By Okeya John
Guaranteeing equitable access to quality family planning services is known to have the effect of improving health outcomes, empowering women, reducing poverty, and promoting social justice and gender equality, although - for the most part, this remains a puzzle for Uganda.
A new Makerere University School of Public Health (MakSPSH) study, undertaken in Uganda in 2020 and published recently, has revealed the challenges thwarting efforts to promote equity in family planning and harness population health.
The World Health Organization indicates that equity in family planning resonates with the efforts for all individuals to have fair and equal access to quality family planning services. This is regardless of their geographic location, socioeconomic status, gender, and cultural background.
These services may range from contraceptive counselling, birth control pills, condoms, and intrauterine devices (IUDs), to reproductive health education - all targeted towards improving maternal and child health and promoting informed decision-making on childbearing, healthier, and more sustainable families for the greater benefit of individuals and communities alike.
Family planning, in itself, means deciding the number and spacing of children. The choice is voluntary, though the benefits accrue to the whole population. Making family planning services fair and accessible remains critical, in Uganda, this is partly hindered by the lack of common understanding of ‘equity’ in designing and implementing family planning programs among different sectoral actors including donors, policymakers, and program implementers.
Today, modern contraceptive use remains relatively low in the country, despite some progress in recent years. The 2022 Uganda Demographic and Health Survey (UDHS) reported a 38 per cent prevalence of modern contraceptive use among married women aged 15-49, with a high total fertility rate of 5.2 children per woman, and an unmet need for modern contraception of 24 per cent among the same group, and equally over 30 per cent for sexually active unmarried women.
Now, according to the new MakSPH study, which was supported by the American People through the United States Agency for International Development (USAID), and published in the International Journal for Equity in Health in March this year, equity is at the core of realizing Uganda’s 2030 national family planning agenda.
This agenda, adopted four years ago in 2020, provides a raft of commitments made by the Government of Uganda, setting in motion plans to increase access to modern contraception, reduce unmet family planning needs, and improve reproductive health outcomes, in line with SDG Three’s aim to "Ensure healthy lives and promote well-being for all at all ages," and specifically, Target 3.7: "By 2030, ensure universal access to sexual and reproductive health-care services, including for family planning, information and education, and the integration of reproductive health into national strategies and programs."
Titled: Equity in Family Planning Policies and Programs in Uganda: conceptualization, dimensions and Implementation Constraints, the study found that varied and often inconsistent definitions, measurements, and implementations of equity across different stakeholders in Uganda, were hindering efforts to engender universal access to and the utilization of quality family planning services among diverse groups in the country.
The researchers, including Mr. Noel Namuhani, Prof. Rhoda Wanyenze, Dr. Suzanne Kiwanuka, Dr. Joseph Matovu, and Ass.Prof. Fredrick Makumbi, reviewed 25 Ugandan literature and interviewed 25 key stakeholders on equity in family planning between April and July 2020, with the view to document the conceptualization, dimensions, and implementation constraints of equity in family planning policies and programs in Uganda.
From the interviews with key stakeholders who included family planning implementing partners, Ministry of Health officials, district health officers at the sub-national level, civil society organizations, and family planning researchers, the investigators cogently note that many Ugandan stakeholders interchangeably use “equity” and “equality,” hence providing a conceptual conflation that undermines agency in addressing specific needs of the marginalized.
“Most of the key informants interchangeably used equity with equality. Almost all of the key informants acknowledged that equity is a very important element that needs to be part of the family planning programming. However, most of the key informants, especially those supporting the implementation of family planning programs, noted that equity was not a focus in most of the family planning programs and does not factor into the design of specific family planning interventions,” the study reports.
As observed before by Whitehead in 1992, also quoted in the study, “Inequality could be the difference in health among different groups of people whereas inequity includes those differences which are avoidable, unnecessary, and unjust.” This distinction, the experts observe, is critical for developing and implementing responsive family planning programs that truly meet the needs of underserved populations like people with disabilities.
Also, the documents reviewed included costed family planning implementation plan, UDHS reports, Performance Monitoring for Action (PMA) reports, national and health sector development plans, research and program reports, program, policy and research briefs, fact sheets, and journal articles. Still, here, the conceptualization of equity was found to vary across programs and policy documents, with some ‘usually focusing on only one dimension of equity’, while most were also unaligned with Uganda’s family planning 2030 vision.
From the document review, only 12 of 25 documents explicitly defined equity, focusing on universal access to family planning services. The study report shows that most documents assessed equity based on geographical location (19/25), socio-demographics (17/25), and economic dimensions (12/25). The common health outcomes used for measuring equity included modern contraceptive prevalence rate, unmet need for family planning, and total fertility rate. Data sources included Health Management Information Systems (HMIS) and various surveys, although data accessibility and quality were challenging.
“To achieve the Family Planning 2030 commitments, there is a need for a common understanding and alignment of the definition of equity within the Family Planning 2030 agenda. A common understanding of equity is a prerequisite for shared practice and implementation among actors,” the study reads in part.
Adding that: “The current definitions deny policymakers and program implementers the chance to explicitly measure and target the disparities in desired fertility across different dimensions such as socio-demographics and geographical location."
In their view, the public health experts argue that policies and programs need to adopt a broad and common definition to consistently measure and track progress, highlighting that a common definition of equity would go a long way in designing policies and programs "with equity as a focus” and in the implementation of equitable family planning.
This is still far from reality, though. Around the globe, significant disparities exist, from unmet needs for family planning to low contraceptive use, especially among low-income countries like Uganda. Globally, Sub-Saharan Africa posts the highest number of women who wish to delay or stop childbearing but are not using any method of contraception, at about 23.7 per cent, with 15.8 per cent wanting to space pregnancies and 7.9 per cent seeking to limit them.
In East Africa, existing data confirms one in every four women of reproductive age has an unmet need for family planning, with Uganda leading the way for the highest prevalence of unmet needs for family planning services in the region.
What’s more, within the country, family planning disparities are also pronounced. Statistics indicate that modern contraception use is higher among educated and wealthier women, with urban areas standing at 41% and rural areas at 33%. The contraceptive prevalence rate is lowest in Karamoja (7 per cent) and highest in Bugisu and Kigezi (43 per cent). In the study, the unmet need for family planning is also higher among the poor, and lower among the wealthy, while rural areas have a higher average number of children born than urban areas, still confirming the gap.
The researchers advocate for targeted interventions to narrow iniquity, noting that: “Conceptualizing equity as equality poses a risk of family planning programs not being responsive to the needs of different groups of people, especially those left out like the rural, poor, very young and people living with disabilities. Therefore, there is a need for a clear understanding among implementers that the concept of equal access to family planning services does not necessarily address the underlying drivers of inequity, which need to be bridged.”
The study also found a major obstacle to achieving equity in family planning being the lack of comprehensive data for certain populations, such as people with disabilities (PWDs) and very young adolescents (10-14 years), highlighting that using average national estimates masks critical disparities in family planning access and utilization. To address this, the researchers call for the need for data collection that captures multiple dimensions of equity— including social, economic, geographical, and empowerment.
Key study findings also point to family planning outcomes often being assessed using modern contraceptive prevalence rates; a narrow focus that overlooks essential indicators such as unmet need, fertility desires, and demand satisfaction. The family planning programs in Uganda were also found to tend to target the general population without considering the specific needs of marginalized groups, while financial barriers and national policies that lacked specific objectives for reaching underserved populations also posed a significant challenge.
The experts underscore the need for a unified approach to promote equity in all family planning policies, calling for comprehensive actions to improve outcomes and ensure equitable access to family planning services across Uganda, as one of the key recommendations of the study towards narrowing equity in family planning.
Previously, research has offered evidence to confirm inequities in family planning have adverse effects in the form of poor health outcomes for the unreached women and children, from low birth weight and infant mortality, to maternal deaths. Particularly, young and teenage mothers are at great risk of unintended births. However, to the experts, the dilemma in addressing this challenge lies in the way equity is defined, measured, and assessed in many family planning programs and policy documents in Uganda.
Different frameworks were found to exist for conceptualizing, defining, and addressing equity in health, including the human rights framework, the PROGRESS framework, the WHO’s Priority Public Health Conditions Analytic Framework, and the equity framework, although, the researchers adopted the U.S. Healthy People framework as a benchmark to understand equity in family planning.
The US Healthy People 2020 initiative established this framework to achieve health equity, eliminate disparities, and improve the health of all groups in the country. Inequities are health differences that are closely linked to economic, social, or environmental disadvantages as the main dimensions of equity, which the study used to measure intervention outcomes to reduce inequities in family planning in Uganda.
From this study, most research participants stressed that family planning programming must include equity. However, equity in family planning efforts in Uganda remains difficult to execute. Some of the stated barriers include lack of quality comprehensive family services, duplication of programs, and a general design that fails to target those in need, hence limiting implementation.
Clients also complained about struggling with limited contraceptive information and policy constraints, such as lack of fairness in guidelines, uneven distribution of family planning programs, in addition to lack of common knowledge among implementers, client restrictions that included socio-cultural norms and myths, poverty, and expensive long-term costs. Also, other policy shortcomings identified included inadequate implementation, limited awareness of family planning policies, and absence of a multisectoral approach, underlying inefficiency.
Consequently, some districts in Uganda were found in the study to have more family planning partners, leading to duplication of services, while others had none, impacting equitable family planning access for groups like persons with disabilities, young people, and those in rural and slum areas.
There is urgent need for a common understanding of equity in family planning, comprehensive data collection, and targeted interventions to address disparities. By aligning definitions and focusing on multi-dimensional assessments, Uganda can better meet the Family Planning 2030 commitments and ensure that no one is left behind in the access and utilization of family planning services, addressing these challenges is not just about improving family planning outcomes, but also, about advancing social justice and ensuring that every individual has the opportunity to make informed choices about their reproductive health, the study concludes.
The Third National Development Plan (NDP III) seeks to harness Uganda’s human capital to increase access to family planning services and improve population health and safety. In this bid, this study is handy in highlighting the need to adopt the concept of equity in all family planning policies and programs, with a shared definition across sectors and actors, to promote equitable family planning programming and access, especially for those in most need.
Insights from this study can inform policymakers, researchers, NGOs, health practitioners, and advocates on strategies to promote equitable access to quality family planning services in Uganda, in line with the country’s vision and global initiatives.
Please find the scientific article here.
