Leveraging Social Accountability to Include Family Planning in Country-Level Universal Health Coverage: Four Lessons Learned from PAI’s UHC Engage Project
Over the past two years, under our UHC Engage project, PAI and civil society partners in sub-Saharan Africa and Asia have focused on the opportunities to advance sexual and reproductive health and rights, including family planning, as part of universal health coverage reform. The challenge is that universal health care is multifaceted and country-specific in nature. Decoding the policy and financing reform environment for each country is key to illuminating the openings that exist for civil society to engage policymakers to increase access to sexual and reproductive health services for everyone, especially women and girls.
The details of emerging policies at the country level are not widely available at the global and regional levels and the country briefs in our Decoding Country-Level UHC Financing Policy series fill this critical knowledge gap.
In Uganda, policymakers introduced a bill in 2019 to create a National Health Insurance Scheme — an important first step for the country’s universal health care financing agenda. Government officials have consulted civil society and local communities along the way to ensure a comprehensive foundation for the most significant health policy and financing reform in decades.
Family Planning Advocacy in Uganda
The goal of universal health coverage (UHC) is inspiring landmark political and systemic change all over the world to guarantee access to the quality services people need — spanning preventive through palliative care — and financial protection to ensure they are not pushed into poverty by realizing their right to health care. However, the details of emerging policies at the country level are not widely available at the global and regional levels. Through the UHC Engage project, PAI and partners collaborated to develop a series of publications demystifying country-specific UHC financing policies to illustrate family planning (FP) advocacy opportunities and inform the international dialogue. As each country is in a different stage of UHC financing reform, these briefs deconstruct UHC policy processes in real time, illuminate multifaceted examples for advancing FP in UHC-oriented policies and offer insights across multiple contexts for sexual and reproductive health and rights (SRHR) advocates to strengthen global action.
In Uganda, policymakers introduced a bill in 2019 to create a National Health Insurance Scheme (NHIS) — an important first step for the country’s UHC financing agenda. Government officials have consulted civil society and local communities along the way to ensure a comprehensive foundation for the most significant health policy and financing reform in decades. Early in policy discussions, the government engaged Partners in Population and Development Africa Regional Office (PPD ARO), which plays a pivotal convening role between civil society and policymakers. In future advocacy opportunities with the Ministry of Health (MoH), PPD ARO will prioritize ensuring that essential FP commodities and services are included in the policies, guidelines and regulations operationalizing the NHIS following the legislative process.
Uganda’s FP Snapshot
In its most recent Family Planning 2020 commitment, the Ugandan government set the primary goals of reducing unmet need for FP to 10% and increasing the modern contraceptive prevalence rate to 50% by 2020. The government has also prioritized a targeted response to meet the sexual and reproductive health needs of adolescents. To reach these objectives, policymakers must prioritize removing access barriers and offering expanded method choice. Across public sector facilities — the country’s main provider of modern contraception — as well as private and faith-based facilities, there is a high level of dependence on short-term methods.
FP is provided under the Uganda National Minimum Health Care Package (UNMHCP), which was introduced in 1999 through a budget allocation and is paid for by the government, as well as private and development partners. All public facilities are expected to provide the UNMHCP free of charge, but many people ultimately pay out of pocket when public services are unavailable due to stockouts, limited method mix or other barriers to care. Additionally, the health sector is currently facing funding challenges and cannot deliver the UNMHCP to all who are eligible.
The government relies heavily on donors to finance FP. In Uganda, 46.9% of total FP spending comes from external financing and FP commodities are fully financed by donors. This represents a trend in Uganda’s health financing, where together, donor funding and out-of-pocket spending comprise 82% of all health financing, compared with the government’s 16% contribution. Out-of-pocket spending alone accounts for 39% of health financing.
As Uganda’s government prepares to introduce a nationwide health insurance program, SRHR champions recognize this context presents a critical advocacy moment. Since the benefits package will be covered by the scheme, including FP commodities and services in this package would provide a path to transition away from donors funding 100% of commodities. As a pre-payment scheme, this program would also mitigate out-of-pocket barriers for Ugandans accessing FP through the public sector; expand FP offerings in facilities; enable the government to increase its domestic financing for FP; and reduce donor reliance on health overall.
Uganda’s Commitment to UHC
Policies to advance UHC have widespread support among Ugandan decision-makers across sectors. The government has elevated UHC as a key strategy for the national development agenda, Uganda Vision 2040, which is a series of policies aimed at transforming Uganda into an upper-middle-income country in the coming decades. Following suit, the MoH and Ministry of Finance introduced the Health Sector Development Plan (HSDP) and Health Financing Strategy (HFS) — two key policies framed around achieving UHC and laying the groundwork for reforms, including a new nationwide health insurance program.
THE HSDP
In 2015, the HSDP established Uganda’s health sector objectives through 2020 and identified UHC as a central goal. Broadly, the plan’s three thematic areas are the social determinants of reproductive, maternal, neonatal, child and adolescent health outcomes; noncommunicable disease prevention and treatment; and communicable disease prevention and treatment. The HSDP has served as a roadmap for all health sector programs and policies, and its 2020-2025 update is currently being developed.
THE HFS
To complement the HSDP, the government introduced the HFS in 2016 with the main objective of achieving UHC. This strategy also set an overall financing goal for the health sector: to decrease its dependence on development partner contributions and out-of-pocket payments, especially among individuals of low socioeconomic status and other vulnerable groups. To that end, the HFS formally introduced plans to increase government funding to protect those who otherwise cannot afford care and to establish a nationwide social health insurance scheme.
