Reproductive Health Financing for Uganda: Advocacy with Concrete Outcomes

Publication date: 2013

Photo credit: Canadian Foodgrains Bank HEALTH POL ICY P R O J E C T Partners in Population and Development Africa Regional Office REPRODUCTIVE HEALTH FINANCING FOR UGANDA Advocacy with Concrete Outcomes August 2013 Overview Over the past four years, the government of Uganda (GOU) has demonstrated an increased commitment to increase funding for family planning and reproductive health (FP/RH) commodities. As a result of advocacy efforts spearheaded by local partners, the GOU increased its contribution for the provision of FP/ RH commodities from US$0.5 million in financial year (FY) 2009/10 to US$6.8 million in FY2013/14. The allocated funds for FY 2013/14 are part of a new commitment made by Uganda’s president, Yoweri Kaguta Museveni, at the London Family Planning Summit in July 2012. This brief highlights the advocacy process used to generate increased funding commitments for FP/RH commodities, the steps needed to ensure that the allocated funds fully translate into the procurement of FP commodities, and how advocates can sustain the momentum in the coming years. Introduction Uganda’s population was projected at 34.1 million people in 2012 (UDHS, 2011). The annual population growth rate of 3.2 percent (UDHS, 2011) implies that Uganda’s population increases by more than one million people every year. Many factors contribute to this high population growth rate, but the fertility rate—6.2 children per woman—stands out (UDHS, 2011). The high level of fertility is partly explained by low access to contraceptives: the contraceptive prevalence rate (CPR) among married women is 26 percent and unmet need for family planning services is 34 percent (UDHS, 2011). The GOU’s Health Sector Strategic Plan III 2010/11– 2014/15 highlights family planning as a low-cost and cost-effective intervention to avert the high maternal mortality ratio and infant mortality rate, 438 maternal deaths per 100,000 live births and 56 deaths per 1,000 live births, respectively (UDHS, 2011). However the Brief Diana Nambatya Nsubuga Partners in Population and Development Africa Regional Office 2 August 2013 allocation, disbursement, and utilisation of government funding for FP remain inadequate. To address the high unmet need for family planning, mechanisms are needed to ensure that civil society organisations (CSOs) can easily access contraceptive supplies through an alternative distribution system. Private not-for-profit organisations (PNFPs) including nongovernmental organisations (NGOs) and CSOs comprise an important part of the family planning programme in Uganda. Fifty-two percent of women in Uganda have access to family planning services through the private sector (PACE, 2012). However, for several years, PNFPs did not receive contraceptives from the National Medical Stores (NMS) due to accountability concerns over pricing. Approach In response to these challenges, local advocates established an objective of advocating for increased government funding for FP/RH commodities and ensuring that the allocated funds fully translate into procurement of FP supplies. To achieve the objective, these partners undertook the following interventions: ƒ An advocacy plan was developed using the Spitfire Strategies Smart Chart approach. The plan specified key stakeholders and target audiences to be reached, as well as key messages, messengers, and specific activities to be undertaken. ƒ Several meetings were held with the key players in funding, procuring, and managing FP/RH commodities in Uganda. These included the Ministry of Finance, Planning and Economic Development (MOFPED), the Ministry of Health (MOH), and NMS. ƒ Evidence-based messages were used to convince the target audiences of the benefits of investing in family planning, and its contribution to Uganda’s development goals. For example, fulfilling unmet need for family planning would generate significant cost savings in meeting five of the Millennium Development Goals: achieving universal primary education; reducing child mortality; improving maternal health; ensuring environmental sustainability; and combatting HIV/AIDS, malaria, and other diseases. The savings would be nearly two times greater than the increased costs of family planning (USAID Health Policy Initiative, 2009). Photo credit: Julio Gonzalez 3 REPRODUCTIVE HEALTH FINANCING FOR UGANDA Advocacy with Concrete Outcomes ƒ A consultant worked with NMS, MOH, MOFPED, NGO service providers, and Partners in Population and Development Africa Regional Office (PPD ARO). The consultant used formal and informal communication channels over a period of 12 months to ensure that committed funds from MOFPED to NMS are captured (“locked”) into the Contraceptive Procurement Tables (CPTs) used to project future funding requirements and any gaps. ƒ The consultant conducted a desk review of financing for reproductive health supplies from the inception of the reproductive health supplies budget line in 2008/9. ƒ Advocates convened coordination meetings with NMS, the MOH Reproductive Health Division, MOFPED, the NGO sector, and CSOs. The meetings ensured that all participants obtained the necessary information to increase funding and improve access to FP, including formal communication letters, verification of figures, tracking funding, and progress on the procurement processes and approvals. ƒ Advocates met with CSOs about the progress towards improving access to contraceptives, the concerns of MOH and NMS, and performance and compliance with the MOH directive to provide contraceptives to six selected NGOs. Outcomes The outcome of these advocacy meetings was MOFPED, MOH, and Parliament agreeing to increase government funding for FP commodities. MOFPED also agreed to transfer FP funds directly from the MOFPED account to NMS through the creation of Vote 116 in financial year (FY) 2009/10, and to create a clear mechanism for NGOs to access contraceptives free of charge from NMS. Vote 116 enabled NMS to reduce the lead time for processing and accessing funds and to enter into long-term framework contracts with suppliers. It also ensured that funds are released from MOFPED directly to the NMS at the beginning of the fiscal year, allowing NMS to procure in bulk. This contributed to the achievement of 100 percent expenditure on procurement of contraceptives and other RH supplies. Achievements Realised— Increased Funding Commitments The GOU has increased its expenditure on procurement of contraceptives and selected RH supplies more than fivefold—from approximately UGX 1.4 billion in FY2009/10 to UGX 7.5 billion in FY2012/13, as shown in Figure 1. This is a great milestone for the Uganda family planning programme; however, it is important to ensure that the funds allocated are fully spent. In FY2005/06, the GOU allocated US$0.78 million towards procurement of FP/RH supplies, but only 37 percent of this was spent (FY2005/06 Budget Framework Paper). The trend continued in FY2006/07, with allocation decreasing to US$0.74 million and actual expenditure declining to 23 percent. This situation deteriorated even further in FY2008/09 and 2009/10, when there was no expenditure on FP/RH supplies using GOU funds. Further analysis of allocations and expenditures and discussions with NMS and MOH officials revealed a backlog of funds that had been released to NMS but were not used because of the 8–12 month lead time for public procurement. This backlog included US$73,600 that had been committed to NMS in an opened Letter of Credit for FY2008/09 and an additional US$560,000 for FY2009/10. Once the backlog of funds was identified, NMS executed procurements that were realised in FY2010/11. PPD ARO and its partners lobbied MOFPED to allocate the backlog of funds for FY2008/09 and 2009/10. The backlog of funds was added to the FY2010/11 allocation of $1.9 million, making a total of US$2.7 million available; the money was spent on procurement of FP/RH supplies (FY2010/11 NMS Vote 116 Allocations). In addition to eliminating the NMS funding backlog, the GOU became a leading funder of FP/RH commodities in FY2010/11, following the U.S. Agency for International Development (USAID) and the United Nations Population Fund (UNFPA). The GOU increased its contribution to the country’s total provision of 4 August 2013 contraceptives from less than 5 percent in FY2009/10 to 36 percent in FY2010/11. This represents an historical shift in the financing of FP/RH supplies in Uganda. The increased political commitment to FP/RH was evident at the 2012 London FP Summit when the president of Uganda committed the government to allocating US$5 million annually over the next five years, commencing in FY2013/14. This major shift in GOU policy was significantly influenced by parliamentarians, development partners, civil society, and other partners advocating at high levels in government and providing technical assistance to track the funding and ensure that allocations are spent as planned. In FY2012/13, the government allocated UGX 8 billion for the procurement of contraceptives and selected reproductive health supplies. Tracking of releases from MOFPED is ongoing to ensure that all funds are released and spent by NMS. The current draft budget framework paper for the health sector for FY 2013/14, shows that the government has allocated UGX 8 billion for the procurement of contraceptives and selected RH supplies on Vote 116, and the World Bank RH Systems Strengthening Project has allocated an additional US$3.6 million. The total estimated allocation is US$6.6 million. This reflects the impact of the president’s pledge at the London Summit. However, Figure 1 indicates that funds for FY2013/14 have been allocated but not yet released/ spent—hence the need to keep track. NGOs’ Access to Contraceptives In 2010, lobbying from advocacy partners led the MOH to issue a directive that NMS contraceptives be provided to six selected NGOs, with new accountability mechanisms created to label these commodities to indicate their origin. The six NGOs are also permitted to distribute these supplies to other CSOs. This policy change has improved the supply flow of FP/RH commodities in the private sector. Figure 1. Government of Uganda Funding for FP/RH Commodities: Allocation versus Expenditure, 2005/06–2013/14 (US$ millions) Source: NMS Procurement Contracts and Delivery notes (2005–2013) 2005/06 2006/07 2007/08 2008/09 2009/10 2010/11 2011/12 2012/13 2013/14 Allocated: 0.78 0.74 0.73 0.75 0.65 1.9 3.3 3.3 6.8 Spent: 0.29 0.17 0.28 0 0 2.7 3.3 3.3 6.8 0 1 2 3 4 5 6 7 8 M ill io n U SD Projected Expenditure 5 Lessons Learned ƒ Increased resources from GOU have made reproductive health supplies more readily available in health facilities at the lower levels. ƒ The alternative distribution system has been efficient in disbursement of supplies to PNFPs including NGOs/CSOs. ƒ Vote 116 has shortened the lead time from requisition to disbursement. ƒ NMS has complied with the schedule for giving supplies to Uganda Health Marketing Group (UHMG) with support from USAID, which holds the contraceptives for the NGOs based on an agreement among MOH, USAID, and UNFPA. Henceforth CSOs can readily access contraceptives. Next Steps To further reduce the unmet need for FP, advocates should ƒ Mobilise additional resources for the alternative system to extend beyond the PNFPs and projects to serve the private for-profit sector, mainly the private hospitals/clinics/pharmacies. ƒ Provide oversight to ensure that current allocations (UGX 8 billion for FY 2013/14) on Vote 116 are maintained. ƒ Continually track allocations to ensure the 100 percent expenditure of funds. REPRODUCTIVE HEALTH FINANCING FOR UGANDA Advocacy with Concrete Outcomes Photo credit: Fabio Beretta 6 REPRODUCTIVE HEALTH FINANCING FOR UGANDA Advocacy with Concrete Outcomes The Health Policy Project is a five-year cooperative agreement funded by the U.S. Agency for International Development under Agreement No. AID-OAA-A-10-00067, beginning September 30, 2010. It is implemented by Futures Group, in collaboration with CEDPA (part of Plan International USA), Futures Institute, Partners in Population and Development, Africa Regional Office (PPD ARO), Population Reference Bureau (PRB), RTI International, and the White Ribbon Alliance for Safe Motherhood (WRA). The information provided in this document is not official U.S. Government information and does not necessarily represent the views or positions of the U.S. Agency for International Development. Contact Us References Ministry of Finance, Planning, and Economic Development/National Medical Stores. (Various). Vote 116 releases, 2011–2013. Ministry of Health. (2005). National Family Planning Advocacy Strategy 2005–2010. Ministry of Health. (2009). Reproductive Health Commodity Security Strategic Plan 2010/11–2014/15. Ministry of Health. (2011). Annual Health Sector Performance Report FY 2010/11. Ministry of Health. (2012). Ministerial Policy Statement FY 2012/13. National Medical Stores. (2013). Procurement Updates. Uganda Bureau of Statistics. Uganda Demographic and Health Survey (UDHS) 2000–2011. Ministry of Health.(2005). Health Sector Strategic Plan III 2010/11–2014/15. Ministry of Health. (2011). Reproductive Health Supply Plan 2011/12. National Medical Stores. (2011/12). Contraceptive Quantification Report. Program for Accessible Health, Communication and Education (PACE). (2012). Family Planning in Uganda. Partners in Population and Development Africa Regional Office (PPD ARO). (2012). Contraceptive Finance Tracking Report FY2011/12. USAID Health Policy Initiative. (2009). Achieving the MDGs: The Contribution of Family Planning, Uganda. Partners in Population and Development Africa Regional Office (PPD ARO) Statistics House, Third Floor, Room 3.2 9 Colville Street P.O. Box 2666 Kampala, Uganda aro@ppdafrica.org

View the publication