Lack of interest among political leaders and policy makers has undermined implementation of policies and guidelines that guarantee access to reproductive health services and commodities. There are many challenges in accessing essential reproductive health commodities and there is need for stronger commitment to enable all Ugandans realise their sexual and reproductive health rights
Why reproductive health supplies?
Secure and sustained access to quality and affordable reproductive health (RH) commodity supplies is a critical driver of reproductive and sexual health. The concept of reproductive health commodity security (RHCS) requires that every person should be able to choose, obtain, and use quality contraceptives, medicines and other medical products for prevention and treatment of sexually transmitted infections (STIs), and to ensure healthy pregnancy and delivery whenever they need them.
The potential health impact of availability and access to essential reproductive health commodities is the foundation for the wellbeing of individuals and families. Simple iron folate preparations can reduce maternal and child mortality from pregnancy-related anaemia; family planning can reduce the rate of unintended pregnancies and risky abortions; and STI treatment can reduce HIV transmission.
Guaranteed access to these commodities is therefore necessary if Uganda is to make visible progress on the Millennium Development Goals (MDGs) and the goals set in the Programme of Action of the 1994 UN International Conference on Population and Development (ICPD).
Reproductive health commodities are many. However, the Ministry of Health in partnership with other stakeholders have drawn the list of essential reproductive health commodity supplies for Uganda. The list (in the table below), includes the 10 commodities recommended by the World Health Organisation (WHO) and the UN Population Fund (UNFPA).
Reproductive health commodity security: The broken promise
It is important to emphasize that it is impossible to have commitment to reproductive health without commitment to RHCS. Such commitment is empty and deceptive. “Trying to run sexual and reproductive health programmes without contraceptives and other reproductive health commodities is like trying to eradicate smallpox without vaccines. It simply cannot be done.”3
The Ministry of Health underscores the critical role of RHCS in attaining better reproductive health status and sustaining services, as stated in the Strategy to Improve Reproductive Health in Uganda (2005-10), and the National Family Planning Advocacy Strategy. The second Health Sector Strategic Plan (HSSP II) targets an increase in contraceptive prevalence rate (CPR) to 40% from the current 23%; full availability of condoms
(100%); eliminate drug stock-outs, including RH commodities in 80% of health units; and provide emergency contraceptives in 60% of health units – all by end of June 2010.
In spite of these and other policy commitments and promises, stock-outs of all drugs, including RH commodities, occurs regularly.
According to the Annual Health Sector performance report 2005/06, 73% of health units had a monthly stock-out of one or more tracer RH commodities and availability had actually deteriorated over the last two years, as the unmet need for reproductive health commodities continues to rise. The annual tracking of essential drugs found that the availability of Depo-Provera, an injectable contraceptive, has varied widely in recent years, with 16% of facilities having a monthly stock-out in 2006/07.
Even though the stock level of RH supplies at central level is officially described as adequate, National Medical Stores (NMS) experiences stock-outs. For instance, in February 2009, NMS was stocked out of one brand of implants and had an inventory of less than two weeks supply of Microgynon, an oral contraceptive, with the next shipment not expected until two months later. The stock levels of four other methods (condoms, a second brand of implants, IUDs and a second brand of oral contraceptives) were lower than the recommended six months of supply.
These supply problems translate into access problems. According to the Uganda demographic health survey (UDHS) of 2006, contraceptive prevalence rate (CPR), which refers to the percentage of married women who are using any method of family planning, is a dismal 24%. At 41%, Uganda’s unmet need for family planning is the third-highest rate in the world! Less than half of women (47%) make the recommended four antenatal care (ANC) visits.
Only 17% of women make their first visit during the recommended first three months of pregnancy.
The quality of ANC is poor because health facilities are short of supplies. The Sexual and Reproductive Health Policy Guidelines for Uganda recommend that women visiting health centres for ANC receive, among other things, supplements of iron and drugs for intestinal parasites, and are weighed, their blood pressure measured and urine and blood samples analysed. Many women do not get this minimum package because women cannot afford or because supplies are simply not available. For instance, only about half of pregnant women (51%) receive the recommended two tetanus toxoid (TT) immunizations.
The price we pay for failure to secure access to RH commodities
Action is urgently needed for reproductive health. The population of Uganda, which was 24.7 million in 2002, is projected to reach 54.8 million by 2025 and, if the trend is not checked, 103 million by 2050! This high population growth rate (3.4%) ranks among the highest in the world, and is attributed to the country’s high fertility rate of 6.7 children. The bulk of the population is below 18 years (55%), meaning a high dependence burden. It is estimated that every working adult, on average, supports 12 dependants.
Many women and their babies get complications and live a poor quality of life because pregnancies are too many and not spaced. According to the Ministry of Health, maternal and neonatal conditions continue to contribute the highest (20.4%) to Uganda’s total burden of ill health and avoidable death. Pregnancy and childbirth-related complications are among the leading cause of death and disability in women of reproductive age.4 The maternal mortality rate (MMR) stands at 435 per 100,000 live births, which translates into about 6,000 deaths per year.
5 One in every five of these deaths are due to unsafe, illegal abortions partly because many women who do not want to be pregnant are not using contraceptives.
Why the concern about reproductive health?
Reproductive health care is vital for improving the well-being of men and women and achieving development.
6 The use of modern contraceptives, for example, helps couples avoid unintended pregnancies and protects both mothers’ and children’s health. Other reproductive health care helps women have healthy pregnancies and helps protect women and men against STIs and HIV/AIDS.
These links between reproductive health and socio-economic development were first clarified at the landmark ICPD meeting held in Cairo in 1994, and have since been cited by the UN and World Bank. The ICPD programme of action made reproductive and sexual rights a priority and explicitly stated that it is the right of all men and women to be “informed and to have access to safe, effective, affordable, and acceptable methods of family planning of their choice, as well as other methods of choice for regulation of fertility, which are not against the law,” and that they have “the right of access to health care services that will enable women to go safely through pregnancy and childbirth.”
7 In addition, national legal instruments and policies oblige the state of Uganda and government to ensure all Ugandans realise their fundamental rights, including the right to health.
8 The Constitution gives government the responsibility to fulfil the fundamental rights of all Ugandans to social justice and economic development.
This requires government to do everything in policy, law and action to ensure people access and afford health services.
For instance, the National Population Policy (2008) recognises that all couples and individuals have the basic right to decide freely and responsibly the number and the spacing of their children, and to have access to information and education in order to make an informed choice; and the means to do so. It recognises that health, in particular reproductive health, is a basic human right, and specifically points out the importance of commodity security and increased budgetary allocation for reproductive health.
RH commodities are starved of funding
The national Health Policy states that the priority for government funding will be the UNHCP, which includes reproductive health. By defining a minimum package, government has committed itself to make this package available and effective. At the operational level, however, the delivery of the minimum package has been rendered ineffective and inefficient, because government is trying to attain universal access with $8 per capita instead of $28. There is such high dependence on donors that between 50-70% of MoH budget for drugs consists of donations. Direct contraceptive funding from UNFPA and USAID represents about two-thirds of the total government budget for contraceptives. Government covers only 14% of the national contraceptive need.
What is worse is that even this small government contribution is not fully forthcoming. For instance, government has allocated Ushs 1.5 billion per year to reproductive health commodities since 2005/06, but much of this
money is either not disbursed or is diverted. For instance, spending on contraceptives has been between 2-6% of allocated funds! The MoH has estimated a 30% gap between contraceptive need and actual availability.
Making Health Rights and Health Responsibilities a Reality
Scarcity amidst plenty
The quantities of RH commodities at the national level are officially described as sufficient, but logistics and procurement management are seen as the problem areas. Procurement planning is weak, and distribution breaks down somewhere at the district level. One problem is that RH commodities are provided on a “third party” basis, meaning that there is no cost to districts to order them but also no financial benefit to National Medical Stores (NMS) for supplying them. Poor stock management in the past months led NMS to destroy expired commodities worth Ushs 800 million, a quarter of which were contraceptives.
Procurement systems are grossly inefficient and wasteful. The MoH and each of its major donors of RH supplies (USAID and UNFPA) handle their own procurement of contraceptives. Moreover, donor coordination related to the delivery of supplies is weak. The MoH normally knows the quantity of contraceptives needed, but it is not always sure what donors will commit and the timing of shipments.
The distribution system does not make timely delivery. The transference of logistics information between NMS, districts and facilities is extremely problematic. The integrated health management information system (HMIS) to monitor consumption for purposes of focusing demand are often full of errors or outrightly not filled, or are not received on time. At NMS, problems range from poor forecasting, too few vehicles and late disbursement of funds from MoH.
Three methods of hormonal contraceptives are included on the national essential medicines list (EML) – implants, injectables and oral contraceptives. They should be included on the national credit line of vital products as well, to increase their prioritisation during ordering.
Government must translate national and international commitments into concrete action by increasing and guaranteeing financing, improving the logistics systems, procurement, and effective service delivery to enable Ugandans realise their reproductive health rights. Ensuring access to high quality reproductive health information, products, and services requires commitment, not only in policy but in action as well. The existing policies and guidelines, are sufficient to improve access to RH commodities, and are being strengthened with new strategies for commodity security. But these policies and strategies count for nothing when they are not implemented. This lack of attention is counterproductive.
1 Ministry of Health, “Uganda Reproductive Health Commodities Situation Analysis”, December 2008
2 Elizabeth Leahy and Esther Akitobi, “A Case Study of Reproductive Health Supplies in Uganda”, Population Action International, June 2009
3 Stephen Sinding, Director-General, International Planned Parenthood Federation in a presentation at a conference on challenges and solutions to safeguard sexual and reproductive health and rights, February 12, 2003; Stockholm, Sweden
4 Ministry of Health, “Health Sector Strategic Plan 2005/06-2009/10 (HSSP II)”
5 Uganda Bureau of statistics (UBOS) and NUCHA (Monitoring reproductive health service delivery in Lira district, unpublished report, September 2009)
6 Population Reference Bureau (2005): “Investing in Reproductive Health to Achieve Development Goals”
7 UNICDP, Reproductive rights and reproductive health, cap.7, 2006, http://www.unfpa.org/icpd/summary.htm#chapter7
8 The Right to Health is enshrined in Article 25(1) of the Universal Declaration of Human Rights; Article 12(1) of the International Covenant on Economic, Social and Cultural Rights; and Articles 16(1) and 6(2) of the African Charter on Human and People’s Rights.
For more information, contact HEPS-Uganda
[Coalition for Health Promotion and Social Development]
Plot 683, Bishop’s Way, Namirembe Hill
P.O. Box 2426, Kampala; Tel: +256-414-270970