By John Okeya
KAMPALA, Uganda — In a bid to revolutionize family planning (FP) programs both locally and globally, the Ministry of Health, in partnership with Makerere University School of Public Health (MakSPH), have been spearheading a major research initiative. This effort, supported by the USAID-funded Research for Scalable Solutions (R4S) project, seeks to generate robust evidence that will inform scalable, equitable, and effective FP programs. By enhancing the use of evidence, the project seeks to increase access to voluntary family planning and improve the timing and spacing of births, ultimately leading to better health outcomes.
The Ministry of Health, together with MakSPH and the FHI360-led R4S project, recently hosted a dissemination workshop to validate the findings of a critical study on family planning practices in Uganda titled "Assessing the Scale, Reach, Quality, and Cost of Service Delivery High Impact Practices in Family Planning." The study calls for the adoption of high-impact practices to maximize the benefits of family planning and improve reproductive health across the nation. This workshop marks a significant step towards implementing evidence-based strategies to enhance the effectiveness of FP programs in Uganda and beyond.
During the May 8, 2024, stakeholders workshop held at the Golden Tulip Hotel in Kampala to discuss the study findings, over 100 family planning stakeholders including implementing partners, health managers, service providers, development partners, policymakers, the media, and academics focused on integrating postpartum contraceptive use, community health work, and drug shops in promoting family planning in Uganda, assessing the scale, reach, quality, and costs of these high-impact practices.
Prof. Rhoda Wanyenze, the Dean MakSPH, in her opening remarks, emphasized that disseminating results under R4S, a project focused on conducting implementation science research to improve the efficiency, cost-effectiveness, and equity of family planning programs in Africa and Asia, was key towards engaging all stakeholders for generating evidence-based policy and practice.
“Traditionally, I know researchers have been looked at like we are in our ivory tower. We design our questions, answer them and come to you with conclusions. I think the way we have worked under research for scalable solutions, and increasingly in the School of Public Health, is that we must engage when designing the research questions and follow them throughout the entire cycle. So, we must sustain that.” Prof. Wanyenze argued.
Research for Scalable Solutions (R4S) works with various country research agencies to strengthen research capacity, support countries in their journey to self-reliance and generate evidence for developing feasible, sustainable strategies to implement High Impact Practices (HIPs) and self-care interventions equitably and at scale. FHI 360, a global organization that mobilizes research, resources and relationships for people everywhere to access the opportunities to lead healthy lives, provides strategic vision, technical leadership, oversight, and financial management of the R4S project, funded by the U.S. Agency for International Development (USAID). While MakSPH leads the R4S technical arm in Uganda.
Today, family planning remains critical in Uganda, with significant implications for public health, socio-economic development, individual and family well-being. While efforts have been made to promote family planning services and education, numerous challenges still persist, contributing to high fertility rates and limited access to contraceptives for many in need.
As of June 2021, more than 3.8 million women of reproductive age are using contraceptives in Uganda. Uganda has one of the youngest populations (68.5%) and the highest fertility rates globally. About 1.2% of girls aged 15-19 and 4.5% of women aged 20-24 had their first birth by age 15. Modern contraceptive use among young people is very low, with over 40% of pregnancies under age 20 unintended. This leads to high unplanned births, unsafe abortions, maternal morbidity/mortality, and school dropouts. Extending voluntary family planning (FP) care to young people is crucial, but they face significant access challenges.
In July 2012, at the London Summit on Family Planning, Uganda committed to attaining universal access to Family Planning (FP). In 2017, it further renewed its commitment, extending it to cover adolescents and young people as a commitment to the present and future mothers and children. Further, Uganda made commitments at the FP2030 re-affirming Family Planning as a priority intervention.
Dr. Richard Mugahi, the Assistant Commissioner for Reproductive and Infant Health Services at the Ministry of Health said Uganda has a high rate of unintended pregnancies, revealing that: “Almost 45 percent of our pregnancies are unintended and 62 percent of these are in teenage age. When we strengthen family services we address that huge burden. So, having services like immediate postpartum family planning is very critical in reducing unintended pregnancies.”
In the study, a phased cross-sectional observational approach was employed, using methods that involved conducting indicator inventory to document monitoring indicators, interviews with the Ministry of Health to assess vertical scale and analyzing routine service statistics for horizontal scale and reach. Plus, key informant interviews with implementing partners, and surveys with community health workers and health providers across the five districts in Uganda, including Kampala, Mukono, Kyenjojo, Tororo, and Gulu.
Additionally, an activity-based costing approach from a government perspective was used to estimate implementation costs. The high impact practices of family planning are defined in the study, as a set of evidence-based family planning practices that are vetted by experts against specific criteria and documented in an easy-to-use format.
Immediate Postpartum Family Planning
Family planning offers control over one’s reproductive health and informed choices about the timing and spacing of pregnancies. From the study on understanding the Implementation and Measurement of Immediate Postpartum family planning in Uganda: Scale, Reach, Quality and Costs, the research showed that offering modern contraception services as part of facility-based childbirth care prior to discharge has the potential to increase postpartum contraceptive use and reduce unintended and closely spaced pregnancies.
Postpartum contraceptive use, here, means the utilization of contraception by women after giving birth to prevent unintended pregnancies in the period following childbirth. This, normally, includes various methods such as condoms, birth control pills, intrauterine devices (IUDs), or hormonal injections, to help women space pregnancies and plan families according to their preferences and health considerations.
In Uganda, data shows that about 15 percent of women give birth every year and 12 percent of the postpartum mothers are not using a modern contraceptive method. To the researchers, this presents the opportunity to invest in Immediate Postpartum Family Planning (IPPFP);
“However, there is no universal understanding of how to measure and implement IPPFP in Uganda. There is limited information on the scale, reach, quality, and costs associated with the implementation.” Their preliminary study report reads in part.
The results disseminated showed that awareness of IPPFP high impact practice is currently limited to only implementing partners, with challenges spanning staff overload, limited supplies, resource constraint affecting integration into national policies, and lack of readiness manifested in gaps in commodities and supplies and capacity confidence at health facilities.
For the integration of immediate postpartum family planning in Uganda, the study recommendations include the need for the health ministry and partners to prioritize awareness and dissemination of the IPPFP high impact practices, address persistent commodity stock-outs, provide ongoing capacity building for IPPFP providers, and integrate IPPFP into the standard of care to reduce implementation costs and scale up efforts in Uganda.
Integrating Drug shops for Family Planning
The second segment of the study, sought to understand the Implementation and Measurement of Drug shops for family planning in Uganda: Scale, Reach, Quality and Costs, highlighting that training and supporting drug shop operators can, indeed, facilitate the use of a broad range of modern contraception, especially in areas where ‘the unmet need is high, access to family planning services is poor, and health worker shortages and other barriers prevent women, men, and youth from accessing family planning services.’
However, it is noted in the study that the challenge comes where there is no universal understanding of how to measure and implement drug shops high impact practices for family planning in Uganda, coupled with limited information on the scale, reach, quality and costs associated with implementing the strategy to boost family planning.
In their inquiry, preliminary findings indicate a widespread awareness of high impact practices among key informants, but limited utilization. Challenges also included high operator turnover and resource constraints, despite integration into national policies. Monitoring and rolling out guidelines were hindered by resource limitations, and while several indicators exist for tracking, challenges remain in data collection and client differentiation, and, although policy standards were generally met, readiness standards regarding availability and operator training fell short.
Among the recommendations in the integration of drug shops for family planning, the Ministry of Health and partners ought to provide drug shops with necessary reporting tools, while also focusing on raising awareness and disseminating the high impact practices to encourage its application, alongside addressing persistent stock-outs and conducting support supervision to enhance the quality of implementation.
Integrating Community Health Workers for Family Planning
This study area aimed at: Understanding the Implementation and Measurement of Community Health Workers/VHTs for family planning in Uganda: Scale, Reach, Quality and Costs, noting that integrating trained, equipped, and supported community health workers into the health system carries the potential to bridge the access gap to contraception.
Community health workers are highlighted as critical to reducing inequities in access to services, bringing information, services, and supplies to women and men in the communities. The study notes, however, that there is no understanding of how to measure and implement community health workers' high impact practices for family planning in Uganda.
Key preliminary findings revealed that while awareness about community health workers' high impact practices is high among stakeholders in Uganda, challenges still persist, including limited comprehensive data capture and poor motivation, monitoring and guideline rollout face resource constraints and while indicators for tracking exist, distinguishing community health worker-served clients poses a challenge. Additionally, readiness standards highlight gaps, particularly in availability of commodities and training.
In light of the study's findings, key recommendations were made including urging the Ministry of Health and partners to promote awareness and utilization of high impact practices among community health workers, equipping them with standardized reporting tools to enhance data collection and reporting and integrating them into the standard of care for sustainability.
“What came out of this meeting is the importance of family planning, which the Ministry of Health is considering as a strong pillar for safe motherhood. It is very important because it directly reduces maternal mortality.” Dr. Richard Mugahi.
