers again convene to boost family planning. The 2017 Family Planning Summit, in London on July 11, is aimed at amping up political commitments and sharing best practices. Uganda shows the power and also limitations of some of those strategies — offering ideas about where new innovation or policy might be needed going forward.
Uganda’s challenge and response
Uganda has the world’s youngest population. Youth below the age of 30 make up over 78 percent of the population, while those under the age of 15 comprise more than half, according to the State of Uganda’s Population Report 2012.
Yet the situation today is far from the “dire” days of the 1990s, as Dr Jotham Musinguzi, the director general of Uganda’s National Population Council, remembers. The country’s contraceptive prevalence rate then was just 3 percent, compared to about 39 percent today among married women and 51 percent among unmarried, sexually active women. Figures show that 58 percent of the total demand for family planning is being met.
“Mortality was very high for women and children, but fortunately we reversed that,” he said.
Over the last decade, the country has reduced its fertility rate from 7.1 children per mother in 1991, to 5.8 per woman in 2014. Health Minister Dr Ruth Aceng told parliament last week that the rate should drop to 4 children per mother in order for Uganda to have a productive population.
The story of that change is one of political will, according to those who saw it unfold. Uganda’s leadership “has come from an attitude of considering family planning taboo to embracing it,” Alain Sibenaler, UNFPA Uganda country representative, told Devex.
The government first became “a bit interested” in family planning about 15 years ago, Musinguzi told Devex. Even then, the response was “lukewarm,” he said.
Also around that time, NGOs and others started to push for stronger policies. Advocates such as Musinguzi remember “prolonged interaction” with Museveni to convince him of family planning’s value.
Economics were an important part of the discussion, and ultimately, “the argument that convinced [Museveni],” said Musinguzi, whose Population Council is a semi-autonomous body within the ministry of finance planning and economic development. If Uganda can combine economic reforms with a decline in fertility, the country’s gross domestic product could increase 17-fold by 2040, compared to 2011, according to projections in a 2014 UNFPA report, Harnessing the Demographic Dividend.
When Museveni arrived in London in 2012, he was beginning to be convinced that it was time for change. Two years later, Museveni hosted his country’s own first National Family Planning Conference. Family planning, he declared, “is good for the health of the mother, good for the health of children, for the welfare of the family, for the welfare of the country.”
The presidential endorsement had a “ripple” effect, trickling down to other members of parliament, district leaders and others, said Musinguzi. Museveni today talks to cabinet members about the importance of family planning, he said.
Jackson Chekweko, executive director of NGO Reproductive Health Uganda, who will attend this week’s summit, agreed. “Previously, you could see very high-ranking officials in government talking against family planning,” he said. “But now the same people are saying ‘we are all for family planning.’ That is the influence of the president.”
That change is one of the key lessons of Uganda’s case, heading into this week’s summit, according to Sibenaler of UNFPA. “I think that’s what every country needs. You need that commitment from the head of state who says ‘this is not just for the health fraternity, not for women activists’ and so on,” he said.
Tools for change, obstacles to progress
After Museveni set a new tone, the country looked at what made family planning successful elsewhere, Sibenaler said.
“The first thing is domestic resources, that you have to dedicate a line in your budget that secures contraceptives and that’s what Uganda has done,” he said. In 2014, for example, the country boosted spending on reproductive health commodity procurement from $3.3 million in 2012, to $6.6 million, according to UNFPA figures.
Uganda also made the case to civil society and the public that there was a link between family planning and economic development, he said. “Investing in family planning will be beneficial because you improve the status of women, of families, and empower your population in a way to become economic agents rather than passive agents.”
In November 2014, the ministry of health and partners developed the Uganda Family Planning Costed Implementation Plan 2015-2020, to set out guidelines and strategies for interventions. Costing a total of $235 million between 2015 and 2020, the plan aims to increase the number of women in Uganda using modern contraception from about 1.7 million in 2014 to 3.7 million in 2020.
Yet by some of its own metrics, Uganda isn’t performing as well. Donors contributed the bulk of the $6.7 million total annual funding for reproductive health commodity procurement in 2016, according to figures from UNFPA. The government, meanwhile, has reduced funding, from $6.6 million in 2015 to $560,000 in 2016.
Although Musinguzi said the process of implementation “is going fairly well,” he told Devex, “What’s still challenging is inadequate funding.”
A local civil society group in Uganda is suing the government to compel the teaching of sex education, after a blanket ban on the subject last year. The debate crystalizes ongoing tensions about how to balance conservative social norms with the need for awareness in a youth-heavy population at risk from HIV transmission.
“The amount that donors put in is so much more substantial than the government, so if they withdrew it would be a disaster,” said Musinguzi. He said the country needs between $15 million to $20 million to be able to sustain its progress.
Advocates such as Chekweko hope the summit will encourage the government, represented at the meeting by Dr. Aceng, to invest more. “We have gone backwards [in funding], so we are looking for the recommitment to be made, and we are pushing for $5 million or more,” said Chekweko.
New funding could help address some of the emerging challenges blocking progress. Sibenaler says two major priorities are addressing low rates of condom use and high teenage pregnancy rates, which stand at 25 percent. Museveni highlighted the latter issue last week, saying that “more efforts should be put into dealing with the root cause of the problems of teenage pregnancy.”
Yet that issue in particular is complicated by social norms. Religious groups recently successfully pushed for a ban on comprehensive sexuality education that Chekweko worries could set back progress. “They [the youth] need information, now you are saying ‘stop giving information,’” he said.
The power of church groups in Uganda is another reason why Musinguzi wants to see continued political commitment from Museveni. “When you have the Catholic church telling people ‘don’t use family planning,’ you need credible leaders at national level, district level, to continue guiding people properly,” he said.
Musinguzi said the Population Council would continue with their advocacy at all levels of leadership. He said he hopes NGOs such as RHU will continue to hold the government accountable.
“Five years is nothing compared to the journey we are going to walk in order for the country to benefit from the demographic dividend, because policies have to be there for quite a long time,” said Musinguzi.
“We are just beginning a long journey, but we are sowing the seeds for that profound journey.”
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